Transcatheter Aortic Valve Implantation with the Edwards SAPIEN 3

- Operator : Jung-Min Ahn

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN 3
- Operator: Jung-Min Ahn, MD
Case Presentation
A 79-year-old gentleman was admitted with dyspnea on exertion. He doesn¡¯t have a remarkable past medical history in the exception of benign prostate hyperplasia. There was no significant stenosis on the coronary computed tomography angiography. Transthoracic echocardiography showed severe degenerative aortic valve (AV) stenosis with normal LV systolic function (ejection fraction [EF) =68%). His logistic EuroSCORE was 5.48%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AV stenosis with normal LV systolic function (EF=68%). AV area by continuity equation was 0.76 cm©÷. Maximal transAV flow velocity was 5.1 m/s. Mean and peak pressure gradient were 66 and 104 mmHg, respectively.
  2. Transesophageal echocardiography showed the opening limitation of AV caused by heavy calcification and thickening. His AV was tricuspid and annulus size by TEE was 23 mm.
CT Findings
  1. Annulus size on CT was about 25 - 31 mm, and perimeter was 89 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 16 and 23 mm (Figure 2), respectively. The lowest diameter of right femoral artery was 7.9 mm (Figure 3).
Procedure
The annulus size by CT was 25 - 31 mm, perimeter was 89 mm. After discussion, we selected the 29 mm sized Edwards SAPIEN 3. Under monitored anesthesia control, 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 angiograms with pig-tail catheter, we checked proper a 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, right femoral artery was dilated and 16 Fr Edwards E-sheath was inserted. An AL 1 diagnostic catheter with a 0.035 inch amplatz stiff wire was used to cross the aortic valve. Aortic root angiography was done. Considering low calcium score of aortic valve, we planned valve implantation without predilatation. Under fluoroscopy control, a 29-mm Edwards SAPIEN 3 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 1). After valve implantation, final fluoroscopy showed well positioned Edwards valve without significant AR. ( Movie 2). After the intervention, puncture site was sutured by prepared two Proglides.

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