Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve
- Operator: Seung-Jung Park, MD
Case Presentation
An 70 years-old male was admitted with chest pain (CCS III-IV) and dyspnea on exertion (NYHA class III) for about a year. He has a past medical history of diabetes mellitus and hyperlipidemia. His logistic EuroSCORE was 5.31%. His coronary angiography showed normal coronary artery.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AS, mild AR, mild functional MR and concentric LVH with normal LV systolic function (EF=76%). AV area by continuity equation was 0.8 cm©÷. Trans AV maximal velocity was 5.0 m/s. Mean and peak pressure gradient were 51 and 99 mmHg.
  2. Transesophageal echocardiography showed the opening limitation of AV because of severe calcification and degenerative thickening. His AV was tricuspid and annulus size by TEE was 25 mm.
CT Findings
  1. Annulus size by CT was 21.1-28.8 mm and perimeter was 82.4 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 13.6 and 14.0 mm, respectively (Figure 2). The right peripheral artery was enough to access and the lowest diameter was 6.3 mm (Figure 3).
Procedure
Because the annulus size by TEE and CT was 21.1-28.8 mm, we selected the 26 mm Edwards SAPIEN XT valve for implantation. Under general anesthesia, 7 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 18 Fr Edwards E-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 25 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 two Proglides.

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