Transcatheter Aortic Valve Implantation with Edwards SAPIEN XT Valve by Trans-apical Approach

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with Edwards SAPIEN XT Valve by Trans-apical Approach

- Operator: Seung-Jung Park, MD

Case Presentation

A 78 years-old male had resting chest pain and dyspnea on exertion (NYHA class II) started 1 month ago. He diagnosed severe aortic stenosis and transferred from initially admitted hospital. He had a past medical history of hypertension, diabetes and dyslipidemia. His logistic Euro-SCORE was 9.46 %. His coronary angiography showed subtotal occlusion at middle LAD. PCI was performed at middle LAD with Xience Xpedition 2.5 x 23mm Stent prior TAVI.

Echocardiographic Findings

Transthoracic echocardiography showed severe degenerative AS and concentric LVH with normal LV systolic function (EF=62%). Aortic valve area by continuity equation was 0.59 cm². Trans-aortic valve maximal velocity was 4.6 m/s. Peak and mean pressure gradient were 84 and 59 mmHg. Transesophageal echocardiography showed severe atherosclerosis and protruding mobile atheroma at aortic arch. (Figure 1)

CT Findings

Annulus size by CT was 22.6 - 29.7 mm and perimeter was 84.2 mm and Annulus area was 543 mm2. (Figure 2) Distance from annulus to LM and RCA ostium was 14.5 and 15.6 mm, respectively. The lowest diameter of right and left ileofemoral artery was 4.2 and 4.3 mm, respectively. (Figure 3)

Procedure

The annulus size by CT was 22.6 - 29.7 mm, perimeter was 84.2 mm. After discussion, we selected the 29mm Edwards SAPIEN XT valve. We planned trans-apical approach cause of severe atherosclerosis and mobile atheroma at aortic arch and small diameter of both ileofemoral arteries. Under general anesthesia, 5 Fr sheath and pig-tail catheter were inserted through left radial artery and trans-apical thoracotomy was done. Puncture of LV apex was followed through trans-apical thoracotomy site with 6 Fr sheath and exchanged to the delivery catheter. Under fluoroscopy control, a 29 mm Edwards SAPIEN XT prosthesis crimped on the delivery catheter (NovaFlex Delivery System) and placed at the best position of the aortic annulus. Then it was successfully deployed by inflating the balloon under rapid ventricular pacing and aortic root angiography. ( Movie 1, Movie 2) Final fluoroscopy showed well positioned Edwards Valve without significant paravalvular leakage. ( Movie 3) And then we removed delivery system and closed thoracotomy site.