Valve-in-Valve Transcatheter Aortic Valve Implantation with the Core Valve

- Operator : Seung-Jung Park

Valve-in-Valve Transcatheter Aortic Valve Implantation with the Core Valve
- Operator: Seung-Jung Park, MD
Case Presentation
The patient is an 87-year-old female who had previous aortic valve replacement (AVR) in 2000. She had AVR with a 25-mm Carpentier-Edwards Perimount bioprosthesis. Over the last year, she had developed progressive dyspnea. Echocardiograms performed over this time period revealed preserved left ventricular (LV) function with deterioration of her aortic bioprosthesis. Her bioprosthetic valve had developed a moderate amount of aortic insufficiency with prolapse of one cusp of aortic bioprosthesis. Follow-up echocardiogram revealed aggravated aortic insufficiency with progressively enlarged LV chamber dimension and slightly decreased left ventricular function.
Echocardiographic Findings
Transthoracic echocardiography showed severe eccentric aortic regurgitation due to coaptation failure with stenotic component. LV systolic function was mildly decreased (EF=50%) and LV end-diastolic dimension was increased (61 mm). Trans AV maximal velocity was 3.7 m/s. Mean and peak pressure gradient were 55 and 33 mmHg.
CT Findings
Annulus size (25-mm Carpentier-Edwards Perimount bioprosthesis) by CT was about 22.8 mm (Figure 1, Figure 2).
Procedure
True internal diameter of bioprosthesis measured by CT was 22.8mm. After discussion, we selected the 26mm sized Core Valve. 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 ( Movie 1).
The 18 Fr Core Valve 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. Immediately after valve implantation, root angiography showed all coronary arteries was patent and minimal paravalvular regurgitation ( Movie 2). Final fluoroscopy showed well positioned Core Valve ( Movie 3). After the intervention, puncture site was sutured by prepared three Proglides.

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