Transcatheter Aortic Valve Replacement with Edwards SAPIEN 3 Valve under Moderate Sedation

- Operator : Jung-Min Ahn

Transcatheter Aortic Valve Replacement with Edwards SAPIEN 3 Valve under Moderate Sedation
- Operator: Jung-Min Ahn, MD
Case Presentation
A 74 year-old woman was referred to work up for chest discomfort with cardiac murmur. She has a past medical history of stroke without sequelae. There was no significant stenosis on the coronary computed tomography angiography. Her logistic EuroSCORE was 5.46%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AV stenosis with normal LV systolic function (EF=68%). AV area by continuity equation was 0.65 cm©÷. Maximal transAV flow velocity was 4.6 m/s. Mean and peak pressure gradient were 84 and 41 mmHg, respectively.
  2. Transesophageal echocardiography showed tricuspid AV with opening limitation caused by heavy calcification and thickening. 13 mm-sized calcified nodule around the RCA ostium was detected.
CT Findings
  1. Annulus size on CT was about 18.1-25.5 mm, and perimeter was 68.8 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 10.4 and 15.5 mm (Figure 2), respectively. The smallest diameter of right and left femoral artery was 6.0 and 5.9 mm (Figure 3).
Procedure
Considering the annulus size by CT, we planned to use 23 mm Edwards SAPIEN 3 valve through left femoral artery. Under monitored anesthesia care, 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, right femoral artery was dilated and 14 Fr Edwards E-sheath was inserted. An AL 1 diagnostic catheter with a 0.035 inch amplatz stiff wire was used to cross the aortic valve. Aortic root angiography was done. ( Movie 1). Considering low calcium score of aortic valve, we planned valve implantation without predilatation. Under fluoroscopy control, a 23-mm Edwards SAPIEN 3 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 without significant AR. ( Movie 3). And then, we removed Edward 14 Fr sheath, checked the right peripheral angiogram and closed puncture site by Proglide device.

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