Transcatheter Aortic Valve Replaceement with the Edwards SAPIEN 3 Valve in a Patient with Severe Aortic Stenosis

- Operator : Jung-Min Ahn

Transcatheter Aortic Valve Replaceement with the Edwards SAPIEN 3 Valve in a Patient with Severe Aortic Stenosis
- Operator: Jung-Min Ahn, MD
Case Presentation
A 78 year-old man was admitted with dyspnea on exertion (NYHA functional classification III). He has a past medical history of non-small cell lung cancer, advanced gastric cancer, chronic obstructive lung disease, hypertension and recently diagnosed as severe AS. There was no significant stenosis on the coronary computed tomography angiography. His logistic EuroSCORE was 3.1%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AV stenosis with moderate LV systolic function (EF=49%). AV area by continuity equation was 0.58 cm©÷. Maximal transAV flow velocity was 5.1 m/s. Mean and peak pressure gradient were 102 and 68 mmHg, respectively.
  2. Transesophageal echocardiography showed the opening limitation of AV caused by heavy calcification and thickening. His AV was tricuspid and annulus size by TEE was 21 mm.
CT Findings
  1. Annulus size on CT was about 21.0-26.9 mm, and perimeter was 76.6 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 15.2 and 19.1 mm (Figure 2), respectively. The smallest diameter of right and left femoral artery was 3.7 and 5.8 mm (Figure 3).
Procedure
Considering the annulus size by TEE and CT was 21.0-26.9 mm and small right femoral artery, we planned to use 26 mm Edwards SAPIEN 3 valve through left femoral artery. Under monitored anesthesia care, 6 Fr sheath and temporary pacemaker were inserted through right femoral vein, and 7 Fr sheath and 6 Fr pig-tail catheter were inserted through right femoral artery. After both peripheral angiogram with pig-tail catheter, we checked proper puncture site of left femoral artery. 8 Fr sheath was inserted through left femoral artery, and then one 8 Fr Proglide devices were placed into the left femoral artery. Left 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 26-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 with trivial AR. ( Movie 3). And then, we removed Edward 14 Fr sheath, checked the left peripheral angiogram and sutured puncture site by prepared Proglide device.

Leave a comment

Sign in to leave a comment.