DATE OF PROCEDURE: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
OPERATOR: Jane Doe, M.D.
PROCEDURE PERFORMED: Left heart catheterization.
PREOPERATIVE DIAGNOSIS: NSTEMI.
POSTOPERATIVE DIAGNOSES:
1. Giant coronary aneurysm of the proximal and middle left anterior descending artery with thrombus, suggesting Kawasaki vasculitis.
2. Normal left ventricular systolic function.
3. No mitral regurgitation.
DESCRIPTION OF PROCEDURE: Informed consent was obtained prior to the procedure. The patient was prepped and draped in the usual sterile fashion. The right groin was anesthetized with 2% lidocaine. A 6-French sheath was introduced into the right femoral artery via modified Seldinger technique. A 6-French angled pigtail was used for left ventriculography and aortic valve pullback. The 6-French JL4 and JR4 catheters were used for selective coronary angiography. Multiple views were obtained.
PROCEDURE FINDINGS:
Coronary Circulation: Coronary circulation is right dominant.
Left Main Artery: Normal.
Left Anterior Descending Artery (LAD): The lumen of the proximal and middle vessel was dilated, by visual estimate 8-10 mm in diameter. The area of dilatation extends into the ostium of the first diagonal branch, although D1 in general is not significantly dilated. In the dilated portion of the LAD, there is an area of haziness suggestive of thrombus. The remainder of the vessel has no significant stenoses, and the flow is brisk (TIMI-III) with adequate lumen. There are no flow-limiting stenoses.
Left Circumflex Artery (LCX): The vessel supplies a small to medium caliber obtuse marginal branch and otherwise has only mild disease.
Right Coronary Artery (RCA): The vessel supplies a posterior descending artery and right posterolateral branch. The proximal vessel has mild ectasia but no other significant disease or stenoses.
Left Ventricle: Ejection fraction is 65%. There are no wall motion abnormalities, mitral regurgitation or aortic valve gradient. The LVEDP is 14.
COMPLICATIONS: None.
Sample # 2
DATE OF PROCEDURE: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
OPERATOR: Jane Doe, M.D.
PROCEDURE PERFORMED: Left heart catheterization.
PREOPERATIVE DIAGNOSES:
1. Chest pain.
2. Abnormal stress test.
3. Diabetes.
POSTOPERATIVE DIAGNOSES:
1. Nearly normal coronary arteries by arteriography.
2. Low normal left ventricular systolic function.
3. No mitral regurgitation.
4. Elevated LVEDP.
DESCRIPTION OF PROCEDURE: Informed consent was obtained prior to the procedure. The patient was prepped and draped in the usual sterile fashion. The right groin was anesthetized with 2% lidocaine. A 6-French 24 cm sheath was introduced into the right femoral artery via modified Seldinger technique. A 6-French angled pigtail was used for left ventriculography and aortic valve pullback. The 6-French JL4 and JR4 catheters were used for selective coronary angiography. Multiple views were obtained. A 6-French Angio-Seal device was used for hemostasis following biplane femoral angiography.
FINDINGS AT LEFT HEART CATHETERIZATION:
1. The coronary circulation is right dominant.
2. Left main artery is normal.
3. Left Anterior Descending Artery: The vessel is large caliber and normal. It supplies an early bifurcating diagonal branch, which is normal.
4. Ramus Intermedius Branch: The vessel is large and subtends a large distribution. It is normal.
5. Left Circumflex Artery: The vessel supplies a medium-caliber obtuse marginal branch and is normal.
6. Right Coronary Artery: There is a smooth 10% narrowing in the proximal to middle vessel. The remainder of the vessel is unremarkable and supplies a large posterior descending artery and two small right posterolateral branches.
7. Left Ventricle: Ejection fraction is 50%. There are no wall motion abnormalities, mitral regurgitation or aortic valve gradient. There does appear to be irregular activation in the contraction pattern consistent with left bundle branch block. The LVEDP is 21.
