Transcatheter Aortic Valve Implantation with Edwards SAPIEN XT Valve

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with Edwards SAPIEN XT Valve

- Operator: Seung-Jung Park, MD

Case Presentation

A 78 years-old male was transferred our hospital for TAVI procedure. He was complaining of dyspnea on exertion (NYHA class II) for several months ago and diagnosed severe AS with bicuspid aortic valve at another hospital. he had a past medical history of hypertension, diabetes. Her logistic EuroSCORE was 38.62 %. His coronary angiography showed mild coronary artery disease with calcification.

Echocardiographic Findings

Transthoracic echocardiography showed severe degenerative AS with bicuspid aortic valve. There was global wall motion abnormality with severe LV systolic dysfunction (EF=21%). AV area by continuity equation was 0.41 cm². TransAV maximal velocity was 4.7 m/s. Peak and mean pressure gradient were 88 and 50 mmHg. The patient was assessed as low flow, high gradient severe aortic valve stenosis

CT Findings

Annulus size by CT was 20.8 - 24.7 mm and perimeter was 74.2 mm and Annulus area was 415 mm2 (Figure 1). Distance from annulus to LM and RCA ostium was 14.0 and 14.6 mm, respectively. The lowest diameter of right ileofemoral artery was 6.9 mm and there was no problem in vessel size and calcification (Figure 2, Figure 3).

Procedure

The annulus size by CT was 20.8 - 24.7 mm, perimeter was 74.2 mm. After discussion, we selected the 26mm Edwards SAPIEN XT valve for implantation. Under general anesthesia, 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. 8 Fr sheath was inserted through right femoral artery, and then two 8 Fr Proglide devices were placed into the right femoral artery. After removal of the sheath, 18 Fr Edwards E-sheath was inserted. An AL 1 diagnostic catheter with a 0.035-inch stiff wire was used to cross the aortic valve. After crossing AV, the stiff wire was replaced by a 0.035-inch Lunderquist super-stiff wire, and then predilatation of the stenotic AV was undertaken with a 23 x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography ( Movie 1). Under fluoroscopy control, a 26-mm Edwards SAPIEN XT prosthesis crimped on the delivery catheter (NovaFlex Delivery System) was placed at the best position of the aortic annulus and then it was successfully deployed by inflating the balloon under rapid ventricular pacing and aortic root angiography ( Movie 2). After valve implantation, mild paravalvular leakage was seen in fluoroscopy ( Movie 1). Additional balloon dilatation was done for paravalvular leakage. After balloon dilatation, final fluoroscopy showed well positioned Edwards Valve ( Movie 4) without significant paravalvular leakage. And then, we removed Edward 18 Fr sheath, checked the right peripheral angiogram ( Movie 5). The puncture site was sutured by prepared two Proglide devices.