Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Valve in a Patient with Severe Aortic Stenosis

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Valve in a Patient with Severe Aortic Stenosis
- Operator: Seung-Jung Park, MD
Case Presentation
A 78 years-old male was admitted with dyspnea (NYHA III) for several months. He had underwent right upper lobectomy due to lung cancer at 20 year ago. He also had a medical history of hypertension and chronic obstructive lung disease. His logistic EuroSCORE was 8.2%. There were no evidence of significant coronary artery disease in the coronary CT angiography.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AS, mild AR and concentric LVH with normal LV systolic function (EF=58%). AV area by continuity equation was 0.91 cm©÷. TransAV maximal velocity was 4.2 m/s. Mean and peak pressure gradient were 41 and 71 mmHg.
  2. 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 22 mm.
CT Findings
  1. Annulus size by CT was 23.1-29.5 mm and perimeter was 83.3 mm (Figure 1).
  2. Distance from annulus to LCA and RCA ostium was 13.2 and 20.0 mm, respectively (Figure 2). The right peripheral artery was enough to access. The minimal diameter was 8.5 mm (Figure 3).
Procedure
Because the annulus size by TEE and CT was 23.1-29.5 mm, we planned to use 29 mm Edwards SAPIEN XT valve by 5cc under-fill 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 29-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). As implantation of 29mm Valve with 5 cc under-filled balloon, mild AR was remained. We applied additional post-ballooning with 3ml under-filled balloon and final fluoroscopy showed well positioned Edwards Valve without significant AR ( Movie 3). After the intervention, puncture site was sutured by prepared two Proglides.

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