Transcatheter Aortic Valve Replacement

- Operator : Duk-Woo Park

Transcatheter Aortic Valve Replacement
- Operator: Duk-Woo Park, MD
Case Presentation
A 67 years old male patient was hospitalized for chest pain started 3 months ago. He has history of diabetes, hypertension, chronic kidney disease, hypothyroidism, peripheral vascular disease, Lt MCA infarction and percutaneous coronary intervention for angina pectoris. The coronary angiogram showed distal LCX total occlusion and patent mid RCA previous stent. The ECG test revealed LVH pattern and echocardiography showed severe aortic stenosis with mild LV systolic dysfunction. His EuroSCORE 1 was 45.94% and Eureoscore II was 4.60%.
Echocardiographic Findings
  1. Transthoracic echocardiography showed severe bicuspid AV stenosis with mild LV systolic dysfunction (EF=48%). Wall motion abnormalities represented ischemic insult of left circumflex artery. AV area by continuity equation was 0.55 cm©÷. Maximal trans-AV flow velocity was 4.2 m/s. Mean and peak pressure gradient were 42 and 69 mmHg, respectively.
  2. Transesophageal echocardiography showed anterior-posterior type bicuspid valve with opening limitation caused by heavy calcification and thickening. The AV annulus diameter was 22 mm.
CT Findings
  1. Annulus size on CT was about 28 x 21 mm, and perimeter was 80 mm (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 11 and 16 mm (Figure 2), respectively. The lowest diameter of right femoral artery was 5.9 mm (Figure 3).
Procedure
The annulus size by CT was 28 x 21 mm and annulus area was 472 mm©÷. After discussion, we decided to implant Evolut R 29 mm. A 6 Fr sheath and temporary pacemaker were inserted through left femoral vein. And a 7 Fr sheath were inserted through left femoral artery and an 8 Fr sheath was inserted through right femoral artery, and then we dilated right femoral artery with Ultimun 14Fr so we could perform the procedure sheathlessly. Next, we expanded AV site with an 18mm sized balloon. Under fluoroscopy control, an Evolut R 29 mm prosthesis 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 Evolut valve with trivial AR ( Movie 2). After the intervention, puncture site was sutured by prepared one Proglides.

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