Transcatheter Aortic Valve Implantation with the Core Valve EVOLUT-R Combined LAD Stenosis

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Core Valve EVOLUT-R Combined LAD Stenosis

- Operator: Seung-Jung Park, MD

Case Presentation

A 79 year-old man was admitted for 2 months of dyspnea on exertion (NYHA class Ⅲ). He has a past medical history of hypertension, chronic kidney disease, atrial fibrillation and history of coronary balloon angioplasty at mid LAD in 2005. His coronary angiogram showed significant stenosis at mid LAD. Her logistic EuroSCORE was 10.04%.

Echocardiographic Findings

Transthoracic echocardiography showed severe bicuspid aortic stenosis with preserved LV systolic function (EF=67%). AV area by continuity equation was 0.63 cm². TransAV maximal velocity was 4.6 m/s. Mean and peak pressure gradient were 50 and 86 mmHg.

CT Findings

Annulus size by CT was about 22.0 - 28.1mm and perimeter was 81.2mm (Figure 1). Distance from annulus to LM and RCA ostium was 12.2 and 17.2 mm, respectively (Figure 2). The lowest diameter of right femoral artery was 7.6mm and there was no problem in vessel size and calcification (Figure 3).

Procedure

After Xience Alpine 3.0 x 18mm stent was successfully deployed at mid LAD, we selected the 29mm 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 replaced. 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 22mm 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.