Transcatheter Aortic Valve Implantation with the Edwards SAPIEN 3

- Operator : Duk-Woo Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN 3
- Operator: Duk-Woo Park, MD
Case Presentation
An 81-year-old woman was admitted with dyspnea on exertion (NYHA class III). She has a history of hypertension, diabetes mellitus and previous percutaneous coronary stent implantation at left anterior descending artery. There was no significant stenosis on the coronary angiography. Electrocardiography showed right bundle branch block. Transthoracic echocardiography showed severe degenerative aortic valve (AV) stenosis with normal LV systolic function (ejection fraction [EF) =63%). Her EuroSCORE was 13.98%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AV stenosis with normal LV systolic function (EF=63%). AV area by continuity equation was 0.77 cm©÷. Maximal trans-AV flow velocity was 4.2 m/s. Mean and peak pressure gradient were 36 and 72 mmHg, respectively.
  2. Transesophageal echocardiography showed the opening limitation of AV caused by heavy calcification and thickening. Her AV was tricuspid and annulus size by TEE was 20 mm.
CT Findings
  1. Annulus size on CT was about 19 - 27 mm, and perimeter was 73 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 10 and 15 mm (Figure 2), respectively. The lowest diameter of right femoral artery was 6.1 mm (Figure 3).
Procedure
The annulus size by CT was 19 - 27 mm and annulus area was 402 mm2. After discussion, we decided to implant Edwards SAPIEN 3 23 mm with 1.5cc overfill. Under monitored anesthesia control, 6 Fr sheath and temporary pacemaker was 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 a puncture site of right femoral artery. 8 Fr sheath was inserted through right femoral artery, and then one Proglide devices were placed into the right femoral artery. After removal of the sheath, right femoral artery was dilated 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. Under fluoroscopy, 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, almost 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 well positioned Edwards valve without significant AR. ( Movie 2). After the intervention, puncture site was sutured by prepared one Proglides.

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