Transapical Transcatheter Aortic Valve Replacement with the Edwards SAPIEN XT

- Operator : Suk Jung Choo

Transapical Transcatheter Aortic Valve Replacement with the Edwards SAPIEN XT
- Operator: Suk Jung Choo, MD
Case Presentation
A 57-year-old man was admitted with effort chest pain. He has a history of hypertension, end stage renal disease on hemodialysis and previous coronary artery bypass surgery. There was native three vessel disease and patent grafts on the coronary angiography. Electrocardiography showed left bundle branch block. Transthoracic echocardiography showed severe degenerative aortic valve (AV) stenosis with moderate LV systolic dysfunction (ejection fraction [EF) =37%). His EuroSCORE 1 was 5.29% and Eureoscore II was 1.32%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AV stenosis with moderate LV systolic dysfunction (EF=37%). Wall motion abnormalities represented ischemic insult of left anterior descending artery and right coronary artery territories. AV area by continuity equation was 0.58 cm©÷. Maximal trans-AV flow velocity was 4.6 m/s. Mean and peak pressure gradient were 52 and 84 mmHg, respectively.
  2. Transesophageal echocardiography showed the opening limitation of AV caused by heavy calcification and thickening. His AV was tricuspid but annulus size by TEE could not be measured due to poor echo window.
CT Findings
  1. Annulus size on CT was about 23.1 - 32.6 mm, and perimeter was 89.7 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 12.7 and 20.2 mm (Figure 2), respectively. The lowest diameter of right femoral artery was 6.0 mm but heavily calcified (Figure 3).
Procedure
Surgical aortic valve replacement was not acceptable because right internal mammary artery and saphenous vein runs over the anterior part of the aortic root. Also because of heavy calcification of bilateral iliac artery, we could not perform transcatheter aortic valve replacement(TAVR) through femoral approach. So we decided to choose transapical approach.
The annulus size by CT was 23.1 - 32.6 mm and annulus area was 609 mm2. After discussion, we decided to implant Edwards SAPIEN XT 29 mm. Under monitored anesthesia control, left thoracotomy through 6th intercostal space was done and LV apex was exposed. Then pledgetted suture at the apex was placed. 7 Fr sheath and temporary pacemaker was inserted through puncture of LV apex and 7 Fr sheath and 6 Fr pig-tail catheter were inserted through right femoral artery. then one Proglide devices were placed into apex. After removal of the sheath, apex was dilated and 26 Fr Edwards E-sheath was inserted. Under fluoroscopy, a 29-mm Edwards SAPIEN XT prosthesis crimped on the delivery catheter (NovaFlex Delivery System) was placed at the best position of the aortic annulus, almost half and half at the annulus level, and was successfully deployed by inflating the balloon under rapid ventricular pacing ( Movie 1). After valve implantation, final fluoroscopy showed well positioned Edwards valve without significant AR ( Movie 2). And we removed delivery system and closed thoracotomy site.

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