Methodist Hospital Cardiac Catheterization Report

Transcription

1 Methodist Hospital Cardiac Catheterization Report Patient Name: Diaz, John R Patient ID: RH Study Date: 6/6/2016 Gender: M Priority: ROUTINE Height: 68.9 in BP: 145/82 DOB, Age: 11/8/1953, 62 yr Weight: lb HR: 89 BSA: 1.95 m² Inpatient History/Clinical: Abdominal aortic aneurysm, Congestive failure, Congestive cardiomyopathy, COPD Procedure: Trancatheter Aortic Valve Replacement (TAVR) Previous Study: Date: 03/31/2016 Stage 1 AO LV RA RV MPA RPA 19 PCW AO AODsc SVC IVC 76 RA 78 RAHi 78 RALo 77 MPA 78 Shunts & Resistances Qs 3.4 l/min Qs I 1.74 l/min/m² Rs (WU) Rs I (WU) 78% 76% 15/ % 15/ / / / / /10 13 HR 80 bpm Hgb 13.2 g/dl VO2 128 ml/min VO2 I ml/min/m² CAo % CVo2 77 % PAo2 78 % O2cap ml O2/l SAC ml O2/l SAC diss O ml O2/l MVC ml O2/l MVC diss O ml O2/l PAC diss O ml O2/l Fick CO 3.4 l/min Fick CI 1.74 l/min/m² Critical Aortic Valve Stenosis Pre Procedure. Valve Areas / Gradients Peak Mean Areas (mmhg) (mmhg) (cm²) AV Arterial Blood Gases ph 7.3 PaO2 93 mmhg PaCO2 32 mmhg HCO meq/l BE -0.9 meq/l Cath Lab Report Page 1

2 Stage 2 AO LV MPA PCW HR 85 bpm Hgb 13.2 g/dl VO2 175 ml/min VO2 I ml/min/m² CAo2 98 % CVo2 78 % O2cap ml O2/l SAC ml O2/l MVC ml O2/l Fick CO 4.87 l/min Fick CI 2.5 l/min/m² AO 98 SVC 78 Valve Areas / Gradients Peak Mean Areas (mmhg) (mmhg) (cm²) AV Shunts & Resistances Qs 4.87 l/min Qs I 2.5 l/min/m² Catheterization Report TAVR Percutaneous The patient is a(n) 62 yr old Hispanic male. Cardiac/Peripheral Indications : Cardiac Cath Status: Elective. Heart failure was cited as a reason for the diagnostic cath procedure. The patient has a history, physical findings, or noninvasive evidence of valvular heart disease. Two cardiac surgeons have independently examined the patient face-to-face to determine the patient's suitability for the procedure. The patient is under care of the heart team. It is furnished in a hospital with appropriate infrastructure for this procedure. The heart team and hospital are participating in a prospective, national, audited registry. The patient is not an operative candidate and has critical/severe aortic stenosis. The patient has congestive heart failure. Consents/Checklists: The patient verbally verified their identification when possible. The patient was identified by hospital ID band. Informed consent was obtained from patient or family, as appropriate. The procedure indications, including possible risks, outcomes, benefits and alternative treatment(s) have been explained to the patient and/or legal guardian/surrogate at length by the performing physician. The patient or family, as appropriate, consents to the sedation plan, alternatives, and risks including the need for possible resuscitation. The patient has been reevaluated immediately before the procedure and is still fit for the planned sedation and procedure. The history and physical paperwork has been obtained. The patient has had an EKG. The patient or family, as appropriate, verbalized understanding of procedure. A pre-procedure "Time Out" was performed. All team members, including physician are present. Verification of the patient's identity, utilizing the double identifiers (Name and DOB) has been accomplished. Agreement on the procedure to be performed has been accomplished. Procedure: The left femoral artery was catheterized using a percutaneous technique. A 8 Fr. sheath was placed in the artery. The arterial sheath was sized up to 11 Fr. The right femoral vein was catheterized using a percutaneous technique. A 6 Fr. sheath was placed in the vein. The patient was brought to the operating room and placed upon the OR table in a supine position. The patient underwent an uneventful induction of general anesthesia, and endotracheal intubation performed by the cardiac anesthesiologist. All pressure points were carefully and appropriately padded. Perioperative antibiotics were administered in a timely fashion. Swan-Ganz catheter and radial arterial line were inserted. TEE was performed by non-invasive cardiologist. The aortic valve annulus was measured at 24 mm. There was critical aortic stenosis and mild aortic regurgitation. The patient has a New York Heart Association (NYHA) functional class of 4. The patient was now broadly prepped and draped in a normal sterile fashion from the chin to the bilateral ankles. The left common femoral artery and vein were accessed percutaneously, and a 6 Fr. arterial and 7 Fr. venous sheath were inserted. Using the arterial sheath, a pigtail catheter was inserted around to non-coronary cusp. Through the venous

3 sheath, a transvenous pacemaker was inserted out to the apex of the right ventricular cavity. Excellent pacing and thresholds were obtained. A 14 Fr. Edwards sheath was subsequently placed in the aorta. The valvuloplasty balloon was removed and a ( )mm Sapien transcatheter heart valve was now approximately oriented and crimped onto the delivery system. Appropriate placement of the valve on the sheath was confirmed. The delivery system was now brought through the sheath over the guidewire and maneuvered around the aortic arch using a retroflexed feature. The valve was now positioned across the native aortic valve. A 28mm Edwards Sapien S3 was now crimped onto the commander delivery system. The patient remained hemodynamically stable with this in place. Appropriate positioning was obtained with a combination of Paieon, fluroscopy, aortic root injection, and TEE. Using biventricular pacing, the valve was deployed. Transesophageal echocardiogram confirmed a well-seated bioprosthetic valve. No paravalvular regurgitation was apparent. The delivery system was now removed from the patient. The guidewire was maintained across the iliofemoral system to maintain access in case of an inverted injury during sheath removal. The sheath was removed under fluoroscopic guidance back to the common iliac artery. Angiography of the iliac system distal to the balloon showed no evidence of dissection or injury. The sheath was fully removed along with the extra stiff guidewire. There was an excellent pulse distally. Repeat angiography confirmed excellent distal flow. The wound was now irrigated with warm saline and closed in layers. Staples followed by a sliver nitrate dressing was applied. The patient tolerated the operation well and was transferred to the cardiothoracic ICU in stable condition. Post-procedure, the arterial sheath was pulled and a closure device was deployed. Estimated blood loss 101 to 150 ml Post-procedure, the venous sheath was pulled and pressure was applied to the site. At the completion of the study, the catheters were removed, hemostasis was maintained, and a dressing was applied. Conclusions: The patient is an62 yrold male with a known history of hypertension, hyperlipidemia, atherosclerotic heart disease, status post multiple coronary interventions in the past, CVA with residual hemiparesis has been experiencing New York Heart Association class 3-4 symptoms of congestive heart failure. He was referred for transcatheter aortic valve replacement. All risks benefits alternatives were discussed with the patient including but not limited to death, myocardial infarction, stroke, vascular injury and need for repair, need for coronary stenting, need for transfusion,need for permanent pacemaker, valve embolization and paravalvular leak requiring multiple valves as well as infection and renal failure. The patient family understood this completely. The procedure was to be performed under conscious sedation. Arterial access was obtained via the left femoral artery and 2 Perclose's were deployed. An 11 Fr. sheath was placed and was sized up to a 14 Fr. Edwards E sheath. In the distal left femoral artery a 7 Fr. sheath was placed. Via the 14 Fr. Edwards E sheath the native valve was crossed using an AL-1 catheter and a Lunderquist wire was placed in the ventricle. Over the Lunderquist wire a 26 mm Edward's E been valve was advanced and positioned using fluoroscopic guidance. Valve was deployed while pacing at 160 bpm. There was mild-tomoderate paravalvular leak post deployment and therefore postdilatation with an additional 2cc was performed. There was trivial if any paravalvular leak noted post. The Edwards E sheath was then withdrawn to the left external iliac artery and via these 7 French sheath in the common femoral artery and a by 6 mm balloon was inflated for hemostasis as the 2 Perclose's were tied off. After prolonged dilatation at the arteriotomy site was no evidence of dissection or extravasation. There was excellent distal runoff. Patient was hemodynamically stable was transferred to the surgical ICU. The case was discussed with the patient's family. Plan: Continue medical management.the findings of the cardiac catheterization suggest that medicaltherapy is the recommended form of treatment.this patient will have a TVT Registry DataCollection Form completed and be entered into the STS/ACC TVT Registry Interpreting MD 1 Cath Procedure Description: FLTime: FLDose: CINEDose: TotalDose: IntFLTime: TotalRuns: 4 Percutaneous entry: Right Femoral artery Closure Device: Suture

4 Cath Lab Report Page 4 Complications: The patient tolerated the procedure with no complications Post Procedure Pulses Bilateral DP: 3+ Bilateral PT: 3+ Staff: Cardiac Cath Physician Tony Malone, MD Circulating Nurse Bobby Brooks, RN Interventionalist Michelle Cohen, MD Radiologic Tech Nicholas Saint, RT Scrub Staff Jeanette Williamson, RN Monitoring Staff Nicole Watts, CVT Cath Lab Report Page 4

5 Methodist Hospital Cardiac Catheterization Report Patient Name: Diaz, Johnny Patient ID: RH Study Date: 6/6/2016 Gender: M Priority: ROUTINE Height: cm BP: 138/67 DOB, Age: 11/8/2013, 2 yr Weight: kg HR: 85 BSA: 0.53 m² Outpatient Procedure: Left and Right Heart Catheterization w/wo LV Angiography, Angioplasy and Stenting of Aortic Coarctation Stage 1 AO AOAsc AODsc LV RA RV MPA RPA PCW / / / % 83/55 62 AO 98 AOAsc 98 AODsc 97 SVC 77 SVCHi 77 IVC 79 RA 77 RV 79 MPA 79 RUPV 98 Shunts & Resistances Eff Flow (Qep) 1.42 l/min (Qep) I 2.68 l/min/m² Qp 1.52 l/min Qp I 2.87 l/min/m² L-R Shunt 0.1 l/min % L-R 6.58 % Rp 3.29 (WU) Rp I 1.74 (WU) TPR 8.55 (WU) TPRI 4.53 (WU) HR 99 bpm Hgb 13.2 g/dl VO ml/min VO2 I 98 ml/min/m² CAo % CVo % PAo2 79 % PVo2 98 % O2cap ml O2/l SAC ml O2/l MVC ml O2/l. PAC PVC Fick CO Fick CI 77% 79% 15/ ml O2/l ml O2/l 1.45 l/min 2.74 l/min/m² Valve Areas / Gradients Peak Mean Areas (mmhg) (mmhg) (cm²) AV / /12 19 Arterial Blood Gases ph 7.3 PaO2 93 mmhg PaCO2 32 mmhg HCO meq/l BE -0.9 meq/l Diaz, Johnny 06/06/2016 RH Cath Lab Report Page 1

6 Diaz, Johnny 06/06/2016 RH Stage 2 AOAsc AODsc AOAsc 98 AODsc 98 SVC / /61 77 Post Coarctation Repair Stent VO ml/min VO2 I 98 ml/min/m² CAo2 98 % CVo2 78 % Situs Solitus, Levocardia. Normal (atrioventricular concordance, normally connected great arteries). Aortic arch anomalies. Coarctation of aorta (COA). Diaz, Johnny RH /8/ yr 6/6/2016 HISTORY: Diaz, Johnny is a 2 yr old M with discrete coarctation of the aorta and left ventricular hypertrophy presenting for diagnostic study and intervention. PROCEDURE: Informed consent was obtained prior to the procedure after discussing the pros and cons of all reasonable alternatives. The patient was brought to the cardiac catheterization laboratory and placed under general anesthesia by the cardiac anesthesia service. The airway was managed with an ETT. A pre-procedural time out was performed. The bilateral groins were prepped and draped in the usual sterile fashion. Access was not difficult using Sonosite. Using a modified Seldinger technique, a 5F short sheath was placed in the right femoral vein and a 4F short sheath was placed in the right femoral artery. After obtaining access, the patient was heparinized to maintain ACTs greater than 220 seconds. At the beginning of the case we performed antegrade right heart catheterization using a 5F end-hole wedge catheter and a retrograde left heart catheterization using a 4F multi-marker pigtail catheter. After obtaining baseline oximetry and hemodynamics, we performed aortic angiography in biplane projections. After imaging the coarctation, we positioned a Amplatzer SuperStiff wire in the right subclavian artery retrograde from the aorta. The arterial sheath was upsized to a 9F flex sheath and advanced across the coarctation into the distal aortic arch. A 36mm Max LD stent was hand-mounted onto a 16-4 Balloon-in-balloon (BIB) catheter. The stent was advanced to the end of the long Diaz, Johnny 06/06/2016 RH

7 Diaz, Johnny 06/06/2016 RH arterial sheath and positioned at the level of the coarctation. The stent was uncovered without difficulty and the position was confirmed with small hand injections through the long sheath. The inner balloon was inflated to [5 atm] and position was again confirmed by small hand injection. The outer balloon was inflated to 6 atm and the stent was fully deployed across the coarctation. Due to residual narrowing at the mid-portion of the stent, we performed post-dilation using a 18-2 Atlas Gold. A cut pigtail catheter was then advanced across the coarctation and pressures were measured above and below the stent simultaneously. The wire was removed and a final angiogram was performed through the cut pigtail. At the end of the case, ropivacaine was infused for additional analgesia. Sheaths were pulled and hemostasis was obtained by manual pressure. There was no hematoma and no pulse loss. The patient was extubated in the cath lab and transferred to the cath recovery unit in stable condition. Complications: none. Total fluoroscopy time: 10 min Total contrast used: 20 ml Estimated Blood Loss: 20 ml Angiography a. A 3D rotational angiography was performed with a power injection in the ascending aorta with RV pacing. Angiography showed a mildly dilated ascending aorta with a normal transverse aorta. There is a Left aortic arch with normal branching pattern of the head and neck vessels. There is severe discrete coarctation of the distal arch with normal caliber descending aorta. There are multiple collaterals seen on this injection b. In straight AP and lateral projections, a multi-marker pigtail catheter has been advanced retrograde across the coarctation into the distal aortic arch. Power injection into the distal aortic arch demonstrate mildly dilated ascending aorta with a normal transverse aorta. There is a Left aortic arch with normal branching pattern of the head and neck vessels. There is severe discrete coarctation of the distal arch with normal caliber descending aorta. There are multiple collaterals seen on this injection. IMPRESSION: Diaz, Johnny is a 2 yr old M with discrete coarctation of the aorta and left ventricular hypertrophy presenting for diagnostic study and intervention. 1) Normal baseline cardiac index. 2) Severe juxtaductal coarctation with peak-to-peak gradient of 30 mmhg gradient. 3) Coarctation stented primarily with 36 mm Max LD and post-dilated using 18 mm Atlas Gold with significant angiographic improvement and reduction in peak-to-peak gradient to < 10mmHg. 4) No complications. Interpreting MD 1 was present throughout the entire case. cc: primary cardiologist and primary care Interpreting MD 1 Diaz, Johnny 06/06/2016 RH