Transcatheter Aortic Valve Implantation with the Core Valve

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Core Valve

- Operator: Seung-Jung Park, MD

Case Presentation

A 77 year-old man was admitted with dyspnea on exertion (NYHA class III) and chest pain for about one month. He has a past medical history of diabetes, porstate cancer and lung cancer. His logistic EuroSCORE was 21.1%. His coronary angiogram showed diffuse stenosis(80%) at middle to distal RCA, so we did PCI at middle to distal RCA.

Echocardiographic Findings

Transthoracic echocardiography showed very severe degenerative AV stenosis and severe concentric LVH with normal LV systolic fuction (EF=34%). AV area by continuity equation was 0.73 cm². TransAV maximal velocity was 4.0 m/s. Mean and peak pressure gradient were 42 and 65 mmHg.

CT Findings

1. Annulus size by CT was about 23.8 - 28.3mm and perimeter was 83.9mm (Figure 1). 2. Distance from annulus to LM and RCA ostium was 14.7 and 17.4 mm, respectively. The lowest diameter of right femoral artery was 7.2mm and there was no problem in vessel size and calcification (Figure 2, Figure 3, Figure 4).

Procedure

The annulus size by CT was 23.8 - 28.3mm, perimeter was 83.9mm. After discussion, we selected the 26mm sized CoreValve. 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. After removal of the sheath, 18 Fr Ultimum sheath was placed. And then, an AL 1 diagnostic catheter with a stiff wire was used to cross the aortic valve. After crossing AV, the stiff wire was replaced by a super-stiff wire, and then we did predilation using Z-MED II balloon 23mm x 4cm ( Movie 1). The 18 Fr CoreValve delivery catheter system (AccuTrak) was advanced gently into the vessel. The Core Valve crossed over AV using the super-stiff wire and deployment was done. Immediately after valve implantation, root angiography showed all coronary arteries was patent and minimal paravavular regurgitation ( Movie 2, Movie 3). Final fluoroscopy showed well positioned CoreValve ( Movie 4, Movie 5). After the intervention, puncture site was sutured by prepared three Proglides.