August 9th 2016 Structural Heart Live: ND, 89 yr.F Presentation: Worsening dyspnea on exertion NYHA class III & fatigue PMH: Severe AS, HTn, HPL, Paroxysmal A Fib, H/o TIA, Reformed smoker, Breast Ca, s/p left lumpectomy and radiotherapy, Hypothyroidism Medications: Aspirin, Synthroid, Lovastatin, Lasix, Amiodarone TTE (7/12/16): Severe valvular AS; PG/MG= 76/48 mmHg, Doppler valve area = 0.76 cm2, Ao peak velocity = 4 m/s, LVEF 63% EKG: Sinus bradycardia with prolonged PR interval Cath 02/4/16 and course: Non-obstructive CAD, Severe AS, and mild AI, S/P BAV (20mm balloon)

August 9th 2016 Structural Heart Live Case Contd…. CT Angiography: The bilateral lower extremity peripheral arterial accesses have minimal diameters 5.6mm STS risk mortality: 10.4% EuroScore II risk: 7% Logistic Euroscore mortality: 8.37 % Course: Patient is determined to be high risk for surgical AVR due to history of breast CA (radiation), age and frailty Plan Today: Patient is planned for Evolut-R CoreValve TAVR (29 mm) via percutaneous femoral access and conscious sedation. SLIDE TO BE EDITED BY JK

Transthoracic Echo Severe valvular aortic stenosis; peak gradient = 76 mmHg, mean gradient = 48 mmHg, Doppler valve area = 0.76 sq cm, Ao peak CW velocity = 4.3 m/sec, LVEF 63%

CTA: Aortic Annulus Annulus Max: 25.2 mm Min: 23.6 mm Mean: 24.4 mm Perimeter = 76.6 mm Area = 4.41 cm2 Annular angle = 31° Annulus diameter: 25.2x 23.6mm Annulus perimeter: 76.6mm Annulus angle: 31°

CTA: SOV and STJ Sinus of Valsalva Mean Diameter : 30.6 mm Sino-tubular junction height (above annulus) : 19.4 mm Ascending aorta : 34 mm 29.9 mm 30. 6mm 31.2 mm RCA: 18.7 mm LM: 16 mm

CTA: Access – 3D

Access: Iliac and Common Femorals Rt CIA: 5.7mm Lt CIA: 6.2mm Rt CFA: 6.7mm Lt CFA: 6.8mm Calcific Left CFA

Our Patient: 24.4 mm 76.6 mm 30.6 mm 19.4 mm 34 mm

Summary of Case - 89 year old female - NYHA Class III - TTE: AS – mean gradient 48 mmHg STS mortality: 10.4% EuroScore II mortality: 7 % Logistic Euroscore mortality: 8.37 % Course: Patient is determined to be high risk for surgical AVR due to history of chest radiation, age and frailty For 29 mm CoreValve Evolut R via percutaneous femoral approach under conscious sedation.