Valve in Valve Transcatheter Aortic Valve Replacement

- Operator : Eberhard Grube

Valve in Valve Transcatheter Aortic Valve Replacement
- Operators: Eberhard Grube, MD, Jung-Min Ahn, MD
Case Presentation
A 79 years-old male was admitted with dyspnea on exertion, NYHA functional class III. He underwent TAVI procedure with CoreValve 31mm due to severe Aortic valve stenosis, 4 years ago. There was mild proximal LAD stenosis on the coronary CT angiogram. Electrocardiography showed normal sinus rhythm and left bundle branch block. His STS score was 2.76.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe eccentric aortic paravalvular leakage, mainly from anterior and lateral side. Maximal trans-AV flow velocity was 2.3 m/s. Mean and peak pressure gradient were 22 and 13 mmHg, respectively. Left ventricle was enlarged with end-diastolic and end-systolic diameter of 70 and 51 mm and showed moderate LV dysfunction(EF=40%).
  2. Transesophageal echocardiography showed about 1 mm sized-gap between anterior mitral leaflet side of Core Valve and aorta and severe eccentric paravalvular leakage.
CT Findings
  1. Core Valve size on CT was about 23.5 x 25.9 mm with 471 mm2 of internal area (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 14.3 and 16.2 mm (Figure 2), respectively. The smallest diameter of right and left femoral artery was 7.0 and 5.8 mm (Figure 3).
Procedure
Considering the size of Core Valve on the CT, we planned to use 29 mm Evolute R valve through right femoral artery. Under general 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 Proglide device was done. And then, right femoral artery was dilated and 18 Fr Sentrant sheath was inserted. Aortic root angiography was done ( Movie 1) and an AL 1 diagnostic catheter with a 0.035 inch Amplatz stiff wire was used to cross the aortic valve. The 14 Fr Core Valve EVOLUT-R delivery catheter system (AccuTrak) was advanced gently into the vessel. The Core Valve EVOLUT-R crossed over pre-existing Core valve using the super-stiff wire and deployment was done around 5 mm above lower margin of the pre-existing Core Valve ( Movie 2). Final Aortic root angiography showed mild Aortic regurgitation ( Movie 3). After the intervention, puncture site was sutured by prepared Proglide device.

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