Transcatheter Aortic Valve Implantation with the Core Valve in a Patient with Severe Aortic Regurgitation due to Tissue Valve Failure

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Core Valve in a Patient with Severe Aortic Regurgitation due to Tissue Valve Failure

- Operator: Seung-Jung Park, MD

Case Presentation

A 84 years-old male was admitted with dyspnea (NYHA IV) for 10 days. He had undergone aortic valve replacement (Hancock II 23mm) 10 years ago due to severe AS. He had a medical history of hypertension. His logistic EuroSCORE was 18.06%. His coronary angiography showed mild coronary artery disease at proximal LCX.

Echocardiographic Findings

Transthoracic echocardiography showed severe eccentric AR and severe AS, with normal LV systolic function (EF=63%). AV area by continuity equation was 0.97 cm². TransAV maximal velocity was 3.4 m/s. Mean and peak pressure gradient were 26 and 47 mmHg. Transesophageal echocardiography showed the prolapsed and flail motion of left coronary cusp resulted in severe eccentric AR. His AV was tricuspid and annulus size by TEE was 23 mm.

CT Findings

Annulus size by CT was about 19.4 - 25.4mm and perimeter was 73.7mm (Figure 1). Distance from annulus to LCA and RCA ostium was 9.8 and 14.5 mm, respectively (Figure 2). The right peripheral artery was enough to access. The lowest diameter was 9.5 mm (Figure 3).

Procedure

Because the annulus size by TEE and CT was 19.4-25.4 mm, we selected the 23mm sized CoreValve 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 both peripheral angiogram with pig-tail catheter, we checked proper puncture site of right 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 Ultimum sheath was placed, sequentially. 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 super-stiff wire. The supra-aortic angiogram showed AR grade 3 filling the LV during diastole ( 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 was deployed. Immediately after valve implantation, root angiography showed all coronary arteries was patent and minimal paravavular regurgitation with well positioned CoreValve ( Movie 2). After the intervention, puncture site was sutured by prepared three Proglides.