Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve on Bicuspid AS

- Operator : Seung-Jung Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN XT Novaflex Plus Valve on Bicuspid AS

- Operator: Seung-Jung Park, MD

Case Presentation

A 75 years-old female was admitted with effort chest pain and dyspnea (NYHA III) for over 6 months. She had had a medical history of hypertension and diabetes mellitus and recently was diagnosed as severe AS. As her coronary angiography showed single vessel disease on mid LAD, we planned to do PCI and TAVI for this patient. Mid LAD was treated with Resolute Onyx 3.5 x 22mm Stent prior to TAVI and her logistic EuroSCORE was 4.81%.

Echocardiographic Findings

Transthoracic echocardiography showed severe degenerative AS, mild AR and concentric LVH with preverved LV systolic function (EF=63%). AV area by continuity equation was 0.64 cm². TransAV maximal velocity was 5.0 m/s. Mean and peak pressure gradient were 100 and 61 mmHg, respectively. Transesophageal echocardiography showed the opening limitation of AV because of severe calcification and degenerative thickening. AV was bicuspid and annulus size measured by TEE was 22 mm.

CT Findings

Annulus size by CT was 23.6-28.9 mm and perimeter was 80.8 mm (Figure 1). Distance from annulus to LCA and RCA ostium was 11.0 and 17.1 mm, respectively (Figure 2). The right peripheral artery was enough to access. The minimal diameter of right femoral artery was 8.0 mm (Figure 3).

Procedure

Because the annulus size by TEE and CT was 23.6-28.9 mm, we planned to use 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. 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. Right 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 23 mm x 40 mm Edwards transfemoral balloon under rapid ventricular pacing and aortic root angiography was done ( Movie 1). And then, under TEE and 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, half and half at the annulus level, and was successfully deployed by inflating the balloon under rapid ventricular pacing ( Movie 2). After valve implantation, final fluoroscopy showed well positioned Edwards valve with mild AR ( Movie 3). And then, we removed Edward 18 Fr sheath, checked the left peripheral angiogram and sutured puncture site by prepared two Proglide devices.