Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve in Octogenarian Patient

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve in Octogenarian Patient
- Operator: Seung-Jung Park, MD
Case Presentation
A 85 years-old female was admitted to our hospital for TAVI procedure. She has been suffered from dyspnea (NYHA III) over 2 years. She had a medical history of hypertension and recently was diagnosed as severe AS. Her coronary angiography was normal. Her logistic EuroSCORE was 3.84%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AS with mild AR and normal LV size with preserved LV systolic function (EF=70%). AV area by continuity equation was 0.68 cm©÷. Trans AV maximal velocity was 4.8 m/s. Mean and peak pressure gradient were 90 and 53 mmHg, respectively.
  2. Transesophageal echocardiography showed the opening limitation of AV because of severe calcification and degenerative thickening. AV was tricuspid and annulus size measured by TEE was 18 mm.
CT Findings
  1. Annulus size by CT was 18.4-23.5 mm and perimeter was 65.4 mm (Figure 1).
  2. Distance from annulus to LCA and RCA ostium was 12.4 and 14.9 mm, respectively (Figure 2). The minimal diameter of right femoral artery was 6.1 mm (Figure 3).
Procedure
Because the annulus size by TEE and CT was 18.4-23.5 mm, we planned to use 23 mm Edwards SAPIEN XT valve by 2cc under-fill 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 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 then two 8 Fr Proglide devices were placed into the right femoral artery. Right femoral artery was dilated using dilators from 16 Fr to 18 Fr, and then 18 Fr Edwards E-sheath was inserted, sequentially. An AL 1 diagnostic catheter with a 0.035 inch stiff wire was used to cross the aortic valve. After crossing AV, predilatation of the stenotic AV was undertaken with a 18 mm x 40 mm Z-MED II balloon under rapid ventricular pacing and aortic root angiography was done ( Movie 1). And then, under TEE and 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, half and half at the annulus level, and was successfully deployed by inflating the balloon under rapid ventricular pacing ( Movie 2). After valve implantation, final fluoroscopy showed well positioned Edwards valve with mild AR. As implantation of 29mm valve with 2cc under-filled balloon remained mild AR, we applied additional post-ballooning with 1cc under-filled balloon and final fluoroscopy showed well positioned Edwards valve without significant AR ( Movie 3). And then, we removed Edward 18 Fr sheath, checked the left peripheral angiogram and sutured puncture site by prepared two Proglide devices.

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