Case

Transcatheter Aortic Valve Replacement With Evolut R in a Patient with Severe Degenerative Aortic Regurgitation

- Operator : Duk-Woo Park

Transcatheter Aortic Valve Replacement With Evolut R in a Patient with Severe Degenerative Aortic Regurgitation
- Operators: Duk-Woo Park, MD, Anna Sonio Petronio, MD
Case Presentation
A 79-year-old male patient was hospitalized for dyspnea, NYHA functional class II-III. He has a past medical history of hypothyroidism, and benign prostatic hyperplasia. There was no significant coronary artery stenosis on the coronary angiogram. Electrocardiography showed normal sinus rhythm. The Society of Thoracic Surgery risk score, EuroSCORE I, and EuroSCORE II were 3.472%, 5.48%, and 1.29%, respectively.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative aortic regurgitation with the mild stenotic component, and normal LV systolic function (EF=67%). LV end systolic and diastolic dimensions were normal (LVESD 30 mm and LVEDD 53 mm). Maximal trans-AV flow velocity was 3.8 m/s. Mean and peak pressure gradient were 29 and 57 mmHg, respectively.
  2. Transesophageal echocardiography showed severe degenerative aortic regurgitation with coaptation failure. AV area by 2D planimetry was 1.64 cm2. The diameter of tubular portion in ascending aorta was 36 mm.
CT Findings
  1. CT revealed tricuspid aortic valve. The annulus size on CT was about 24.3 x 19.1 mm with 359 mm2 of annulus area, and perimeter was 68.1 mm (Figure 1). The volume of calcium over 850 HU was 101 mm2.
  2. Distance from the annulus to LM and RCA ostium was 14.2 and 15.5 mm (Figure 2), respectively. The smallest diameter of right and left femoral artery was 6.4 and 6.7 mm (Figure 3).
Procedure
Considering the annulus size by CT, we planned to use 26-mm Evolut R valve through left femoral artery. 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 right femoral artery. After both peripheral angiogram with pig-tail catheter, we checked proper puncture site of left femoral artery. 8 Fr sheath was inserted through left femoral artery and preclosure with one Proglide device was done. And then, the left femoral artery was dilated and 18 Fr Sentrant 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). And another 6 Fr pig-tail catheter was inserted through the right radial artery and placed on the left coronary cusp to check the axis of annulus plane ( Movie 2). Under fluoroscopy control, the 14 Fr Evolut R delivery catheter system was advanced gently into the vessel. The Evolut R crossed over aortic valve using the super-stiff wire and deployment was done under gradually decreasing ventricular pacing rate from 120 to 90 bpm. After valve implantation, final fluoroscopy showed well positioned Evolut R valve without significant AR. ( Movie 3). After the intervention, puncture site was closed by prepared Proglide device.

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