Transcatheter aortic valve implantation with the Core Valve

- Operator : Seung-Jung Park

Transcatheter aortic valve implantation with the Core Valve
- Operator: Seung-Jung Park, MD
Case Presentation
An 83 year-old female was admitted with dyspnea on exertion (NYHA class II) for about three months. She has a past medical history of diabetes, hypertension, and claudication. Her logistic EuroSCORE was 26.35%. Her coronary angiogram was normal.
Echocardiographic findings
1. Transthoracic echocardiography showed very severe degenerative AV stenosis and severe concentric LVH with normal LV systolic fuction (EF=66%). AV area by continuity equation was 0.66 cm©÷. TransAV maximal velocity was 5.4 m/s. Mean and peak pressure gradient were 63 and 115 mmHg.
2. Transesophageal echocardiography showed the opening limitation of AV because of heavy calcification and thickening. Her AV was tricuspid and annulus size by TEE was 21mm (Figure 1, Figure 2).
CT findings
1. Annulus size by CT was 20-21mm and perimeter was 81mm (Figure 3, Figure 4, Figure 5).
2. Distance from annulus to LM and RCA ostium was 14.7 and 15.2 mm, respectively. The right lowest diameter was 7.6mm and there was no problem in vessel size and calcification (Figure 6, Figure 7, Figure 8).
Procedure
Although the annulus size by TEE and CT was 21mm, perimeter was 81mm. After discussion, we selected the larger sized CoreValve (29mm). 6 Fr sheath and temporary pacemaker were inserted through left femoral vein, and 7 Fr sheath and 6 Fr pig-tail catheter were inserted through left femoral artery. After right peripheral angiogram with pig-tail catheter, we checked proper puncture site of right femoral artery. 7 Fr sheath was inserted through right femoral artery, and then three 8 Fr Proglide devices were placed into the right femoral artery. After removal of the sheath, 18 Fr Ultimum sheath was placed. And then, an AL 1 diagnostic catheter with a stiff wire was used to cross the aortic valve ( Movie 1). After crossing AV, the stiff wire was replaced by a super-stiff wire, and then the 18 Fr CoreValve delivery catheter system (AccuTrak) was advanced gently into the vessel. The Core Valve crossed over AV using the super-stiff wire and deployment was done ( Movie 2). After the CoreValve implantation, Adjunctive balloon dilatation was done using a Tyshak II 25x40mm ( Movie 3). Final fluoroscopy showed well positioned CoreValve ( Movie 4). After the intervention, puncture site was sutured by prepared three Proglides.

Comments

  • Wei-Hsian Yin 2014-02-10 Why an over-sized CoreValve was chosen? It's obvious that the frame did not open very well. Would that be possible it's a little by risky?
  • Sung Han Yoon 2014-02-12 Many studies clarified that 3D-MDCT derived diameter (i.e. area derived diameter or perimeter derived diameter) was more accurate than 2D derived diameter (figure 2, 3 and 4) for selection of THV size. With analysis of aortic annulus ("virtual ring¡±) reconstructed by MDCT (figure 5), area/perimeter derived diameter were measured as 25.0mm and 25.8mm, respectively. Due to self-expandable frame, over-sized-CoreValve should be selected. According to current recommendation, 29mm CoreValve should be used for 72-84mm perimeter. As you mention, the outflow part of the valve was not opened well but this part works only as anchor. The inflow part, the most important part, was opened well and, as a result, paravalvular leak was only mild.

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