CARDIAC CATHETERIZATION TRANSCRIBED EXAMPLE REPORT
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURES PERFORMED:
1. Selective coronary angiography.
2. Left heart catheterization.
3. Left ventriculogram.
4. Selective left internal mammary artery injection.
5. Selective saphenous vein graft to right coronary artery injection.
6. Selective saphenous vein graft to the diagonal artery injection.
7. Saphenous vein graft to the obtuse marginal branch injection.
8. Percutaneous coronary intervention and stent placement of the saphenous vein graft to the ramus intermedius or obtuse marginal branch.
9. Percutaneous coronary intervention of the saphenous vein graft to the diagonal branch.
INDICATIONS FOR PROCEDURE:
1. Angina pectoris.
2. History of coronary artery disease.
3. Status post arrest with severe bradycardia and ST elevation MI.
DESCRIPTION OF PROCEDURE: The indications, risks, and benefits of cardiac catheterization and the procedure were fully explained to the patient and consent was obtained. The right femoral area was prepped and draped in a sterile technique in the usual fashion. Lidocaine 2% was used for local anesthesia. A 5 French sheath was placed in the right femoral artery using single entry technique. Using the JL4 catheter, the left main coronary artery was engaged and multiple shots were obtained. Using the Judkins right catheter, the right coronary artery was engaged and multiple shots were obtained. Using the same catheter, the LIMA to the left anterior descending artery was engaged and multiple shots were obtained. Using the same catheter, two saphenous vein grafts were engaged. Using a pigtail catheter, the aortic valve was crossed and LV pressure measurements were obtained. Left ventriculogram was performed in the RAO projection using hand injection.
PROCEDURE FINDINGS:
1. The left main coronary artery has a distal 50% stenosis.
2. The left anterior descending artery has a proximal 50-60% stenosis followed by luminal irregularities. The distal LAD fills it antegradely as well as competitively through a LIMA graft. The first diagonal branch appears to be diffusely diseased and is subtotally occluded. There is probably some competitive flow in the distal diagonal branch.
3. The circumflex artery has proximal luminal irregularities followed by diffuse segment of 70-80% stenosis.
4. The left internal mammary artery to the left anterior descending artery is patent and robustly fills the LAD.
5. The right coronary artery has patent stent in its proximal segment with diffuse luminal irregularities. There is diffuse 60-70% stenosis in the mid to distal right coronary artery. The PDA of the right coronary artery is supplied by saphenous vein graft that fills retrogradely through the native injection up to the aorta.
6. The saphenous vein graft to this distal PDA has a proximal 60% stenosis. It fills the distal PDA; however, the retrograde part of this PDA does not appear to be diseased.
7. The saphenous vein graft to the ramus intermedius has a proximal 95% stenosis.
8. The saphenous vein graft to the diagonal branch is totally occluded.
9. Global left ventricular systolic function is severely depressed with estimated ejection fraction of 25%. The LVEDP was 24. There was no gradient upon pullback from the LV to the aorta.
Because of the above findings, the decision was to proceed with percutaneous coronary intervention of the saphenous vein graft. Heparin and Integrilin were given per protocol. A 6 French sheath was placed and exchanged for the previously placed sheath. A JR4 guide catheter was used to engage the saphenous vein graft to the ramus intermedius with 95% stenosis. A coronary wire was then advanced through the stenosis into the distal vessel and a 2.5 x 15 balloon was then advanced over the wire and placed across the lesion, and the balloon was inflated up to 12 atmospheres. Repeat angiogram demonstrated residual stenosis, so a 3.0 x 18 Cypher drug-eluting stent was then advanced over the wire and placed across the lesion, and the balloon was inflated to 18 atmospheres for 30 seconds. Repeat shots revealed excellent angiographic results; however, the obtuse marginal branch that this branch was filling appears to be diffusely diseased distally.
The guide was then advanced to the saphenous vein graft to the diagonal branch, and the wire was then advanced through this 100% stenosis. The balloon was then advanced over the wire and placed across the lesion, and the balloon was inflated up to 15 atmospheres for 30 seconds. Repeat shots revealed excellent angiographic results; however, this diagonal branch that is filled by the SVG appears to be diffusely diseased. Because of the very good angiographic results by balloon angioplasty and because of the distal diffuse disease nature of the native coronary arteries, decision was to avoid putting any stenting at this juncture.
CONCLUSIONS:
1. Severe native coronary artery disease.
2. Patent LIMA to LAD and patent, although diseased, SVG to the right coronary artery and 100% occluded SVG to the diagonal branch and a 95% diseased SVG to ramus intermedius or obtuse marginal branch.
3. Severely depressed ejection fraction.
4. Successful PTCA and a 3.0 x 18 Cypher drug-eluting stent placement in the SVG to the ramus intermedius obtuse marginal branch with reduction of the stenosis to 0%.
5. Successful PTCA of the 100% occluded SVG to diagonal with reduction of the stenosis to less than 10%.
PLAN:
1. The patient will be observed overnight.
2. He will be on aspirin and Plavix.
3. Further management of his coronary artery disease will be determined after he is extubated and after recovery.
4. He will be also referred for EP for evaluation for possible ICD placement.
