Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Valve

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Valve
- Operator: Seung-Jung Park, MD
Case Presentation
An 81 years-old female was admitted with dyspnea on exertion (NYHA class II-III) and syncope. She has a past medical history of diabetes, stroke and dimentia. Her logistic EuroSCORE was 17.6%. Her coronary CT angiography showed mild coronary disease. First, we recommended open heart surgery but patient refused.
Echocardiographic Findings
1. Transthoracic echocardiography showed severe degenerative AS, mid AR, moderate pericardial effusion and concentric LVH with normal LV systolic function (EF=72%). AV area by continuity equation was 0.52 cm©÷. TransAV maximal velocity was 6.0 m/s. Mean and peak pressure gradient were 144 and 88 mmHg.
2. Transesophageal echocardiography showed the opening limitation of AV because of severe calcification and degenerative thickening. Her AV was tricuspid and annulus size by TEE was 19mm (Figure 1, Figure 2).
CT Findings
1. Annulus size by CT was 16.8 - 21.4 mm and perimeter was 63.4mm and Aunnulus area was 285.9mm2 (Figure 3, Figure 4, Figure 5).
2. Distance from annulus to LM and RCA ostium was 10.6 and 14.5 mm, respectively (Figure 6, Figure 7). The right peripheral artery was enough to access. The minimal diameter was 6.89 mm (Figure 8, Figure 9).
Procedure
Because the annulus size by TEE and CT was 16.8 - 21.4 mm and annulus area by CT was 285.9 mm2, we selected the 23mm Edwards SAPIEN XT valve for implantation. Under general anesthesia, 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 right peripheral angiogram with pig-tail catheter, we checked proper puncture site of right femoral artery. 7 Fr sheath was inserted through right femoral artery, and then three 8 Fr Proglide devices were placed into the right femoral artery. Right femoral artery was dilated using dilators from 16 Fr, and then 17 Fr Edwards sheath was inserted, sequentially. An AL 1 diagnostic catheter with a 0.035 inch stiff wire was used to cross the aortic valve. After crossing AV, the stiff wire was replaced by a 0.035 inch Lunderquist super-stiff wire, and then predilatation of the stenotic AV was undertaken with a 20 mm x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography ( Movie 1). Under fluoroscopy control, a 23-mm Edwards SAPIEN XT prosthesis crimped on the delivery catheter (NovaFlex Delivery System) was placed at the best position of the aortic annulus and then it was successfully deployed by inflating the balloon under rapid ventricular pacing and aortic root angiography ( Movie 2). Final fluoroscopy showed well positioned Edwards Valve ( Movie 3). After the intervention, puncture site was sutured by prepared three Proglides.

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