Because the annulus size by TEE and CT was 23.6-28.9 mm, we planned to use 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 was done ( Movie 1). And then, under TEE and 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 was successfully deployed by inflating the balloon under rapid ventricular pacing ( Movie 2). After valve implantation, final fluoroscopy showed well positioned Edwards valve with mild AR ( Movie 3). And then, we removed Edward 18 Fr sheath, checked the left peripheral angiogram and sutured puncture site by prepared two Proglide devices.
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