Transcatheter Aortic Valve Implantation with the Edwards Valve

- Operator : Martin Bert Leon

Transcatheter Aortic Valve Implantation with the Edwards Valve

- Operators: Martin B. Leon, MD, Seung-Jung Park, MD

Case Presentation

A 74 year-old female was admitted with dyspnea on exertion (NYHA class II) for about two months. She has a past medical history of diabetes, hypertension, COPD and claudication. Her logistic EuroSCORE was 24.34%. Her coronary angiogram was normal.

Echocardiographic findings

1. Transthoracic echocardiography showed severe degenerative AV stenosis and concentric LVH with normal LV systolic fuction (EF=66%). AV area by continuity equation was 0.8 cm². TransAV maximal velocity was 4.4 m/s. Mean and peak pressure gradient were 41 and 78 mmHg. 2. Transesophageal echocardiography showed the opening limitation of AV because of calcification and degenerative change. Her AV was tricuspid and annulus size by TEE was 20mm (Figure 1, Figure 2).

CT findings

1. Annulus size was 19-20mm and perimeter was 70mm (Figure 3, Figure 4, Figure 5). 2. Distance from annulus to LM and RCA ostium was 16.2 and 13.7mm, respectively (Figure 6, Figure 7). 3. The right peripheral artery was enough to assess (Figure 8).

Procedure

The aortic annulus size measured by TEE and CT was about 20mm and perimeter was 70mm. Therefore, a 23mm Edwards SAPIEN valve was selected for implantation. Under sedation, 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. 7 Fr sheath was inserted through right femoral artery, and then three 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 sheath was inserted, sequentially. An AL 2 diagnostic catheter with a 0.032 inch Terumo wire was used to cross the aortic valve. After crossing AV, predilatation of the stenotic AV was undertaken with a 20 mm x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography ( Movie 1). Under fluoroscopy control, a 23-mm Edwards SAPIEN prosthesis crimped on the delivery catheter (RetroFlex 3 Delivery System) was placed at the best position of the aortic annulus 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 ( Movie 3). After the intervention, puncture site was sutured by prepared three Proglides.