You also cite the study by Omran in Lancet which is oft quoted by fellows to prove that the valve should not be crossed (Omran H, Schmidt H, Hackenbroch M, et al. Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: A prospective, randomised study. Lancet 2003;361:1241-1246.).

I have not heard anyone question the technique used in the Omran study. They used a Terumo wire in crossing the valve. This hydrophilic wire is known to have a tendency to go through and under plaques and can easily cause dissections. I believe it is reasonable to suggest that a hydrophilic tip wire would be more likely to dislodge calcified debris than a more conventional one. It may be the wire that was the problem.

I do not think the Omran study can be used to suggest that all attempts at crossing a stenotic aortic valve should be abandoned. I would say that the study showed that the use of a hydrophilic wire to cross the stenotic valve has an unacceptably high incidence of silent and apparent stroke, and should not be used. The study should be repeated with a more conventional wire.

Sincerely,
Marshall H. Crenshaw, MD, FACC
Assistant Professor of Medicine
Vanderbilt Heart and Vascular Institute
Nashville, TN
marshall.h.crenshaw@vanderbilt.edu

Dr. Kern’s response:

Dr. Crenshaw identifies an important fact little known to most of us. I agree that the Terumo wire carries more risk than non-coated wires with the potential to lift plaques. I have never used this technique for aortic stenosis and agree with Dr. Crenshaw that this study should be repeated with alternate wire technique. Thanks for an astute observation.

MK

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