Transcatheter Aortic Valve Implantation with Edwards SAPIEN XT Valve

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with Edwards SAPIEN XT Valve
- Operator: Seung-Jung Park, MD
Case Presentation
A 69 years-old woman was admitted with dyspnea on exertion (NYHA class III). She had had coronary bypass graft surgery 19 years ago (SVG to dLAD, SVG to D1, SVG to D2, SVG to OM), had redo-coronary bypass graft surgery 10 years ago (LIMA to LAD, tRA to PL). She had a past medical history of hypertension, diabetes and dyslipidemia. Her logistic EuroSCORE was 39.38 %. Her coronary angiography showed patent arterial graft (LIMA to LAD, tRA to PL), moderate tubular stenosis of Left main coronary artery, total occlusion of proximal LAD artery and proximal LCX artery and diffuse moderate stenosis of proximal to distal RCA. She was planned to have TAVI first. After assessing the improvement of symptoms, PCI will be considered.
Echocardiographic Findings
  1. Transthoracic echocardiography showed moderate to severe degenerative AS. There was multiple regional wall motion abnormality with severe LV dysfunction (EF=22%). AV area by continuity equation was 0.85 cm©÷. TransAV maximal velocity was 3.4 m/s. Peak and mean pressure gradient were 46 and 27 mmHg. The patient was assessed as low flow, low gradient moderate to severe aortic valve stenosis
CT Findings
  1. Annulus size by CT was 19.3 - 21.5 mm and perimeter was 67.3 mm and Annulus area was 348 mm2 (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 13.3 and 9.5 mm, respectively. The lowest diameter of right femoral artery was 6.87 mm and there was no problem in vessel size and calcification (Figure 2, Figure 3).
The annulus size by CT was 19.3 - 21.5 mm, perimeter was 67.3 mm. After discussion, we selected the 23mm 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 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 then two 8 Fr Proglide devices were placed into the right femoral artery. After removal of the sheath, 16 Fr Edwards E-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 20 x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography ( Movie 1). Under fluoroscopy control, a 23-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 2). Final fluoroscopy showed well positioned Edwards Valve ( Movie 3). After the removal of Edward 16 Fr sheath, we checked the right peripheral angiogram ( Movie 4), and the puncture site was sutured by prepared two Proglide devices.

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