Valve-in-Valve Transcatheter Aortic Valve Implantation With The Edwards SAPIEN 3

- Operator : Duk-Woo Park

Valve-in-Valve Transcatheter Aortic Valve Implantation With The Edwards SAPIEN 3
- Operator: Duk-Woo Park, MD
Case Presentation
A 66-year-old male was admitted for dyspnea on exertion of NYHA class III, He underwent surgical AVR with CE Perimount 23 mm due to infective endocarditis in 2005.Transthoracic echocardiography (TTE) showed severe eccentric aortic regurgitation (AR) and moderate aortic stenosis (AS) due to prolapsed and thickening of the tissue valve and normal LV systolic function (ejection fraction [EF] =67%). His STS and EuroSCORE were 3.67% and 2.38%, retrospectively.
Echocardiographic Findings
  1. TTE showed prosthetic aortic tissue valve in situ. But TTE showed severe eccentric AR and moderate AS due to thickening and severe prolapse of right coronary cusp of aortic tissue valve. AV area by continuity equation was 1.04 cm©÷. Maximal transAV flow velocity was 3.8 m/s. Mean and peak pressure gradient were 59 and 31 mmHg, respectively.
  2. Transesophageal echocardiography showed incomplete coaptation of non-coronary tissue valve cusp. The prosthetic aortic tissue valve was tricuspid and the annulus size by TEE was 20 mm.
CT Findings
  1. Valve internal diameter on CT was about 19.2 - 21.1 mm, and perimeter was 64.4 mm (Figure 1) compared with CE Perimount 23 mm bioprosthetic AV (Figure 2).
  2. Distance from annulus to LM and RCA ostium was 10.8 and 14.8 mm (Figure 3), respectively.
Procedure
Judging by CT analysis, we decided implant the 23 mm sized Edwards SAPIEN 3 with norminal volume. 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 angiograms with pig-tail catheter, we checked proper a puncture site of right femoral artery. 8 Fr sheath was inserted through right femoral artery, and then one 8 Fr Proglide devices were placed into the right femoral artery. After removal of the sheath, right femoral artery was dilatated and 14 Fr Edwards E-sheath was inserted. An AL 1 diagnostic catheter with a 0.035 inch Amplatz stiff wire was used to cross the aortic valve. Aortic root angiography was done. Under 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 1). After valve implantation, final fluoroscopy showed trivial aortic regurgitation. ( Movie 2). Then After the intervention, puncture site was sutured by prepared Proglides.

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