Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve in Short Height of LCA (Left Coronary Artery) Ostium

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve in Short Height of LCA (Left Coronary Artery) Ostium

- Operator: Seung-Jung Park, MD

Case Presentation

A 75 years-old male was admitted with chest pain (CCS III-IV) and dyspnea on exertion (NYHA class III) for a year. He had a medical history of hypertension, diabetes mellitus, hyperlipidemia and cerebral infarction. His logistic EuroSCORE was 7.88%. His coronary angiography showed mild coronary artery disease at mid LAD and proximal LCX.

Echocardiographic Findings

Transthoracic echocardiography showed severe degenerative AS, mild AR and concentric LVH with normal LV systolic function (EF=61%). AV area by continuity equation was 0.54 cm². TransAV maximal velocity was 4.7 m/s. Mean and peak pressure gradient were 55 and 89 mmHg. Transesophageal echocardiography showed the opening limitation of AV because of severe calcification and degenerative thickening. His AV was tricuspid and annulus size by TEE was 23 mm.

CT Findings

Annulus size by CT was 21.7-27.9 mm and perimeter was 81.9 mm (Figure 1). Distance from annulus to LCA and RCA ostium was 8.8 and 18.8 mm, respectively (Figure 2). The right peripheral artery was enough to access. The lowest diameter was 6.2 mm (Figure 3).

Procedure

Because the annulus size by TEE and CT was 21.7-27.9 mm, we selected the 26 mm 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 both 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. Right femoral artery was dilated using dilators from 16 Fr to 18 Fr, and then 18 Fr Edwards E-sheath was inserted, sequentially. An AL 1 diagnostic catheter with a 0.035 inch stiff wire was used to cross the aortic valve. After crossing AV, predilatation of the stenotic AV was undertaken with a 23 mm 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, half and half at the annulus level, and then it was successfully deployed by inflating the balloon under rapid ventricular pacing and aortic root angiography ( Movie 2). Final fluoroscopy showed well positioned Edwards Valve with intact LCA ostium ( Movie 3). After the intervention, puncture site was sutured by prepared two Proglides.