Case

Limited Expansion of the Self-expandable Transcatheter Aortic Valve Prosthesis in Severe Aortic Stenosis with Bicuspid Aortic Valve

- Operator : Seung-Jung Park

Limited Expansion of the Self-expandable Transcatheter Aortic Valve Prosthesis in Severe Aortic Stenosis with Bicuspid Aortic Valve
- Operator: Seung-Jung Park, MD
Case Presentation
A 81-year-old female patient was hospitalized for dyspnea. There was no significant coronary artery stenosis on the coronary angiogram. Electrocardiography showed normal sinus rhythm and left ventricular hypertrophy. Our heart team decided that she was a candidate for transcatheter aortic valve replacement(TAVR) on the basis of her high operative risk (STS score 2.913%, EuroSCORE I 11.59% and EuroSCORE II 2.01%)
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe bicuspid AV stenosis with moderate LV systolic dysfunction (EF 39%). AV area by continuity equation was 0.37 cm2. Maximal trans-AV flow velocity was 7.1 m/sec. Mean and peak pressure gradient were 127 and 202 mmHg, respectively.
  2. Because of her non-compliance, the transesophageal echocardiography was not done.
CT Findings
  1. Multidetector computed tomography showed a bicuspid valve with raphe and(AP type) and leaflet thickening and heavy calcification.
  2. Annulus size on CT was about 19.5 x 28. 5 mm with 411 mm2 of annulus area, and perimeter was 76.6 mm (Figure 1). The volume of calcium over 850 HU was 445 mm3.
  3. Distance from annulus to LM and RCA ostium was 9.8 and 14.5 mm (Figure 2), respectively. The smallest diameter of right and left femoral artery was 4.1 and 4.7 mm (Figure 3).
Procedure
Considering the bicuspid AV and small annulus, we prepared the CoreValve¢ā Evolut¢ā R(Medtronic, Minneapolis, Minnesota) to minimize the risk of annulus rupture.
The procedure was performed in local anesthesia. After femoral access, we performed pre-dilation with a 20 mm Z-MED II¢ā balloon(NuMED, Canada) ( Movie 1). A 29 mm CoreValve¢ā Evolut¢ā R was implanted( Movie 2). The simultaneous left ventricular and aortic pressure tracing showed a mean pressure gradient of 45 mmHg(Figure 4) and the fluoroscopy confirmed a not fully expanded valve( Movie 3). Therefore, we performed post-dilatation using a 20 mm Z-med II¢ā balloon, but it was not successful( Movie 4). We performed post-dilatation again using a high-pressure 20mm ATLAS¢ē balloon(BARD, Tempe, Arizona)( Movie 5). On fluoroscopy the CoreValve¢ā Evolut¢ā R prothesis was expanded more than before, but not fully expanded( Movie 6). The simultaneous left ventricular and aortic pressure tracing showed a mean pressure gradient of 27 mmHg(Figure 5). The operative and postoperative course was uneventful. Final echocardiography showed a good result with a mean pressure gradient of 12 mmHg and mild paravalvular leak. The patient did not complain dyspnea afterward.

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