TWilliam2019
Guru
procedure: WOULD 33361 BE CORRECT?
#1 transcatheter aortic valve replacement with a 29 mm Medtronic Evolut Pro bioprosthetic valve DL left femoral arterial access
#2 cerebral protection with the sentinel device via right radial artery
Surgeon: DR R MY DR
interventional cardiology: Dr. S
Intraoperative findings:
-Intraoperative transthoracic echo: Performed by Dr. H. Please see his official dictation for those results.
-Mean gradient native aortic valve: 50 mmHg
-LVEDP: 5 mL mercury
-mean gradient bioprosthetic aortic valve: 8 mmHg
-paravalvular leak: Not present
-pericardial effusion: Not present
-peripheral vascular findings: Pre-intervention on the iliac artery was performed by Dr. B in order to achieve access via the left femoral artery. We see his official dictation for those results. At the completion of the procedure, focal external iliac dissection was identified and stented by Dr. B. This was not an unexpected finding nor was intervention surprising. Iliofemoral runoff revealed severe chronic peripheral arterial disease involving the left SFA with collateralization being identified distally. Again, please see Dr. B official dictation for conduct of this aspect of the procedure.
Specimens: None
estimated blood loss: 20 mL's
blood replaced: None
drains: None
implants: Transcatheter bioprosthetic aortic valve as described
condition at completion of procedure: Guarded
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite and placed on the operating table where he underwent monitored anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the procedure to be performed. Antibiotics given prior the incision.
Dr. B scrubbed into the case at this point. Bilateral femoral arterial access was achieved by Dr. B and balloon angioplasty of the left femoral artery was performed. Again, please see his official dictation for those results.
Preprocedural transthoracic echo was performed by Dr. H.
Once that was completed, a right radial artery was accessed. Guidewire was advanced into the aortic arch under fluoroscopic guidance. The sentinel device was then deployed with possible basket being positioned within the innominate artery and the distal basket being positioned within the left carotid artery.
The patient had a permanent pacemaker and therefore, central venous access was not obtained. Pigtail catheter was placed to the right femoral artery and advanced into the aortic root and positioned within the noncoronary sinus.
Pre-closure of the left femoral artery was then performed with deployment of 2 pre-closure devices. The 6 French sheath which and been placed by Dr. B was upsized to an 8 French sheath. Using the a.l. 1 catheter, a soft-tipped from the wire along with the catheter was advanced into the aortic root. The native aortic valve was then crossed and the aorta 1 catheter was advanced into the left ventricle. The Terumo catheter was exchanged for a J-wire. The a.l. 1 catheter was exchanged for a pigtail catheter. Hemodynamics were then taken with findings as described above. Once this was completed, the safari wire was deployed within the left ventricle. It should be noted, that the patient was heparinized with ACT greater than 300 seconds at this point.
Serial dilation of left femoral artery was then performed. The Medtronic in-line sheath was then placed over wire and advanced in a Seldinger technique into the femoral artery. It was then advanced through the vascular system across the aortic arch, eventually carefully navigating across the native aortic valve. Once in position, and aortic root shot was taken with parallax removed, confirming appropriate position. The patient was then paced at 120 beats per second and the valve was deployed to 80%. Transthoracic echo was performed which showed excellent positioning and no paravalvular leak, with a low mean gradient. The valve was then completely deployed with final transthoracic echo performed with findings as described.
The in-line delivery device along with the safari wire was pulled back into the descending aorta. The sentinel device was recaptured and removed. Protamine was then delivered to reverse the effects of heparin. The in-line sheath was removed and percutaneous closure of the right femoral artery was performed. Direct pressure was also held to achieve hemostasis.
Secondary to the severe peripheral arterial disease which was known preoperatively, decision was made to perform an aortoiliac runoff. The aortoiliac runoff revealed a dissection flap within the external iliac was somewhat sluggish flow into the common femoral artery. This finding was not surprising given the patient's severe peripheral arterial disease. At this point, Dr. B scrubbed into the procedure, crossed over the aortic bifurcation and placed a stent in the proximal aspect of the external iliac artery. Please see his dictation for those official results. This achieved a much improved runoff into the common femoral and SFA. An iliofemoral runoff revealed extensive collateralization extending down the leg with reconstitution of the SFA, confirming chronic PAD. Next
All access wires and she's were removed. The patient tolerated the procedure well was transferred recovery.
#1 transcatheter aortic valve replacement with a 29 mm Medtronic Evolut Pro bioprosthetic valve DL left femoral arterial access
#2 cerebral protection with the sentinel device via right radial artery
Surgeon: DR R MY DR
interventional cardiology: Dr. S
Intraoperative findings:
-Intraoperative transthoracic echo: Performed by Dr. H. Please see his official dictation for those results.
-Mean gradient native aortic valve: 50 mmHg
-LVEDP: 5 mL mercury
-mean gradient bioprosthetic aortic valve: 8 mmHg
-paravalvular leak: Not present
-pericardial effusion: Not present
-peripheral vascular findings: Pre-intervention on the iliac artery was performed by Dr. B in order to achieve access via the left femoral artery. We see his official dictation for those results. At the completion of the procedure, focal external iliac dissection was identified and stented by Dr. B. This was not an unexpected finding nor was intervention surprising. Iliofemoral runoff revealed severe chronic peripheral arterial disease involving the left SFA with collateralization being identified distally. Again, please see Dr. B official dictation for conduct of this aspect of the procedure.
Specimens: None
estimated blood loss: 20 mL's
blood replaced: None
drains: None
implants: Transcatheter bioprosthetic aortic valve as described
condition at completion of procedure: Guarded
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite and placed on the operating table where he underwent monitored anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the procedure to be performed. Antibiotics given prior the incision.
Dr. B scrubbed into the case at this point. Bilateral femoral arterial access was achieved by Dr. B and balloon angioplasty of the left femoral artery was performed. Again, please see his official dictation for those results.
Preprocedural transthoracic echo was performed by Dr. H.
Once that was completed, a right radial artery was accessed. Guidewire was advanced into the aortic arch under fluoroscopic guidance. The sentinel device was then deployed with possible basket being positioned within the innominate artery and the distal basket being positioned within the left carotid artery.
The patient had a permanent pacemaker and therefore, central venous access was not obtained. Pigtail catheter was placed to the right femoral artery and advanced into the aortic root and positioned within the noncoronary sinus.
Pre-closure of the left femoral artery was then performed with deployment of 2 pre-closure devices. The 6 French sheath which and been placed by Dr. B was upsized to an 8 French sheath. Using the a.l. 1 catheter, a soft-tipped from the wire along with the catheter was advanced into the aortic root. The native aortic valve was then crossed and the aorta 1 catheter was advanced into the left ventricle. The Terumo catheter was exchanged for a J-wire. The a.l. 1 catheter was exchanged for a pigtail catheter. Hemodynamics were then taken with findings as described above. Once this was completed, the safari wire was deployed within the left ventricle. It should be noted, that the patient was heparinized with ACT greater than 300 seconds at this point.
Serial dilation of left femoral artery was then performed. The Medtronic in-line sheath was then placed over wire and advanced in a Seldinger technique into the femoral artery. It was then advanced through the vascular system across the aortic arch, eventually carefully navigating across the native aortic valve. Once in position, and aortic root shot was taken with parallax removed, confirming appropriate position. The patient was then paced at 120 beats per second and the valve was deployed to 80%. Transthoracic echo was performed which showed excellent positioning and no paravalvular leak, with a low mean gradient. The valve was then completely deployed with final transthoracic echo performed with findings as described.
The in-line delivery device along with the safari wire was pulled back into the descending aorta. The sentinel device was recaptured and removed. Protamine was then delivered to reverse the effects of heparin. The in-line sheath was removed and percutaneous closure of the right femoral artery was performed. Direct pressure was also held to achieve hemostasis.
Secondary to the severe peripheral arterial disease which was known preoperatively, decision was made to perform an aortoiliac runoff. The aortoiliac runoff revealed a dissection flap within the external iliac was somewhat sluggish flow into the common femoral artery. This finding was not surprising given the patient's severe peripheral arterial disease. At this point, Dr. B scrubbed into the procedure, crossed over the aortic bifurcation and placed a stent in the proximal aspect of the external iliac artery. Please see his dictation for those official results. This achieved a much improved runoff into the common femoral and SFA. An iliofemoral runoff revealed extensive collateralization extending down the leg with reconstitution of the SFA, confirming chronic PAD. Next
All access wires and she's were removed. The patient tolerated the procedure well was transferred recovery.