Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve in a Patient with Very Severe Aortic Stenosis

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve in a Patient with Very Severe Aortic Stenosis

- Operator: Seung-Jung Park, MD

Case Presentation

A 72 year-old woman was admitted with dyspnea on exertion (NYHA functional classification II). She has a past medical history of hypertension and recently diagnosed as severe AS. There was no significant stenosis on the coronary computed tomography angiography.Her logistic EuroSCORE was 4.81%.

Echocardiographic Findings

Transthoracic echocardiography showed very severe degenerative AV stenosis with normal LV systolic function (EF=66%). AV area by continuity equation was 0.4 cm². Maximal transAV flow velocity was 6.8 m/s. Mean and peak pressure gradient were 184 and 115 mmHg, respectively. Transesophageal echocardiography showed the opening limitation of AV caused by heavy calcification and thickening. His AV was tricuspid and annulus size by TEE was 20 mm.

CT Findings

Annulus size on CT was about 20.7-23.2 mm, and perimeter was 69.6 mm (Figure 1). Distance from annulus to LM and RCA ostium was 11.5 and 12.6 mm (Figure 2), respectively. And the anomalous origin of RCA, came from Lt. coronary cusp was also noticed. The lowest diameter of right femoral artery was 6.7 mm(Figure 3).

Procedure

Because the annulus size by TEE and CT was 20.7-23.2 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 we implanted 23mm valve with 2cc under-filled balloon and there was 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.