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Transcatheter Aortic Valve Replacement in a Patient with Chronic Kidney Disease
- Operator: Seung-Jung Park, MD
Case Presentation
A 86-year-old male patient was hospitalized for dyspnea, NYHA functional class III. He has a past medical history of hypertension, paroxysmal atrial fibrillation, hypothyroidism and old cerebral infarction without neurologic sequelae. And he also had chronic kidney disease (eGFR 32 ml/min/1.73m). There was no significant coronary artery stenosis on the coronary angiogram. Electrocardiography showed normal sinus rhythm and left ventricular hypertrophy. His EuroSCORE I was 5.1% and EuroSCORE II was 2.41%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe tricuspid AV stenosis with normal LV systolic function (EF=59%). AV area by continuity equation was 0.7 cm. Maximal trans-AV flow velocity was 4.2 m/s. Mean and peak pressure gradient were 42 and 70 mmHg, respectively.
  2. Transesophageal echocardiography showed tricuspid aortic valve with opening limitation caused by heavy calcification and degenerative thickening. The diameter of tubular portion in ascending aorta was 28 mm (Figure 1).
Non-enhanced MR Findings (instead of CT findings due to CKD)
  1. MR revealed a tricuspid aortic valve with a heavy calcification. Annulus size on MR was about 26 x 18 mm with 385 mm2 of annulus area, and perimeter was 71.6 mm (Figure 2). The volume of calcium over 850 HU was 450 mm2 on non-enhanced CT (Figure 3, Figure 4).
Procedure
Considering the annulus size by MR and TEE, we planned to use 23 mm Edwards SAPIEN 3 valve through right femoral artery. Under monitored anesthesia care, 6 Fr sheath and temporary pacemaker were inserted through right femoral vein, and 7 Fr sheath and 6 Fr pig-tail catheter were inserted through left femoral artery. After right 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 pre-closure with one Proglide device was done. And then, right femoral artery was dilated, and 14 Fr Edwards E-sheath was inserted. 9Fr long sheath was inserted to Lt femoral vein to manipulate intracardiac echocardiography. An AL 1 diagnostic catheter with a 0.035-inch amplatz stiff wire was used to cross the aortic valve. Considering little amount of calcium of aortic valve, we planned valve implantation without pre-dilatation. 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 with minimal contrast agents and was successfully deployed by inflating the balloon under rapid ventricular pacing ( Movie 1). After valve implantation, we performed ICE and TTE to check AR which showed trivial degree ( Movie 2). And then, we removed Edward 14 Fr sheath, checked the right peripheral angiogram and closed puncture site by Proglide device. Total amount of contrast dye used was 30 cc.
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