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
A 78 year-old woman was admitted for 3 years of dyspnea, NYHA class III. She had gone coronary bypass graft surgery 15 years ago (LIMA to LAD, SVG to OM, SVG to RCA). She has a past medical history of hypertension, dyslipidemia. Her logistic EuroSCORE was 47.9%. Her coronary angiogram showed patent grafts with diffuse disease at LAD and LCx native vessels.
Echocardiographic Findings
Transthoracic echocardiography showed severe degenerative AV stenosis, mild aortic regurgitation and concentric LVH with normal LV systolic fuction (EF=66%). AV area by continuity equation was 0.50 cm©÷. TransAV maximal velocity was 5.1 m/s. Mean and peak pressure gradient were 68 and 102 mmHg.
CT Findings
  1. Annulus size by CT was about 15.7 - 22.9mm and perimeter was 64.2mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 12.0 and 14.5 mm, respectively (Figure 2). The lowest diameter of right femoral artery was 5.6mm and there was no problem in vessel size and calcification (Figure 3).
Procedure
The annulus size by CT was 15.7 - 22.9mm, perimeter was 64.2mm. After discussion, we selected the 23mm sized CoreValve. 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 two 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. After crossing AV, the stiff wire was replaced by a super-stiff wire, and then we did predilation using Z-MED II balloon 23mm x 4cm ( Movie 1). 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 was deployed. Immediately after valve implantation, root angiography showed all coronary arteries was patent and minimal paravavular regurgitation witn well positioned CoreValve ( Movie 2). After the intervention, puncture site was sutured by prepared three Proglides.

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