CASE DESCRIPTION:
An 89-year-old man with a history of hypertension and type 2 diabetes
mellitus presented with shortness of breath and bilateral legs edema 2
weeks prior to evaluation. Severe symptomatic aortic stenosis was
confirmed in other hospital, and the patient was referred to our
institution for TAVR. Chest X-ray revealed prominent lung edema with
bilateral pleural effusion. Transthoracic echocardiography demonstrated
poor left ventricular systolic function (left ventricular ejection
fraction: 36.4 %) and tricuspid configuration aortic valve with severe
stenosis (peak velocity: 4.2 m/s; mean transvalvular pressure gradient:
41 mmHg; estimated valve area: 0.53 cm2). He was
dependent on intravenous infusion of inotropic agents, and was deemed at
high risk for surgical aortic valve replacement with predicted surgical
mortality of 8.234 % by STS-PROM (Society of Thoracic
Surgeons-Predicted Risk of Mortality) and 17.37% by EuroSCORE (European
System for Cardiac Operative Risk Evaluation-II). Multidetector computed
tomography (CT) showed a huge annulus measuring 37.9 × 27.8 mm in
diameter and an area of 831.8 mm2 (Figure 1). The
measured annulus size exceeds the upper limit of both the commercially
available self-expanding and balloon-expanding THV in our institution.
In view of the patients age and high surgical risk, the decision was
made by the heart team to proceed with TAVR by over-expansion of 29 mm
SAPIEN 3 THV.
The procedure was performed under conscious sedation and right femoral
access. Temporary pacemaker was placed in right ventricle via internal
jugular vein. A 29 mm Edwards SAPIEN S3 THV was inserted and expanded by
overfilling of the deployment balloon with 4 ml of additional volume
under rapid pacing. The post-TAVR aortography revealed a well-positioned
THV with mild paravalvular regurgitation (Figure 2). The maximal
diameter of post-deployment THV was 32.23 mm by quantitative fluoroscopy
analysis (Figure 3). The procedure was uncomplicated and there was no
new conduction disturbance requiring permanent pacemaker. The patient
was discharged 6 days after TAVR. The 1-month follow-up transthoracic
echocardiography showed well-functioning THV (peak velocity= 1.9 m/s;
mean transvalvular gradient= 7.9 mmHg; estimated valve area= 2.1
cm2) with a mild paravalvular leakage (Figure 4).