Thank you!
RT & LT cath(ventriculogram)- 93460-26
Impella- 33990
aortogram ? 93567 or 75625-26
iliac and femoral angiography- 75710-26
Cardiac Catheterization
DATE: 08/07/2017
INDICATIONS:
Congestive heart failure, persistent chest pain, positive troponins for acute coronary syndrome.
PROCEDURES:
1. Left heart catheterization.
2. Coronary angiography.
3. Left ventriculogram.
4. Distal aortogram.
5. Selective left iliac and femoral angiography.
6. Right heart catheterization.
7. Left common femoral vein and common femoral artery access with ultrasound guidance.
8. Impella CP insertion. Insertion of external heart assist system into heart, percutaneous approach.
9. Assistance with cardiac output using impeller pump continuous.
COMPLICATIONS:
None.
APPROACH:
Cardiac catheterization was performed by right radial artery. Swan-Ganz insertion was through left common femoral vein. Impella insertion was placed in the left common femoral artery.
OPERATIVE REPORT:
The risks and benefits of cardiac catheterization were discussed with the patient. She is agreeable to procedure. Consent was obtained
Time-out was performed. The patient’s position and procedure to be performed were identified.
The patient was prepped and draped in normal fashion. A 1% lidocaine was generously infiltrated into the right radial artery. A 6-French sheath was introduced without difficulty. Selective coronary angiography was performed using 6-French TIG catheter. All catheter exchanges were performed over a long J-wire and a Manifold double flushing between all catheter exchanges. Multiple RAO and LAO with cranial and caudal angulations were obtained.
The left main is large, short and without significant disease. The left anterior descending artery and diagonal branches were without significant disease. The circumflex and obtuse marginal arteries were also large and without significant disease. The right coronary artery was large, dominant and without significant disease.
Left ventriculogram was performed in the RAO projection. There is akinesis of the distal anterior septal apical inferior region with normal contractility in the basal anterior and septal region, ejection fraction 10 to 15%. The patient was noted to have outflow obstruction as noted with positive Brockenbrough-Braunwald sign with increase in left ventricular systolic pressure. The gradient is approximately 10 to 20 mmHg. There does not seem to be a gradient across the aortic valve itself.
Distal aortogram was performed using a pigtail catheter. The pigtail catheter was placed to the level of the renal arteries. Contrast injection to distal aorta showed no abdominal aortic aneurysm. No significant right and left renal artery stenosis. The iliac arteries appeared not to have disease.
Selective angiography of the left iliac and femoral arteries were performed using a 6-French multipurpose guide. Selective angiography of the left iliac and femoral artery showed no significant stenosis.
Vascular ultrasound was used to access the right common femoral artery and common femoral vein. A 6-French sheath was introduced and right heart catheterization was performed. Mean right atrium pressure is 12, RV is 45/4, PA is 45/21, mean pulmonary capillary wedge pressure is 26 mmHg.
The central aortic pressure is 94/63. Left ventricular end-diastolic pressure is 24 mmHg.
Due to the patient with hypertension, congestive heart failure, severe Takotsubo cardiomyopathy, ejection fraction 10% to 15% and outflow obstruction. It was decided to place an Impella. An Impella CP 4.0 was inserted into the left common femoral artery without difficulty. After the Impella was placed, there was good hemodynamic output. The patient’s chest pain, shortness of breath and back pain resolved.
The Impella and Swan-Ganz sheath were sutured in place and the patient transferred to the intensive care unit in stable condition.