Transcatheter Aortic Valve Implantation with the Edwards SAPIEN 3

- Operator : Duk-Woo Park

Transcatheter Aortic Valve Implantation with the Edwards SAPIEN 3
- Operator: Duk-Woo Park, MD
Case Presentation
A 79-year-old woman was admitted with dyspnea on exertion. She has a history of hypertension, pulmonary tuberculosis and asthma. There was no significant coronary artery stenosis on coronary CT angiography. Electrocardiography shows normal sinus rhythm and left ventricular hypertrophy. Transthoracic echocardiography showed severe degenerative aortic valve (AV) stenosis with normal LV systolic function (ejection fraction [EF) =64%). Her EuroSCORE was 11.66%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe degenerative AV stenosis with normal LV systolic function (EF=64%). AV area by continuity equation was 0.56 cm©÷. Maximal transAV flow velocity was 5.5 m/s. Mean and peak pressure gradient were 68 and 119 mmHg, respectively.
  2. Transesophageal echocardiography showed the opening limitation of AV caused by heavy calcification and thickening. Her AV was tricuspid and annulus size by TEE was 20 mm.
CT Findings
  1. Annulus size on CT was about 22 - 24 mm, and perimeter was 72 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 13 and 13 mm (Figure 2), respectively. The lowest diameter of right femoral artery was 8.1 mm (Figure 3).
Procedure
The annulus size by CT was 22 - 24 mm, perimeter was 72 mm. After discussion, we decided implant the 23 mm sized Edwards SAPIEN 3 with 1 cc overfill. 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 one 8 Fr Proglide devices were placed into the right femoral artery. After removal of the sheath, right femoral artery was dilated and 14 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 23-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 one Proglides.

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