Transcatheter Aortic Valve Implantation Via Trans-aortic Approach

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation Via Trans-aortic Approach

- Operator: Seung-Jung Park, MD

Case Presentation

A 93 year-old male patient was admitted with recently aggravated chest pain (CCS III-IV) and dyspnea (NYHA IV) for a month. He had a medical history of hypertension, diabetes mellitus, hyperlipidemia and received PCI at dLAD and PTCA at both CIA, 5 years ago. His coronary angiography showed patent dLAD stent and otherwise normal vessels. Diagnosed as severe AS, we planned to perform TAVI for this patient. His logistic EuroSCORE and STS score was 30.2% and 16.0%, respectively. Peripheral stents were all patent, but showed severe tortuosity which was not suitable for transfemoral approach. ( Movie 1) As both subclavian arteries were severely diseased, we decided to undergo TAVI via trans-aortic approach. ( Movie 2, Movie 3)

Echocardiographic Findings

Transthoracic echocardiography showed severe degenerative AS, mild AR with moderate LV dysfunction (43%). AV area by continuity equation was 0.53 cm². TransAV maximal velocity was 4.2 m/s. Mean and peak pressure gradient were 43 and 71 mmHg.

CT Findings

Annulus size by CT was 21.9-26.9 mm and perimeter was 76.4 mm (Figure 1). Distance from annulus to LCA and RCA ostium was 13.2 and 16.4 mm, respectively (Figure 2).

Procedure

Because the annulus size by CT was 21.9-26.9 mm, we selected the 26 mm Edwards SAPIEN XT valve for implantation. Under general anesthesia, J-sternotomy extension to the right 4th intercostal space was done. While preparing the access site, 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 exposing the ascending aorta, we selected the optimal puncture considering the device length and angle. Ascending aorta was punctured and purse string sutures were made for the insertion of a 7 Fr sheath. We placed a 0.035 inch stiff wire crossing the aortic valve, and exchanged 7Fr sheath into the 24 Fr Edwards sheath. Predilatation of the stenotic AV was undertaken with a 20 mm x 30 mm Edwards balloon under rapid ventricular pacing and aortic root angiography ( Movie 4). And then, under TEE and fluoroscopy guidance, a 26-mm Edwards SAPIEN XT prosthesis was successfully deployed by inflating the balloon under rapid ventricular pacing and aortic root angiography ( Movie 5). We removed the catheter and tied the purse-string sutures and closed sternum with 6 steel wires and titanium plate. Final fluoroscopy showed well positioned Edwards Valve with mild AR ( Movie 6).