I feel like I'm missing something, can someone verify it for me, appreciate it a lot


1. Aortic balloon valvuloplasty x3 across the aortic valve.
2. A 12-French side-arm sheath was placed in right femoral arteriotomy with
Perclose device. At the end of the case, Percloses were performed as well as
manual pressure given some bleeding.
3. Moderate sedation.
4. Ultrasound for vascular access.
5. Supervision and interpretation of above.
6. Left heart catheterization.
7. Left ventriculogram.

The patient is an 85-year-old, Caucasian male with recent worsening shortness
of breath, pleural effusions with severe paradoxical calcific aortic stenosis
as well as multivessel coronary artery disease. I was asked by Dr. Joseph Quan
for further evaluation for balloon valvuloplasty with likely transcatheter
aortic valve replacement in the future. Informed and witnessed signed consent
was placed in the patient's medical record. The patient understood the risk,
benefits, alternatives to balloon valvuloplasty and likely stents with Dr.
xxxxx and myself, wished to proceed with procedure. Risks include, but
are not limited to stroke, myocardial infarction, renal failure, bleeding, limb
loss, aortic insufficiency, and death.

The patient was brought to the cardiac catheterization laboratory in the
fasting state. Both groins were prepped and draped in sterile fashion.
Because of Angio-Seal and prior cardiac catheterization by Dr. xxxx on
the right, we went into the left femoral artery using modified Seldinger
technique, ultrasound and micropuncture kit. With a 6-French sheath in place,
Perclose sutures were affixed. Next, upsized to a 12-French side-arm sheath.
There was some calcium noted, however, was able to place a 12-French side-arm
sheath into the femoral artery. Next, with the Amplatz AL1 and straight wire,
we were able to cross across the valve and pressures were measured with pigtail
catheter. Next, left ventriculogram was also performed. Next, I proceeded
with placement with an Amplatz extra stiff wire into the left ventricle.
Balloon valvuloplasty was performed with a Bard true flow balloon at 20 mm up
to compliant pressure x3 across the aortic valve. Pigtail catheter on pullback

showed no changing gradient suggesting successful balloon valvuloplasty. Next,
continue with the rotablation part of the procedure. Please see Dr. xxxx note. In addition, prior to balloon valvoplasty, a pacemaker device was
placed using modified Seldinger technique and ultrasound with sheath access in
the right femoral vein and a balloon tipped pacemaker placed in the right
ventricle wire.

1. Successful balloon valvoplasty x3 across the aortic valve with no gradient
at the end of the case.
2. Proceeded with coronary stent placement.

1. The patient will have staged procedure with CSI atherectomy and balloon
angioplasty and stent placement on November 20th and will come back likely in
mid December for transcatheter aortic valve replacement when all the workup is
complete for that.
2. Groin precautions x1 week. Bed rest for at least 10 hours with Femstop in
left femoral artery.