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Transcatheter Aortic Valve Implantation with the Core Valve EVOLUT-R
- Operator: Seung-Jung Park, MD
Case Presentation
A 76 year-old woman was admitted for 2 months of dyspnea on exertion (NYHA class III). He has a past medical history of hypertension, hepatocellular carcinoma due to HCV infection. Her coronary angiogram showed normal coronary arteries. Her logistic EuroSCORE was 12.46%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative aortic stenosis, mild aortic regurgitation with preserved LV systolic fuction (EF=63%). AV area by continuity equation was 0.70 cm². TransAV maximal velocity was 6.1 m/s. Mean and peak pressure gradient were 90 and 146 mmHg.
CT Findings
  1. Annulus size by CT was about 18.0-22.7mm and perimeter was 64.0mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 12.4 and 18.4 mm, respectively (Figure 2). The lowest diameter of right femoral artery was 6.6mm and there was no problem in vessel size and calcification (Figure 3).
Procedure
The annulus size by CT was 18.0-22.7mm, perimeter was 64.0mm. After discussion, we selected the 23mm sized CoreValve EVOLUT-R. 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, 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, and then we did predilation using Z-MED II balloon 18mm x 4cm ( Movie 1). The 18 Fr CoreValve EVOLUT-R delivery catheter system (AccuTrak) was advanced gently into the vessel. The Core Valve EVOLUT-R 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 paravavular regurgitation ( Movie 2). After the intervention, puncture site was sutured by prepared two Proglides.
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