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Trans-apical Transcatheter Aortic Valve Replacement for severe AS

- Operator : Seung-Jung Park

Trans-apical Transcatheter Aortic Valve Replacement for severe AS
- Operator: Seung-Jung Park, MD
Case Presentation
A 70 year-old female patient was admitted with recently aggravated dyspnea (NYHA III). She had a history of hypertension, moyamoya disease, history of cerebrovascular attack, and Alzheimer disease. Her coronary angiography showed mild coronary artery disease. Echocardiography showed severe AS and mild AR. His logistic EuroSCORE and STS score was 16.5% and 1.9%, respectively.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AS and mild AR with normal LV systolic function. AV area by continuity equation was 0.38 cm². Trans-aortic valve maximal velocity was 5.5 m/s. Peak and mean pressure gradient were 121 and 79 mmHg.
CT Findings
  1. Annulus size was measured 20.2-25.8 mm and perimeter was 71.5 mm by CT (Figure 1).
  2. Distances from annulus to LCA and RCA ostium were 10.7 mm and 13.7 mm, respectively (Figure 2).
Procedure
The annulus size by CT was 20.2 - 25.8 mm, perimeter was 71.5 mm. After discussion, we planned trans-apical TAVR with 26 mm Edwards SAPIEN XT valve as severe atherosclerosis and mobile atheroma at aortic arch and small ileofemoral arteries. Under general anesthesia, 7 Fr sheath and pig-tail catheter were inserted through left femoral and trans-apical thoracotomy was done. Because of low left main orifice and localized calcium near left main orifice, we passed the BMW wire to LAD before procedure (Figure 3). Puncture of LV apex was followed through trans-apical thoracotomy site with 8 Fr sheath and exchanged to the delivery catheter. Under fluoroscopy control, a 26 mm Edwards SAPIEN XT prosthesis crimped on the delivery catheter (NovaFlex Delivery System) and placed at the best position of the aortic annulus. Then it was successfully deployed by inflating the balloon under rapid ventricular pacing and aortic root angiography ( Movie 1, Movie 2). Final fluoroscopy showed well positioned Edwards Valve without significant paravalvular leakage ( Movie 3). And we removed delivery system and wire of LAD and closed thoracotomy site.

Comments

  • Khondaker Atiqur Rahman 2016-06-16 Is it necessary to anchor LAD wire by inflating ballon?
  • ahn jung min 2016-06-16 Thank you for your comment. I am Dr. Ahn. This patient have low coronary height and narrow sinus of Valsalva, which increases the risk of coronary obstruction. The coronary obstruction is rare, but catastrophic complication. For the rescue LM stenting in case of coronary obstruction, we kept the wire with stent in the left coronary artery before aortic valve procedure.

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