The report below describes a patient undergoing a transcatheter aortic valve replacement. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed.
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Date of Procedure: XX/XX/20
Referring Physician: A.M., MD
Performing Physicians: L. V., MD and S. P., DO. Both co-surgeons participated jointly in this catheter-based procedure.
Assisting Physician: S. L., MD. A second interventional cardiologist was required for this procedure due to complex anatomic factors resulting in the need for a second operator with complex catheter training.
Anesthesiologist: A. T., MD and R.S., MD
- Severe, symptomatic aortic valve stenosis
- Successful transcatheter aortic valve replacement 23 mm Sapien Ultra
- No significant paravalvular regurgitation.
- Transvalvular mean gradient was reduced from 57 mmHg to 3 mmHg
- Aortic valve pathology: Tricuspid
- Transfemoral transcatheter aortic valve replacement
- Balloon aortic valvuloplasty using an 18 mm Z-med balloon
- Ultrasound guidance for arterial and venous access.
- Perclose Proglide deployment
Indications 89 year old female with a history of severe, symptomatic aortic stenosis. The patient was evaluated by a multidisciplinary team and deemed an appropriate candidate for TAVR.
Description of Procedures:
The patient was brought to the hybrid operating room in the fasting and non-sedated state. The patient underwent monitored anesthesia care and was prepped in the usual sterile fashion. Transthoracic echocardiography was obtained for baseline assessment. Using ultrasound guidance and a micropuncture needle, the left femoral artery and left femoral vein were punctured and a 6 Fr sheath and 6 Fr sheath were, respectively, placed using the Seldinger technique. The right femoral artery was punctured and pre-close with Perclose devices was performed. Unfractionated heparin (UFH) was administered to achieve a goal activated clot time (ACT) > 250 sec. A 14 Fr E-Sheath was placed without difficulty.
A transvenous pacemaker was placed in the right ventricle and threshold testing was performed. A pigtail catheter was advanced into the aortic root and aortography was performed to confirm co-planar angles. The aortic valve was crossed with a AL1 catheter and simultaneous aortic and ventricular pressures were obtained. Next, a Safari wire was placed in the left ventricle. After aortography was performed, an 18-mm Z-med balloon was delivered. After rapid pacing started, balloon aortic valvuloplasty was performed using the Z-med balloon, which was inflated at nominal pressure, and deflated. This was removed via the sheath.
A 23 mm Sapien Ultra Valve was prepped according to manufacturer’s recommendations. The delivery system was introduced into the descending aorta and the valve was mounted onto the balloon in the usual fashion. The Sapien valve was then advanced across the stenotic aortic valve and carefully positioned during aortography. The valve was deployed during rapid pacing at 180 bpm. The delivery system was removed and transthoracic echocardiography revealed no significant paravalvular leak and a mean gradient of 3 mmHg.
The pacemaker was removed and iliofemoral aortography revealed absence of vascular complications (e.g. dissection, perforation). The E-sheath was removed and hemostasis was achieved with application of the Perclose Proglide devices. The contralateral arterial sheath was removed and hemostasis was achieved with application of a Perclose Proglide device. The venous sheath was removed and hemostasis was achieved with application of a Perclose Proglide device.
Baseline aortic valve gradient: Mean 57 mmHg Final aortic valve gradient: Mean 3 mmHg
Echocardiography: Refer to the separate TTE note for full details of the findings. Briefly, there is severe aortic stenosis at baseline. Following implant of a 23 mm Sapien Ultra valve, the gradient improved from 57 mmHg (from previous echo) to 3 mmHg. There is no significant paravalvular regurgitation. No new pericardial effusion at the conclusion of the procedure.
Estimated Blood Loss: < 50 cc
Complications: None apparent
Implantations: 23 mm Sapien Ultra Valve
Contrast: 100 cc
The patient underwent successful balloon aortic valvuloplasty and transfemoral transcatheter aortic valve replacement for severe, symptomatic aortic stenosis using a 23 mm Sapien Ultra valve. The procedure was without apparent complication.
- Transfer to the ICU in stable condition.
- Bedrest for 6 hours.
- Aspirin 81 mg daily starting tomorrow morning.
- Restart Eliquis 5 mg po BID in 6 hours if no bleeding issues.
- Transthoracic echocardiogram to be performed tomorrow to re-evaluate valvular hemodynamics