Trans-femoral Transcatheter Aortic Valve Implantation for severe ASR

- Operator : Seung-Jung Park

Trans-femoral Transcatheter Aortic Valve Implantation for severe ASR
- Operator: Seung-Jung Park, MD
Case Presentation
A 83 year-old female patient was admitted with recently aggravated dyspnea (NYHA III). She had a medical history of hypertension, hyperlipidemia. Her coronary angiography showed diffuse, intermediate stenosis at dLCX and other vessels were nearly normal. Diagnosed as severe AS and moderate AR, we planned to perform TAVI for this patient. His logistic EuroSCORE and STS score was 41.7% and 4.2%, respectively. Peripheral arteries were suitable for transfemoral approach. ( Movie 1)
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AS, moderate AR with moderate LV dysfunction (41%). AV area by continuity equation was 0.40 cm©÷. TransAV maximal velocity was 6.1 m/s. Mean and peak pressure gradient were 150 and 93 mmHg.
CT Findings
  1. Annulus size was measured 22.6-28.7 mm and perimeter was 79.7 mm by CT (Figure 1).
  2. Distance from annulus to LCA and RCA ostium were 11.9 mm and 17.0 mm, respectively (Figure 2).
Procedure
Because the annulus size was measured 22.6-28.7 mm, we selected the 26 mm Edwards SAPIEN XT valve for implantation. Under general anesthesia, 6 Fr sheath and temporary pacemaker were inserted through 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 stiff wire, and then predilatation of the stenotic AV was done with a 20 x 40 mm Z-MED II transfemoral balloon under rapid ventricular pacing and aortic root angiography ( Movie 2). And then, under TEE and fluoroscopic guidance, a 26-mm Edwards SAPIEN XT prosthesis was deployed by inflating the balloon up to 23.5-mm, regarding the large amount of calcium and the shorter perimeter than the reference ( Movie 3). As fluoroscopy showed moderate AR ( Movie 4), additional balloon dilatation up to 24.5-mm was done ( Movie 5). After balloon dilatation, final fluoroscopy revealed well positioned Edwards Valve with much reduced AR amount, grading mild AR ( Movie 6). Then, we removed Edward 18 Fr sheath, checked the left peripheral angiogram and sutured punctured site by prepared two Proglide devices.

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