jtb57chevy
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Would someone with TAVR knowledge help me with this note? I think the transaortic approach -33365 - is the code that best describes this, but I'd really appreciate any thoughts from those who have TAVR experience. Thanks!!!
PREOPERATIVE DIAGNOSIS: Severe aortic stenosis.
POSTOPERATIVE DIAGNOSIS: Severe aortic stenosis.
OPERATION: Transcatheter aortic valve replacement with a #26 mm Edwards Sapien heart valve, via an abdominal aortic conduit. Additional procedures transesophageal echocardiography and aortic arteriography.
DESCRIPTION OF PROCEDURE: The patient was placed in supine position on the operating room table. Antibiotics were administered according to scip protocols, and will be discontinued within 24 hours. After general endotracheal intubation, transesophageal echocardiogram probe was passed by Dr. AAA. This showed evidence of good biventricular function. There was evidence of severe aortic stenosis, with just trivial aortic insufficiency and mild mitral regurgitation. With these findings, the patient was sterilely prepped and draped in normal fashion. Percutaneously I accessed the left common femoral artery and left common femoral vein, using a Seldinger technique an 8 French introducer was placed into each of these vessels. A pigtail catheter was passed over a wire into the distal abdominal aorta. Using diluted contrast, a distal angiogram was performed to identify the anatomical position of the right common femoral artery. This was marked with a clamp externally on the skin. A cutdown was then made in the right groin to expose the right common femoral artery. The profunda branch and SFA were ensnared. The common femoral artery was then accessed with a needle. Guide wire was passed through the needle under fluoroscopic guidance, into the distal abdominal aorta. Progressive sheaths were then passed over an Amplatz extra-stiff wire under fluoroscopic guidance. However, despite the final dilator shaft being able to be brought into the distal aorta, the sheath introducer for the Sapien heart valve would not pass. There was a point of resistance in the mid iliac. For this reason, this approach was abandoned. The sheaths were removed. The common femoral artery was repaired in interrupted fashion with 5-0 Prolene suture. A distal aortogram was performed, which showed no evidence of dissection or traumatic injury to the right iliac or common femoral artery, with good runoff.
Discussion between all of the team members took place, and it was decided with Dr. YYY, vascular surgeon, to place a conduit on the mid abdominal aorta in order to gain access to the aorta for valve deployment. This part of the procedure will be fully dictated by Dr. YYY, but in brief, a laparotomy was performed. The abdominal aorta was then isolated. An area that was distal to the superior mesenteric artery and superior to the inferior mesenteric artery was controlled. The patient was systemically heparinized, a 10 mm x 30 Hemashield tube graft was sewn in an end-to-side fashion to the abdominal aorta. The Sapien heart valve sheath system was then passed thru this conduit once again under fluoroscopic guidance into the distal thoracic aorta.
At this point in the procedure, Dr. ZZZ passed a pigtail catheter through the left groin and placed it into the right coronary cusp. A temporary pacing lead was passed via the left femoral venous sheath and thresholds were checked and found to be acceptable. Dr. ZZZ then performed a root shot to determine the optimal positioning for valve deployment. Then through the Sapien sheath a straight J wire was used to cross the aortic valve. Once the valve was crossed, this was exchanged to a Lunderquist. Aortic balloon valvuloplasty catheter was then placed. With rapid ventricular pacing, a balloon valvuloplasty was performed. Echocardiography post BAV showed no evidence of aortic insufficiency. The patient remained hemodynamically stable. A 26 mm Edwards Sapien transcatheter aortic valve had been previously selected based on CT and echocardiographic measurements. It was passed easily into position across the aortic valve, once in correct position, rapid ventricular pacing was initiated and the valve was then deployed. The sheath was then withdrawn into the descending thoracic aorta. Echocardiography showed evidence of good heart function, good prosthetic valve function, and minimal central aortic insufficiency without evidence of perivalvular leak. The guidewire, sheath and temporary pacing leads were then all removed.
A right angle clamp was then placed on the Hemashield tube graft, and it was transected close to the abdominal aorta and then oversewn with 5-0 Prolene suture. With evidence of excellent hemostasis, the wound was closed with anatomic PDS and vicryl. The skin was closed with staples. The right groin wound was closed in anatomic layers of Vicryl, and the skin with Monocryl. Sterile dressing was applied. The venous and arterial sheaths in the left groin were then removed. The patient remained hemodynamically stable. All needle, sponge, and instrument counts were found to be correct, and the patient was taken to the recovery room in stable condition.
The patient had a total of 31 ½ minutes of fluoroscopy time, and 94 mL of 15% diluted contrast was administered in the case.
There were no transfusions, no specimens, and no complications.
PREOPERATIVE DIAGNOSIS: Severe aortic stenosis.
POSTOPERATIVE DIAGNOSIS: Severe aortic stenosis.
OPERATION: Transcatheter aortic valve replacement with a #26 mm Edwards Sapien heart valve, via an abdominal aortic conduit. Additional procedures transesophageal echocardiography and aortic arteriography.
DESCRIPTION OF PROCEDURE: The patient was placed in supine position on the operating room table. Antibiotics were administered according to scip protocols, and will be discontinued within 24 hours. After general endotracheal intubation, transesophageal echocardiogram probe was passed by Dr. AAA. This showed evidence of good biventricular function. There was evidence of severe aortic stenosis, with just trivial aortic insufficiency and mild mitral regurgitation. With these findings, the patient was sterilely prepped and draped in normal fashion. Percutaneously I accessed the left common femoral artery and left common femoral vein, using a Seldinger technique an 8 French introducer was placed into each of these vessels. A pigtail catheter was passed over a wire into the distal abdominal aorta. Using diluted contrast, a distal angiogram was performed to identify the anatomical position of the right common femoral artery. This was marked with a clamp externally on the skin. A cutdown was then made in the right groin to expose the right common femoral artery. The profunda branch and SFA were ensnared. The common femoral artery was then accessed with a needle. Guide wire was passed through the needle under fluoroscopic guidance, into the distal abdominal aorta. Progressive sheaths were then passed over an Amplatz extra-stiff wire under fluoroscopic guidance. However, despite the final dilator shaft being able to be brought into the distal aorta, the sheath introducer for the Sapien heart valve would not pass. There was a point of resistance in the mid iliac. For this reason, this approach was abandoned. The sheaths were removed. The common femoral artery was repaired in interrupted fashion with 5-0 Prolene suture. A distal aortogram was performed, which showed no evidence of dissection or traumatic injury to the right iliac or common femoral artery, with good runoff.
Discussion between all of the team members took place, and it was decided with Dr. YYY, vascular surgeon, to place a conduit on the mid abdominal aorta in order to gain access to the aorta for valve deployment. This part of the procedure will be fully dictated by Dr. YYY, but in brief, a laparotomy was performed. The abdominal aorta was then isolated. An area that was distal to the superior mesenteric artery and superior to the inferior mesenteric artery was controlled. The patient was systemically heparinized, a 10 mm x 30 Hemashield tube graft was sewn in an end-to-side fashion to the abdominal aorta. The Sapien heart valve sheath system was then passed thru this conduit once again under fluoroscopic guidance into the distal thoracic aorta.
At this point in the procedure, Dr. ZZZ passed a pigtail catheter through the left groin and placed it into the right coronary cusp. A temporary pacing lead was passed via the left femoral venous sheath and thresholds were checked and found to be acceptable. Dr. ZZZ then performed a root shot to determine the optimal positioning for valve deployment. Then through the Sapien sheath a straight J wire was used to cross the aortic valve. Once the valve was crossed, this was exchanged to a Lunderquist. Aortic balloon valvuloplasty catheter was then placed. With rapid ventricular pacing, a balloon valvuloplasty was performed. Echocardiography post BAV showed no evidence of aortic insufficiency. The patient remained hemodynamically stable. A 26 mm Edwards Sapien transcatheter aortic valve had been previously selected based on CT and echocardiographic measurements. It was passed easily into position across the aortic valve, once in correct position, rapid ventricular pacing was initiated and the valve was then deployed. The sheath was then withdrawn into the descending thoracic aorta. Echocardiography showed evidence of good heart function, good prosthetic valve function, and minimal central aortic insufficiency without evidence of perivalvular leak. The guidewire, sheath and temporary pacing leads were then all removed.
A right angle clamp was then placed on the Hemashield tube graft, and it was transected close to the abdominal aorta and then oversewn with 5-0 Prolene suture. With evidence of excellent hemostasis, the wound was closed with anatomic PDS and vicryl. The skin was closed with staples. The right groin wound was closed in anatomic layers of Vicryl, and the skin with Monocryl. Sterile dressing was applied. The venous and arterial sheaths in the left groin were then removed. The patient remained hemodynamically stable. All needle, sponge, and instrument counts were found to be correct, and the patient was taken to the recovery room in stable condition.
The patient had a total of 31 ½ minutes of fluoroscopy time, and 94 mL of 15% diluted contrast was administered in the case.
There were no transfusions, no specimens, and no complications.