# Percutaneous Closure of Aortic Paravalvular Leak



## shescka (Oct 22, 2015)

*Hello a little help with the cpt for this service, all I found as possible is 33496.
I really will appreciate the help.*




Clinical Indications: severe aortic paravalvular regurgitation 
64 y/o M with h/o AVR was admitted for heart failure and found with severe aortic paravalvular leak regurgitation. Today he is referred for percutaneous closure of the aortic PVL. Procedure, its indications, possible alternatives, risks, and benefits were explained to the patient, and wishes to proceed.

Description of procedure: 
Informed consent signed and placed in chart 
Patient was intubated and general anesthesia started by anesthesia team
A transesophageal echocardiogram was performed by the noninvasive cardiology team throughout the procedure 
Intra-procedural TEE confirmed severe paravalvular leak/regurgitation 
Prepped and draped in usual sterile fashion 
2% lidocaine in right groin 
Micropuncture needle used for access right common femoral artery with the Seldinger technique 
Micropuncture canula placed 
Right iliofemoral angiogram performed, adequate access confirmed 
A regular J Wire was advanced into the ascending aorta
Micropuncture canula exchanged for a 6F 35 cm sheath 
Heparin was used for anticoagulation during the procedure and appropriate ACT levels were maintained throughout the case 
A 5F MP diagnostic catheter was advanced into the aortic root and used to try to cross the PVL defect
The MP would not cross and was exchanged for a 5F AL1 diagnostic catheter 
A 260 cm stiff Terumo wire was used to cross the defect and left in the LV
A Quick Cross catheter was advanced over the wire to be inserted into the LV but would not cross
At this point all wires and catheters were removed and the sheath was exchanged for a 8.5F SL1 over the J wire
The same AL1 with the stiff Terumo wire was inserted again and were used to cross the PVL defect again
A 4F AL1 diagnostic catheter was inserted over the stiff Terumo to cross the defect but would not go
At this point we removed all wires and catheters and a 8.5F sheath was exchanged for a 9F Torq delivery system
The same AL1 with the stiff Terumo wire was inserted again and were used to cross the PVL defect again
Multiple guiding and diagnostic catheters were used to try to go across the defect over the stiff Terumo but none of those worked
Catheters used included: 6F AL1 guiding, 6F MP guiding, 8F AL1 guiding, 4F MP, 5F MP, 5F AL1, etc. (see attached report from technician for details)
A 5F Neuron BER catheter was advanced into the LV and the stiff Terumo was exchanged for a Lunderquist wire that was inserted and coiled in the LV
The Amplatzer delivery system was advanced over the Lunderquist into the LV
Under echocardiographic and fluoroscopic guidance a 4 mm Amplatzer Duct Occluder was successfully deployed across the defect
Post-implantation TEE confirmed the severe paravalvular leak decreased to trace/mild 
All wires and catheter were removed
The R CFA arteriotomy was closed with 1 Perclose 
Procedure finished, patient stable, transferred to ICU

1. Successful Percutaneous Closure of Aortic Paravalvular Leak


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