Considering annulus size and perimeter, we selected the 29mm sized Evolut R valve. CT analysis also showed that low implantation of previous valve and this could be a main mechanism of paravalvular leakage (Figure 4, Figure 5). After discussion, we planned to implant Evolut R valve with relative upper position compared with previous prosthetic valve. Under monitored anesthesia control, 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. After removal of the sheath, 18 Fr sheath was placed, sequentially. A pig tail catheter with a 0.035 inch stiff wire was used to cross previous Core Valve. After crossing previous valve, the stiff wire was replaced by a super-stiff wire. The supra-aortic angiogram showed AR grade 4 filling the LV during diastole ( Movie 1). The 18 Fr Evolut R Valve delivery system was advanced gently into the vessel. The Evolut R valve crossed over previous Core Valve using the super-stiff wire and was deployed about 5 mm higher position compared with previous one. Immediately after valve implantation, root angiography showed all coronary arteries was patent and trivial aortic regurgitation with well positioned Evolut R 29 mm Valve ( Movie 2). After the intervention, puncture site was sutured by prepared two Proglides.
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