# percutaneous  balloon valvuloplasty



## Bonnie Owen (Sep 22, 2013)

A new Dr. has come on board along with new procedure, percutaneous balloon valvuloplasty. I apologize for the length of the 2 reports. My questions are can both the selective coronary cineangiography done before the valvuloplasty and the rt and lt hc, with temp ppm, ascending aortograpy be done during the valvulplasty? What I am thinking is yes to the selective coronary before as dx but no to the rt and lt hc during the procedure due to mapping? Please give me guidance. Thank you very much.

Date of procedure: 08/21/13
Indications: The patient is a pleasant 79 year old female who is here with cardiogenic shock and critical aortic valve stenosis here for coronary angiogram PRIOR to POSSIBLE surgical valve replacement.
Procedure performed: Selective coronary cineangiograpy
Procedure in detail: The patient to the was brought to the cardiac catch lab intubated and ventilated on 50 mcg/minute of Neo-Synephrine. She was stable hemodynamically on these settings……….(I am not typing all of this for the question, if needed; I will go back and fill in).
Left Ventriculography: LV was not performed during the procedure since we did not cross the aortic valve.
RC artery: The right coronary artery arose normally from the right coronary cusp. It was technically a medium caliber vessel. It was dominant giving rise to a medium size RPDA and RPLB, there is some mild plaque. No significant angiographic stenosis. The dorsum of the right coronary artery has a 20% stenotic area without pressure dampening. The mid RCA has a tubular 30% to 40% stenosis. 
LM artery: Left main coronary artery arose normally from the left main coronary cusp. Technically medium caliber vessel that had a 30% RCA lesion without pressure dampening.
LC artery: LC coronary artery arises normally from the LM artery. It is medium caliber that gives rise to 1 large obtuse marginal brank. The left circumflex artery system has some mild plaquing without significant angiographic stenosis.
LAD: LAD artery arises normally from the LM. Medium caliber vessel with type 2 configuration going down to the apex.  It has 30% mid portion tubular stenosis. It gives rise to a large diagonal branch. It has 30% proximal stenosis.
Assessment: A 30% ostial LM lesion, A 40% mid RC lesion, A 30% mid LAC descending lesion, A 30% proximal first diagonal lesion and a 30% RC lesion.
Plans: Discussed further options with the patient and the family regarding options including surgical AVR vs. TAVR including a balloon aortic valvuloplasty as a bridge for her TAVR.


Date of procedure: 08/28/13
Procedure: Cardiac Cath
Indications: The patient is a pleasant 79 year old female with critical aortic valve stenosis, cardiogenic shock requiring inotropic support here for balloon aortic valvuloplasty as a bridge for her transthoracic aortic valve replacement.
Consent :…….( not typing for the question)
Procedure performed: Rt cath, temporary pacemaker insertion, lt hc, ascending aorta,  successful aortic valvuloplasty using Z-Med 14 mm balloon with decrease in the mean valve gradient from 65 mm to 42 mm.
Procedure: Patient brought to the cardiac cath area in fasting nonsedated state. The patient was on Neo-Synephirne drip for blood pressure support. Blood pressure, heart rate and oxygen saturation levels were checked at the beginning and at the conclusion of the procedure. Bilateral groins were appropriately scrubbed and draped in the usual fashion. After infiltrating the rt groin with 20 ml of 1% lidocaine. The rt common femoral vein was accessed in the modified Seldinger technique and 4 French Micro-Access kit, then 8 French femoral venous sheath was inserted. Also, the rt common femoral artery was accessed in the modified Sedlinger technique and a 4 French Micro Access kit and then dilatation was performed with a 6 French and an 8 French sheath dilator and then 12 French femoral arterial sheath was inserted without difficulty. Also, after infiltrating the lt groin with 20 ml of 1% lidociane the lt common femoral artery was accessed in modified in Seldinger technique and a 4French Mico-Aceess kit and then a 6 French femoral arterial sheath was inserted without difficulty. We initially processed with the 7.5 French Swans Ganz catch to perform a right heart cath to obtain the hemodynamics and ? consideration. Then the Swan Ganz was removed and then a 8 French balloon tipped pacemaker wire was placed in the apex of the RV with proper pacing threshold at 0.2 MA. Then we went on the left side where a 6 French pigtail cath was inserted in the ascending aorta. Then we used the left atrial sheath, we went with 6 French diagnostic cath over a J wire and then the wire was removed and showed the glide wire to cross the aortic valve down to the LV with the JR4 introduced to the LV and the glidewire removed and then in exchange length J wire was introduced with the JR 4 removed and then pigtail cath inserted all the way down with the wire removed. Prior to the crossing of the glidewire, pt. received total of 6000 units of intravenous heparin with SD mode on 300 seconds at all times. The transaortic valvular gradient was achieved and performed reviewing mean gradient of 65 mm Hg and LVDP of 26mm Hg. Then we went with a long 0.035 Amplatz superstiff wire with proper wide curve to minimize LV perforation and then the pigtail removed and then we went with a 14mm Z-Med balloon for which we performed an aortic valve valvoplasty times 1, inflation was 15ml of diluted contrast. Then the balloon was removed and then Amplatz superstiff wire was exchanged for a pigtail again. Again, invasive measurements with the 2 pigtails revealed now decrease of the mean gradient to 42mmHg. LVDP was up to 34 mm Hg. Meanwhile, echocardiographic images revealed AI to be from mild to moderate at best. The mean gradient also was echographically corresponding with invasive measurement of 42mm Hg. Of note at the baseline, the mean gradient of the echocardiogram was 65 mmHg at the time. Also, we did a baseline ascending aortography with a 6 French pigtail initially revealing mild eccentric AI initially with normal size aortic root and mildly dilated ascending aorta. There was no evidence of dissection at that time. At the completion of the procedure, a repeating ascending aortography was performed as a final one revealing a still eccentric AI without evidence of dissection in the ascending aorta. At that time, all pigtails and pacemaker wires were removed.  Repeat SVT was 220 seconds so the sheaths were sutured in to be removed in the Intensive Care Unit using the manual pullout protocol as the SVT is less than 170 seconds. The patient was then transported back to the ICU still apparently stable. At that time, she was completely off Neo-Synephrine drip and maintaining excellent hemodynamics. Neurologically, the patient was awake and moving all upper and lower extremities.
Impression: Successful balloon aortic valvoplasty with 14mm Z-Med balloon with decrease of the mean aortic valve gradient from 65 mmHg to 42 mmHg with increase from a baseline of mild to moderate aortic insufficiency at best. Elevated pulmonary artery pressure with estimated pulmonary artery pressure of 65/22 mmHg. Mildly dilated ascending aorta.


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## lward (Oct 10, 2013)

were you able to get an answer to your question?  I would like to know if you are able to also code/charge for temporary pacer and IABP insertion.  Both are removed at the end of the case.


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