Case

Balloon-expandable Transcatheter Aortic Valve Prosthesis(Edwards SAPIEN 3) in Severe Aortic Stenosis with Large Size Bicuspid Aortic Valve

- Operator : Duk-Woo Park

Balloon-expandable Transcatheter Aortic Valve Prosthesis(Edwards SAPIEN 3) in Severe Aortic Stenosis with Large Size Bicuspid Aortic Valve
- Operator: Duk-Woo Park, MD
Case Presentation
A 81-year-old male patient was hospitalized for operation of right hip intertrochanter fracture. The echocardiogram as pre-operation exam showed severe bicuspid aortic valve stenosis and large valve size. The coronary angiogram was normal. The electrocardiography showed normal sinus rhythm with right bundle branch block. Our heart team decided that he was a candidate for transcatheter aortic valve replacement (TAVR) on the basis of his high operative risk (STS score 2.913%, EuroSCORE I 6.21% and EuroSCORE II 1.22%) before operation for hip joint fracture.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe bicuspid AV stenosis with normal systolic function (EF 70%). AV area by continuity equation and maximal trans-AV flow velocity and pressure gradient could not evaluated appropriately due to poor echo window and inappropriate alignment of axis.
  2. The transesophageal echocardiography showed anterior-posterior type of biscuspid arotic valve and 0.6 cm2 of AV area by planimetry and 38 mm of ascending aorta by post-stenotic dilatation.
CT Findings
  1. Multidetector computed tomography showed a bicuspid valve with raphe (AP type) and leaflet thickening and heavy calcification.
  2. Annulus size on CT was about 25.6 x 34.9 mm with 659 mm2 of annulus area, and perimeter was 95.0 mm (Figure 1). The volume of calcium over 850 HU was 705 mm3.
  3. Distance from annulus to the LM and RCA ostium was 10.7 and 19.5 mm (Figure 2), respectively. The smallest diameter of the right and left femoral artery was 8.6 and 10.0 mm (Figure 3).
Procedure
Given the bicuspid AV and large annulus, we planned to use 26 mm Edwards SAPIEN 3 valve through the right femoral artery. Under monitored anesthesia care, a 6 Fr sheath and temporary pacemaker were inserted through the left femoral vein, and 7 Fr sheath and 6 Fr pig-tail catheter were inserted through the left femoral artery. After both peripheral angiogram with the pig-tail catheter, we checked the proper puncture site of the right femoral artery. A 8 Fr sheath was inserted through the right femoral artery and preclosure with the Proglide device was done. And then, the right femoral artery was dilated and a 16 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). Because of the high amount of calcium of aortic valve, we planned valve implantation with predilatation using a 23 mm x 4 cm Edward transfemoral balloon. Under fluoroscopy control, a 29-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 the Edward 16 Fr sheath, checked the right peripheral angiogram and closed puncture site by the Proglide device.

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