Thread by @adnanalkhouli

AV Rails are useful in complex paravalvular leak closure, but not commonly discussed in the literature

This short🧵sheds some light on AV rails & their attributes.

#CardioTwitter #MedEd

💢When should I I use a rail?

📌 Simple leaks don’t require a rail

📌 Rail upfront in serpiginous/Ca++ leaks. I use it in 1/3 of cases. When in doubt, use a rail!

📌 Rails are also great opportunity to ‘electively’ master snaring 😉

But sometimes rails can be challenging👇

💢 e.g. Presence of 2 mechanical valves. Here u have 3 options:

1. Transapical rail
Caveat: TA🩸risk

2. AV rail across the mechanical AV
Caveat: leaflet impingement (can often be done carefully)

3. VV rail if double MV leaks: (aka LAMPOON style)
Caveat: valve instability

💢 Can also use other sources of support as an alternative to rail

In👇case of 2 mechanical valves and 2 MV leaks

- Planned to make a VV rail through the leaks (like a LAMPOON)

- But, skipped the rail as leaning the Agilis on the RA free wall providing adequate back support

💢 Aortic PVL can also be challenging & railing may help

In👇case:

- Plugs couldn’t advance retrograde but went through antegrade with an AV rail

- Apical rail considered but avoided due to prior TA TAVR

- Caveat: need to carefully watch the IAS to avoid tears or large ASD

💢 Final thoughts:

- Longest wires possible:
Glide ES, Nitrex 400 cm

- EnSnares >> Gooseneck

- Keep 👁 on AO: AV rails cause AI which can be ⬇️ by easing the rail

- Like with anchor wire techniques, the rail wire will occupy space, consider👇 when selecting u plug