Case 1A 86-year old female patient presented to the outpatient cardiology clinic with angina and shortness of breath (NYHA class 3). ECG showed normal sinus rhythm.
Case 2A 81-year old female patient presented to the outpatient cardiology clinic with increasing breathlessness (NYHA class 3) secondary to severe AS. ECG showed sinus rhythm with complete right bundle branch block.

Case 1TTE : concentric LVH and dilated LA with good  LV function and severe AS, AV Vmax 5.2 m/sec and AVA 0.58 cm².  TEE : severe AS with AVA 0.5 - 0.7 cm². MSCT : annulus aorta 17.1 x 23.9 mm, perimeter 60.3 mm, area 314 mm² and total calcium score 380 mm²Case 2TTE : normal chambers with preserved LV function and severe AS, AV Vmax 4.5 m/sec and a AVA 0.61 cm². TEE : severe AS with  AVA 0.6 cm². MSCT : annulus aorta 20.5 x 24.3 mm, perimeter 71.1 mm, area 390.4 mm² and total calcium score 166 mm²

Case 1CAG revealed severe stenosis in mid LCX. Moderate stenosis in mid RCA and severe stenosis in distal RCA.
Case 2CAG showed no significant stenosis of the coronary arteries.
CAG LCA case 1.mp4
CAG RCA case 1.mp4

Case 1PCI using Genoss DES 2.5 x 15 mm at distal RCA and mid LCX . TEE and TPM  used and 6Fr marker pigtail catheter into NCC. Unable to cross AV using  6Fr AL2 catheter and 0.035 Emerald guidewire (Cordis). Change to 0.035 Amplatz guidewire (Boston Scientific). After several attempt we are unable to cross AV.  Eventually using Dr Rha’s Technique for targeted AV crossing of 0.035 wire guided by AS jet flow , we are able to cross the AV. Change guidewire to Safari² extra small pre-shaped guidewire (Boston Scientific). Upgrading sheath to a 14 Fr Edwards E-sheath system and crossing the calcified AV,  20 mm Edwards Sapien3 ultra via Sapien 3 Commander delivery system and balloon valvuloplasty was done. Valve was implanted in an uncomplicated fashion with a minimal PVL. Peak to peak PG from 48.57 mmHg  decrease until 2 mmHg post TAVI.
Case 2 TEE and TPM used and 6Fr marker pigtail into NCC. 0.035 Amplatz guidewire (Boston Scientific) over 6Fr AL2 catheter able to cross the AV using Dr Rha’s Technique for AS Jet Flow guided 0.035 wire crossing. Changed guidewire to Safari² extra small pre-shaped guidewire (Boston Scientific). Upgrading sheath to 14 Fr Edwards E-sheath system and crossing the calcified AV, 23 mm Edwards Sapien3 Ultra via Sapien 3 Commander delivery system and balloon valvuloplasty was done. The valve was implanted in an uncomplicated fashion with a minimal PVL. Peak to peak PG from 57.2 mmHg until 0 mmHg.
LCX PCI Case 1.mp4
AV crossing Case 1.mp4
AV crossing Case 2.mp4

Extreme angulation, heavy calcification, and bicuspid morphology are risk factors for difficulties in AV crossing.
Currently, no definite expected targeted 0.035 wire crossing through tight AV and too diverse methods are used among physicians.
We suggest an effective 0.035 wire crossing within short time even if the operator could not see the AS jet.
Methods : 1.     Ready for at least 6Fr AL2 catheter2.     Try to approach 6Fr AL2 catheter closer near the AV3.     Observe the oscillating tip of 6Fr AL2 catheter by strong AS jet flow. The shorter distance from 6Fr AL2 tip to tight AV will be better to identify the AS orifice4.     0.035 wire crossing through the 6Fr AL2 tip vibrating position