Transcatheter Aortic Valve Implantation (Edwards SAPIEN XT Valve) with Peripheral Balloon Angioplasty

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation (Edwards SAPIEN XT Valve) with Peripheral Balloon Angioplasty
- Operator: Seung-Jung Park, MD
Case Presentation
A 76 years-old gentleman was admitted with dyspnea on exertion (NYHA class III). He has a past medical history of hypertension, dyslipidemia, cerebral infarction, prostate cancer, and old myocardial infarction. His logistic EuroSCORE was 7.57%. His coronary angiography showed patent previous stent at mid-LAD and chronic total occlusion at proximal RCA. First, we recommended open heart surgery but patient refused.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AS, mild AR, akinesia of apex, and concentric LVH with normal LV systolic function (EF=57%). AV area by continuity equation was 0.38 cm©÷. TransAV maximal velocity was 6.5 m/s. Peak and mean pressure gradient were 169 and 101 mmHg.
CT Findings
  1. Annulus size by CT was 21.9 - 27.2 mm and perimeter was 78.9mm and Annulus area was 470.4 mm2 (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 14.8 and 14.2 mm, respectively. The lowest diameter of right femoral artery was 8.3mm and there was no problem in vessel size and calcification (Figure 1, Figure 2, Figure 3).
Procedure
The annulus size by CT was 21.9 - 27.2mm, perimeter was 78.9mm. After discussion, we selected the 26mm 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. After removal of the sheath, 19 Fr Edwards E-sheath was inserted. 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 23 x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography ( Movie 1). Under fluoroscopy control, a 26-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 removal of Edward 19 Fr sheath, we checked the right peripheral angiogram ( Movie 4), and the puncture site was sutured by prepared three Proglides.

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