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 74 years-old male was admitted with dyspnea on exertion (NYHA class III) for about a year. He has a past medical history of hypertension and hyperlipidemia. His logistic EuroSCORE was 4.4%. His coronary CT angiography showed mild stenosis at proximal LCx without calcified plaque.
Echocardiographic Findings
  1. Transthoracic echocardiography showed bicuspid aortic valve with severe degenerative AS and preserved LV systolic function (EF=57%). AV area by continuity equation was 0.9 cm©÷. TransAV maximal velocity was 4.3 m/s. Mean and peak pressure gradient were 39 and 76mmHg.
  2. Transesophageal echocardiography showed the opening limitation of AV and calcification was dominant in the left and non coronary cuspid. Raphe was seen between the right and non coronary cuspid and there were diffuse thickening.
CT Findings
  1. Annulus size by CT was 25.6-25.7 mm and perimeter was 79.6 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 12.0 and 17.7 mm, respectively (Figure 2). The both peripheral artery was enough to access. The lowest diameter was 10.0 mm (Figure 3).
Procedure
Because the annulus size by CT was 25.6-25.7 mm, we selected the 26 mm Edwards SAPIEN XT valve for implantation. Under general anesthesia, 6 Fr sheath and temporary pacemaker were inserted through right femoral vein, and 7 Fr sheath and 6 Fr pig-tail catheter were inserted through right femoral artery. After both peripheral angiogram with pig-tail catheter, we checked proper puncture site of left femoral artery. 8 Fr sheath was inserted through right femoral artery, and then two 8 Fr Proglide devices were placed into the left femoral artery. Left femoral artery was dilated using dilators from 16 Fr to 18 Fr, and then 20 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, predilatation of the stenotic AV was undertaken with a 23 mm 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 intervention, puncture site was sutured by prepared three Proglides.

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