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Transcatheter Aortic Valve Implantation with the Edwards SAPIEN 3 Valve in a Patient with Severe Aortic Stenosis
- Operator: Seung-Jung Park, MD
Case Presentation
A 84 year-old woman was admitted with dyspnea on exertion (NYHA functional classification IV). She has a past medical history of hypertension, atrial fibrillation and recently diagnosed as severe AS. There was no significant stenosis on the coronary computed tomography angiography. Her logistic EuroSCORE was 15.56%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AV stenosis with normal LV systolic function (EF=59%). AV area by continuity equation was 0.51 cm². Maximal transAV flow velocity was 4.6 m/s. Mean and peak pressure gradient were 85 and 52 mmHg, respectively.
  2. Transesophageal echocardiography showed the opening limitation of AV caused by heavy calcification and thickening. Her AV was tricuspid and annulus size by TEE was 19 mm.
CT Findings
  1. Annulus size on CT was about 20.7-25.7 mm, and perimeter was 73.1 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 12.3 and 17.1 mm (Figure 2), respectively. The lowest diameter of right femoral artery was 7.4 mm(Figure 3).
Procedure
Because the annulus size by TEE and CT was 20.7-25.7 mm, we planned to use 23 mm Edwards SAPIEN 3 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,14 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. Aortic root angiography was done. ( Movie 1). And then, under TEE and fluoroscopy control, a 23-mm Edwards SAPIEN 3 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 without AR. ( Movie 3). And then, we removed Edward 14 Fr sheath, checked the left peripheral angiogram and sutured puncture site by prepared two Proglide devices.
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