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Transcatheter Aortic Valve Implantation (Edwards SAPIEN XT Valve) with Peripheral Balloon Angioplasty

- Operator: Seung-Jung Park, MD

Case Presentation

An 86 years-old gentleman was admitted with dyspnea on exertion (NYHA class III-IV). He has a past medical history of hypertension, and old MI. He has history of balloon PTA at right internal iliac artery and stent insertion at the left common iliac artery. His logistic EuroSCORE was 27.82%. His coronary angiography showed mild coronary disease. First, we recommended open heart surgery but patient refused.

Echocardiographic Findings

1. Transthoracic echocardiography showed severe degenerative AS, noderate to severe AR, and concentric LVH with normal LV systolic function (EF=72%). AV area by continuity equation was 0.62 cm². TransAV maximal velocity was 4.8 m/s. Mean and peak pressure gradient were 91 and 53 mmHg.
2. Transesophageal echocardiography showed the opening limitation of AV because of severe calcification and degenerative thickening. Her AV was tricuspid and annulus size by TEE was 21mm (Figure 1, Figure 2).

CT Findings

1. Annulus size by CT was 24.70 - 28.04 mm and perimeter was 83.5mm and Aunnulus area was 509.6 mm2 (Figure 3, Figure 4, Figure 5).
2. Distance from annulus to LM and RCA ostium was 12.8 and 12.1 mm, respectively (Figure 6, Figure 7). There were stenosis in right common iliac artery, and the minimal diameter was 3.11 mm (Figure 8, Figure 9). And the stent in left common iliac artery was crushed at proximal portion. So both iliac arteries were not enough to access. Therefore we decided to perform PTA just before TAVI prodecure.

Procedure

Because the annulus size by TEE and CT was 24.70 - 28.04 mm and annulus area by CT was 509.6 mm2, we selected the 26mm Edwards SAPIEN XT valve for implantation. Under general anesthesia, 6 Fr sheath and temporary pacemaker were inserted through left femoral vein, and 7 Fr sheath was were inserted through left femoral artery. And we tried to advance 6 Fr pig-tail catheter, but it was not possible. So we checked the left peripheral aniogram. It showed moderate stenosis at the left common iliac artery (

Movie 1). After sequential balloon dilatation using FoxCross 3.0x40, Amphirion Deep 4.0x40, and EverCross 5.0x40 (Figure 10, Figure 11, Figure 12), pig-tail catheter was able to advance upto distal abdominal aorta. The peripheral angiogram with pig-tail catheter showed significant stenosis in the right common iliac artery (

Movie 2). 7 Fr sheath was inserted guided by right peripheral angiogram through right femoral artery, and then three 8 Fr Proglide devices were placed into the right femoral artery. Right femoral artery was dilated using dilators from 14 Fr, but 17 Fr Edwards sheath was not able to be inserted due to stenosis of the right common iliac artery. Then we performed balloon dilatation using EverCross 5.0x40 and Conquest 6.0x40 (Figure 13, Figure 14). After balloon dilatation the right peripheral angiogram showed improved patency (

Movie 3). Then 17 Fr Edwards sheath was inserted. An AL 1 diagnostic catheter with a 0.035 inch stiff wire was used to cross the aortic valve. After crossing AV, the stiff wire was replaced by a 0.035 inch Lunderquist super-stiff wire, and then predilatation of the stenotic AV was undertaken with a 23 mm x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography (

Movie 4). Under fluoroscopy control, a 26-mm Edwards SAPIEN XT prosthesis crimped on the delivery catheter (NovaFlex Delivery System) was placed at the best position of the aortic annulus and then it was successfully deployed by inflating the balloon under rapid ventricular pacing and aortic root angiography (

Movie 5). Final fluoroscopy showed well positioned Edwards Valve (

Movie 6). After the removal of Edward 17Fr sheath, we checked the right peripheral angiogram (

Movie 7), and the puncture site was sutured by prepared three Proglides.