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Transcatheter Aortic Valve Replacement with Edwards SAPIEN 3 Valve Under Conscious Sedation
- Operator: Seung-Jung Park, MD
Case Presentation
A 68-year-old male patient was hospitalized for dyspnea, NYHA functional class III. He has a past medical history of alcoholic liver cirrhosis, hypothyroidism, and old cerebral infarction without neurologic sequelae. There was no significant coronary artery stenosis on the coronary angiogram. Electrocardiography showed normal sinus rhythm and left ventricular hypertrophy. His EuroSCORE I was 4.68% and EuroSCORE II was 1.07%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe bicuspid AV stenosis with normal LV systolic function (EF=66%). AV area by continuity equation was 0.51 cm. Maximal trans-AV flow velocity was 6.3 m/s. Mean and peak pressure gradient were 100 and 157 mmHg, respectively.
  2. Transesophageal echocardiography showed bicuspid aortic valve with opening limitation caused by heavy calcification and degenerative thickening. The diameter of tubular portion in ascending aorta was 48 mm.
CT Findings
  1. CT revealed a type 1 bicuspid aortic valve with RL fusion. Annulus size on CT was about 30 x 24 mm with 279 mm2 of annulus area, and perimeter was 86.2 mm (Figure 1). The volume of calcium over 850 HU was 1132 mm2.
  2. Distance from annulus to LM and RCA ostium was 10.5 and 14.1 mm (Figure 2), respectively. The smallest diameter of right and left femoral artery was 7.7 and 8.0 mm (Figure 3).
Procedure
Considering the annulus size by CT, we planned to use 26 mm Edwards SAPIEN 3 valve through right femoral artery. Under monitored anesthesia care, 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 angiogram with pig-tail catheter, we checked proper puncture site of right femoral artery. 8 Fr sheath was inserted through right femoral artery and preclosure with one Proglide device was done. And then, 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. Aortic root angiography was done ( Movie 1). Considering high amount of calcium of aortic valve, we planned valve implantation with predilatation using 20 mm x 4 cm Edward transfemoral balloon. Under 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 without significant AR ( Movie 3). And then, we removed Edward 14 Fr sheath, checked the right peripheral angiogram and closed puncture site by Proglide device.
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