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Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Valve in a Patient with Severe Aortic Stenosis
- Operator: Seung-Jung Park, MD
Case Presentation
A 81 years-old male was admitted with dyspnea (NYHA II) for several months. He had a medical history of hypertension and PCI for coronary artery disease. His logistic EuroSCORE was 6.2%. There were no evidence of significant coronary artery disease in the coronary CT angiography.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AS and concentric LVH with normal LV systolic function (EF=64%). AV area by continuity equation was 0.74 cm². TransAV maximal velocity was 5.1 m/s. Mean and peak pressure gradient were 104 and 62 mmHg.
  2. Transesophageal echocardiography showed the opening limitation of AV because of severe calcification and degenerative thickening. His AV was tricuspid and annulus size by TEE was 25 mm.
CT Findings
  1. Annulus size by CT was 24.3-30.5 mm and perimeter was 85.8 mm (Figure 1).
  2. Distance from annulus to LCA and RCA ostium was 14.8 and 20.3 mm, respectively (Figure 2). The right peripheral artery was enough to access. The minimal diameter was 7.0 mm (Figure 4).
Procedure
Because the annulus size by TEE and CT was 24.3-30.5 mm, we planned to use 29 mm Edwards SAPIEN XT valve by nominal pressure 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 23 mm x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography ( Movie 1). Under fluoroscopy control, a 29-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 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 without significant AR ( Movie 3). After the intervention, puncture site was sutured by prepared two Proglides.
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