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Valve-in-Valve Transcatheter Aortic Valve Replacement with Evolut R
- Operators: Jung-Min Ahn, MD, Eberhard Grube, MD
Case Presentation
A 69-year-old male patient was hospitalized for dyspnea, NYHA functional class III. He has a past medical history of Behcets disease and permanent pacemaker implantation due to complete AV block. And He underwent Bentall operation with 25 mm sized Prima bioprosthetic aortic valve due to periaortic abscess 16 years ago. There was no significant coronary artery stenosis on coronary angiogram. Electrocardiography showed paced rhythm. The Society of Thoracic Surgery risk score, EuroSCORE I, and EuroSCORE II were 2.908%, 21.00%, and 5.62%, respectively.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative aortic regurgitation with suspicious perforation of left coronary cusp, and global hypokinesia with mild to moderate LV dysfunction (EF=44%). LV end systolic and diastolic dimensions were enlarged (LVESD 49 mm and LVEDD 68 mm). Maximal trans-AV flow velocity was 3.0 m/s. Mean and peak pressure gradient were 17 and 36 mmHg, respectively.
  2. Transesophageal echocardiography showed severe degenerative aortic regurgitation with suspicious perforation of left coronary cusp. And there was no evidence of vegetation or thrombus.
CT Findings
  1. The annulus size on CT was about 21.3 x 17.5 mm with 289 mm2 of annulus area, and perimeter was 61.7 mm (Figure 1). The volume of calcium over 850 HU was 14.2 mm3.
  2. Distance from the annulus to LM and RCA ostium was 7.0 and 12.5 mm (Figure 2), respectively. The smallest diameter of right and left femoral artery was 8.3 and 7.4 mm (Figure 3).
Procedure
Considering the annulus size by CT, we planned to use 26-mm Evolut R valve through right 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 left femoral artery. After both 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 preclosure with one Proglide device was done. And then, the right 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). Under fluoroscopy control, the 14 Fr Evolut R delivery catheter system was advanced gently into the vessel. The Evolut R crossed over pre-existing stent-less valve using the super-stiff wire and deployment was done ( Movie 2). 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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