Symptomatic severe aortic stenosis, coronary artery disease, status post CABG, hypertension on metoprolol, chronic kidney disease stage
PREOPERATIVE DIAGNOSES: Symptomatic severe aortic stenosis, coronary artery disease, status post CABG, hypertension on metoprolol, chronic kidney disease stage 3, hypothyroidism on synthyroid, congestive heart failure on bumex, familial hypercholesterolemia on statins, chronic atrial fibrillation, rate controlled, not on anticoagulation, and anemia due to chronic disease.
POSTOPERATIVE DIAGNOSES: Same as above
INDICATIONS: The patient is an 87-year-old female with extensive medical history with increasing symptomatic aortic stenosis. The lady is of sound mind and cognition and fully understands her disease processes as well as the risks and benefits of a transcatheter aortic valve replacement (TAVR) procedure. Her estimated ejection fracture is 60-65%, but she had decreased left ventricular diastolic compliance and/or increased left atrial pressure. She has been managed medically for several years by her primary care physician, cardiologist, nephrologist, endocrinologist and now by her interventional cardiology physician and cardiovascular surgeon. She was evaluated and approved by two cardiologists for the new technology Edwards device TAVR procedure and is considered a good candidate based on her current medical conditions and treatments but would be unable to withstand an open thoracotomy for an aortic valve replacement.
PROCEDURE(S) PERFORMED: Transcatheter aortic valve replacement with Edwards Intuity Elite Valve System using rapid deployment technique through a minimally invasive surgical approach. (Bovine pericardial aortic bioprosthetic valve, zooplastic.) Preceded by the placement of the new technology cerebral embolic protection system (Claret Medical Sentinel) for the prevention of a stroke as a complication of the TAVR procedures. TAVR includes an aortic valve balloon valvuloplasty, insertion of Swan-Ganz catheter, and placement of temporary ventricular pacing wire.
DESCRIPTION OF PROCEDURE: Within the operating room, the patient induced to general anesthesia, positioned, draped, and prepped sterile. Two left subclavian introducer sheaths inserted. Swan-Ganz catheter as well as temporary right ventricular pacing lead placed. Next, a left femoral arterial venous access was obtained percutaneous. A right common femoral artery was identified and accessed percutaneous, and 2 Perclose devices placed. Next, a single deflection filter was placed in the aortic arch to reduce the risk of an ischemic stroke from the release of vascular debris during the TAVR procedure. The wire was then placed to the aortic arch and following dilation, a 14-French sheath inserted centrally following systemic heparinization. The aortic valve was crossed and the delivery system comprised of a balloon expandable stent that permitted the new valve to be precisely placed under rapid deployment. A balloon aortic valvuloplasty performed. An Edwards Intuity Elite bioprosthesis valve was then implanted and secured in place with three Ethibond stitches. This was completed under rapid ventricular pacing with contrast aortography identifying the aortic annulus and delivered through this location. Additional 2 mL of contrast was used to facilitate expansion of the valve, which resulted in a well-seated valve with trivial residual paravalvular insufficiency. Catheters were extracted and hemostasis was achieved with closure of the Perclose device following removal of sheaths and catheters within the right groin. Effects of heparin reversed with protamine. An additional Perclose device was used to facilitate hemostasis at the left femoral arterial access site. With assurance of hemostasis, the patient awoke in the operating room, transferred to the cardiac intensive care for recovery and care.
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