Valve > Cases

Transcatheter Aortic Valve Implantation with The Edwards SAPIEN 3
- Operator: Seung-Jung Park, MD
Case Presentation
An 80-year-old woman was hospitalized for dyspnea on exertion of NYHA class II. She has no past medical history. There was no significant coronary artery stenosis on coronary CT angiography. Electrocardiography shows normal sinus rhythm and left ventricular hypertrophy. Transthoracic echocardiography (TTE) showed severe rheumatic aortic stenosis (AS) with mild AR and normal LV systolic function (ejection fraction [EF] =61%) and mild rheumatic MS. Her EuroSCORE was 15.66%.
Echocardiographic Findings
  1. TTE showed severe rheumatic AS with mild AR. TTE also showed mild rheumatic mitral stenosis and regurgitation, mild pulmonary hypertension. AV area by continuity equation was 0.64 cm. Maximal transAV flow velocity was 6.0 m/s. Mean and peak pressure gradient were 142 and 85 mmHg, respectively.
  2. Transesophageal echocardiography showed the opening limitation of AV caused by heavy calcification and thickening. Her AV was tricuspid and annulus size by TEE was 20 mm.
CT Findings
  1. Annulus size on CT was about 20.6 - 23.5 mm, and perimeter was 66.9 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 16.1 and 16.8 mm (Figure 2), respectively.
Procedure
Judging by CT analysis, we decided implant the 23 mm sized Edwards SAPIEN 3 with 1 cc underfill. 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 angiograms with pig-tail catheter, we checked proper a puncture site of right femoral artery. 8 Fr sheath was inserted through right femoral artery, and then one 8 Fr Proglide devices were placed into the right femoral artery. After removal of the sheath, right femoral artery was dilatated 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. Considering high calcium score at left coronary cusp, we performed pre-dilatation with Z-med 18mm.( Movie 1) 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 aortic regurgitation. ( Movie 3). Then we performed post-dilatation up to nominal volume and . (Movie 4, 5). After the intervention, puncture site was sutured by prepared one Proglides.
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