Transcatheter Aortic Valve Implantation with Edwards SAPIEN XT Valve in Octogenerian Patient

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with Edwards SAPIEN XT Valve in Octogenerian Patient

- Operator: Seung-Jung Park, MD

Case Presentation

A 80 year-old female admitted to our hospital for TAVI procedure. She has been suffered from dyspnea (NYHA class III) and chest discomfort for 2 years and was diagnosed as severe AS and mild AR. She had medical history of hypertension, hyperlipidemia and received MVR due to severe MS 20 years ago. Her logistic EuroSCORE was 41.2 %. Her coronary angiography was normal.

Echocardiographic Findings

Transthoracic echocardiography showed severe degenerative AS and mild AR with calcification and thickening. There was no regional wall motion abnormality and LV systolic function was reserved (EF=62%). AV area by continuity equation was 0.45 cm². TransAV maximal velocity was 5.0 m/s. Peak and mean pressure gradient were 101 and 59 mmHg. The patient was assessed as normal flow, high gradient severe aortic valve stenosis.

CT Findings

Annulus size by CT was 20.8 - 24.0 mm and perimeter was 71.5 mm. Annulus area was 393 mm2 (Figure 1). Distance from annulus to LCA and RCA ostium was 13.8 and 16.3 mm, respectively. The lowest diameter of left external iliac artery was 6.6 mm and there was no problem in vessel size and calcification (Figure 2, Figure 3).

Procedure

After discussion, 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. 8 Fr sheath was inserted through right femoral artery, and then two 8 Fr Proglide devices were placed into the right femoral artery. After removal of the sheath, 18 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 done with a 20 x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography ( Movie 1). Under fluoroscopy, 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). After valve implantation, final fluoroscopy showed well positioned Edwards Valve ( Movie 3) without significant paravalvular leakage. And then, we removed Edward 18 Fr sheath, checked the left peripheral angiogram ( Movie 4). The puncture site was sutured by prepared two Proglide devices.