Transcatheter Aortic Valve Replacement(TAVR) with EVOLUT-R in a Patient with Severe Paravalvular Leakage after Previous TAVR

- Operator : Jung-Min Ahn

Transcatheter Aortic Valve Replacement(TAVR) with EVOLUT-R in a Patient with Severe Paravalvular Leakage after Previous TAVR

- Operators: Jung-Min Ahn, MD, Seung-Jung Park, MD

Case Presentation

A 85 year-old male was admitted with dyspnea (NYHA III) for several months. He had undergone transcatheter aortic valve implantation (Core Valve 29mm) about 4 years ago. Immediate TTE after previous TAVR showed moderate paravalvular leakage and recent TTE showed aggravation of paravalvular leakage with severe AR. He had a medical history of hypertension, dyslipidemia and pacemaker insertion due to sick sinus syndrome. His logistic STS score was 4.811%. His coronary CT angiography showed total occlusion at proximal LCX.

Echocardiographic Findings

Transthoracic echocardiography showed severe eccentric paravalvular AR with normal LV systolic function (EF=70%). AV area by continuity equation was 1.66 cm². TransAV maximal velocity was 2.7 m/s. Mean and peak pressure gradient were 30 and 16 mmHg. Previous prosthetic aortic valve was protruded to the LVOT side. Transesophageal echocardiography showed that the ratio of paravalvular AR jet to the AV circumference was over 20%. Combined with the result of holodiastolic reversal flow on TTE, that TEE finding indicated severe AR caused by paravalvular leakage.

CT Findings

Annulus size by CT was about 23.8 - 28.0mm and perimeter was 82.0mm (Figure 1). Distance from annulus to LCA and RCA ostium was 13.3 and 16.9 mm, respectively (Figure 2). The right peripheral artery was enough to access. The lowest diameter of right external iliac artery was 6.1 mm (Figure 3).

Procedure

Considering annulus size and perimeter, we selected the 29mm sized Evolut R valve. CT analysis also showed that low implantation of previous valve and this could be a main mechanism of paravalvular leakage (Figure 4, Figure 5). After discussion, we planned to implant Evolut R valve with relative upper position compared with previous prosthetic valve. Under monitored anesthesia control, 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. After removal of the sheath, 18 Fr sheath was placed, sequentially. A pig tail catheter with a 0.035 inch stiff wire was used to cross previous Core Valve. After crossing previous valve, the stiff wire was replaced by a super-stiff wire. The supra-aortic angiogram showed AR grade 4 filling the LV during diastole ( Movie 1). The 18 Fr Evolut R Valve delivery system was advanced gently into the vessel. The Evolut R valve crossed over previous Core Valve using the super-stiff wire and was deployed about 5 mm higher position compared with previous one. Immediately after valve implantation, root angiography showed all coronary arteries was patent and trivial aortic regurgitation with well positioned Evolut R 29 mm Valve ( Movie 2). After the intervention, puncture site was sutured by prepared two Proglides.