Transcatheter Aortic Valve Implantation with the Core Valve

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Core Valve
- Operator: Seung-Jung Park, MD
Case Presentation
A 76 year-old gentleman was admitted for recurrent syncope. He has a past medical history of claudication, COPD, and hyperlipideima. His logistic EuroSCORE was 19.57%. His coronary angiogram showed normal. Transthoracic echocardiography showed severe degenerative AV stenosis and concentric LVH with normal LV systolic function (EF=60%). Firstly, we recommended aortic valve replacement, but he refused. So we decided to perform the TAVI.
Echocardiographic Findings
1. Transthoracic echocardiography showed very severe degenerative AV stenosis and severe concentric LVH with normal LV systolic function (EF=60%). AV area by continuity equation was 0.46 cm©÷. TransAV maximal velocity was 5.2 m/s. Mean and peak pressure gradient were 72 and 107mmHg.
2. Transesophageal echocardiography showed the opening limitation of AV because of heavy calcification and thickening. His AV was bicuspid and annulus size by TEE was 20 mm (Figure 1).
CT Findings
1. Annulus size by CT was about 22 - 24 mm, and perimeter was 77 mm (Figure 2, Figure 3).
2. Distance from annulus to LM and RCA ostium was 16 and 14 mm, respectively. The lowest diameter of right femoral artery was 7.5 mm and there was no problem in vessel size and calcification (Figure 4).
Procedure
The annulus size by CT was 22 - 24 mm, perimeter was 77 mm. After discussion, we selected the 26 mm sized CoreValve. 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 right peripheral angiogram with pig-tail catheter, we checked proper puncture site of right femoral artery. 7 Fr sheath was inserted through right femoral artery, and then three 8 Fr Proglide devices were placed into the right femoral artery. After removal of the sheath, 18 Fr Ultimum sheath was placed. And then, an AL 1 diagnostic catheter with a stiff wire was used to cross the aortic valve. After crossing AV, the stiff wire was replaced by a super-stiff wire. And then predilatation was done using a Z-MED II balloon 20 x 40 mm ( Movie 1), and 18 Fr CoreValve delivery catheter system (AccuTrak) was advanced gently into the vessel. The Core Valve crossed over AV using the super-stiff wire and deployment was done ( Movie 2). Postdilatation was done using a Z-MED II balloon 23 x 40 mm ( Movie 3). Final fluoroscopy showed well positioned CoreValve ( Movie 4). After the intervention, puncture site was sutured by prepared three Proglides.

Comments

  • Charles Chan 2013-05-30 Why was post dilatation done with a 23 mm balloon? Was it because of significant aortic regurgitation?
  • Won-Jang Kim 2013-06-03 Thank you for your valuable comment. After implantation of Corevalve, moderate amount of AR was observed and then we decided the post balloon dilation.
  • Wei-Hsian Yin 2014-02-10 Underdeployment of CoreValve due to heavy calcification, successfully treated by post-dilatation. Excellent!

Leave a comment

Sign in to leave a comment.