36224-50, 93460-26, 93567, 99152
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PROCEDURES PERFORMED:
Combined right and left heart catheterization, left ventricular angiography,
aortic root angiography, selective right and left coronary angiography,
selective right carotid angiography, selective left carotid angiography,
selective left subclavian angiography, left internal mammary angiography,
selective left vertebral angiography, Fick cardiac outputs, monitored
anesthesia care for 57 minutes supervised by myself.
CLINICAL DATA:
83-year-old male, who recently diagnosed with prostate
cancer anticipating brachytherapy. He has already had external radiation.
His preoperative EKG suggests inferior wall infarct, asymptomatic with
no history of atherosclerotic heart disease. Physical exam, he has
evidence of carotid disease bilaterally. He had evidence of aortic
stenosis. An echocardiogram demonstrates normal LV function with moderate
aortic stenosis. A stress test is high-risk study demonstrating reversible
defects in the anterior wall, apex, septum, and inferior and inferior
lateral walls with a drop in ejection fraction of about 20 points with
pharmacologic stress. The procedure is performed from the right groin.
We used a monitoring Swan-Ganz for the right heart cath. The 6-French
diagnostic catheters were used for the remainder.
HEMODYNAMIC DATA:
The patient is in a sinus rhythm in the 60 to 65 beat per minute range.
The arterial pressure of 136/60, mean of 90. The LV pressure of 180
with an LVEDP.
COMMENTS:
The gradient across the aortic valve ranged from 50 to 60 during the
case. The mean right atrial pressure was 4. Kussmaul sign negative.
RV pressure of 30/6, PA pressure of 30/10 with a mean of 18. Pulmonary
capillary wedge pressure was 12. No significant V waves were noted.
The mean arterial saturation 93%, mean mixed venous saturation 72%.
Cardiac output was 5.3 L/minute with an index of 2.9 L/minute per meter
squared. The mean planimetered gradient was 47. The peak-to-peak gradient
was about 55. The flow was 295 mL/second, systolic ejection period
0.27 seconds per beat with a heart rate of 65. The aortic valve area
is about 0.9 cm2, calculated using the Fick method, 0.8 cm2 using the
Quick formula.
Left ventricular angiography is performed in a shallow RAO projection.
There is severe mitral annular calcification and severe calcifications
of all epicardial coronary arteries. The left ventricle is well opacified
with dye. There is evidence of mild LVH. Systolic function is well
preserved. There is hypokinesis of the inferior basal segment. Ejection
fraction is estimated in the 55% to 60% range. No significant mitral
regurgitation was seen.
The aortic root angiogram is performed in a LAO projection. The aortic
valve is a trileaflet structure. There is moderate restriction of valve
leaflet excursion of the right coronary leaflet. The left coronary
and noncoronary leaflets do not appear to be moving. The origin of
both right and left coronary arteries are noted to be severely calcified.
There was no aortic insufficiency. There was minimal post stenotic
aortic root dilatation.
CORONARY ANGIOGRAPHY:
Coronary angiography is performed in multiple projections.
A. The right coronary artery appears to been a dominant vessel in this
patient. There is an ostial total occlusion of the right coronary artery.
A second subtotal occlusion is noted about 10 mm from the ostium and
the vessel is totally occluded at the acute margin. The distal right
coronary artery appears graftable and fills via the septal arcade from
the left coronary system and also the circumflex.
B. The left main coronary artery arises from the left cusp, ends in
a trifurcation. The left main coronary artery has mild atherosclerotic
plaquing, but no significant obstructive disease.
C. The circumflex is a moderate, but nondominant vessel. There is an
ostial 90% stenosis followed by 75% stenosis. The circumflex basically
ends as a marginal branch, which is graftable.
D. The left anterior descending artery is a large wrap-around type LAD,
severely calcified, but well distributed in the left ventricular apex.
The origin of the LAD is patent. It immediately gives rise to a diagonal
branch/ramus branch, which has a 90% stenosis at its ostium. The vessel
is tortuous, but graftable. As the LAD continues to give rise to a
second diagonal branch, which has an 80% diameter stenosis, this vessel
is diffusely diseased. In the LAD proper, there was a severe calcific
lesion in the mid LAD of about 70% diameter stenosis. The distal LAD
is free of significant obstructive disease and appears graftable.
Carotid angiography: A selective right carotid angiogram is performed
in a single oblique view. The carotid bifurcation is patent. The right
external carotid artery is patent. There is a high-grade 70% stenosis
in the proximal right internal carotid artery with an atherosclerotic
ulcer just proximal to it appears to be mild thrombus in this area.
Selective views of the left carotid were performed. Visualization
was not as good as on the right. In the distal left common carotid
artery, there is a high-grade lesion of about 70%. The left external
carotid artery is patent. The right external carotid artery has an
ulcerated lesion approaching 90% diameter stenosis is a web type lesion.
Left internal mammary angiography is performed in a single AP projection.
The left internal mammary artery is somewhat small, but appears to
be adequate in length and diameter for use as an in-situ graft. Next,
the left vertebral artery appears to be a dominant artery, luminal irregularities
are noted, but it appears to be free of significant obstructive disease.
There was some ostial spasm.
IMPRESSIONS:
1. Normal right heart pressures.
2. Normal sinus rhythm.
3. Normal cardiac output.
4. Moderately severe aortic stenosis.
5. Well-preserved left ventricular function with inferior wall motion
abnormalities.
6. No significant mitral valve disease.
7. Severe calcific coronary artery disease with:
a. Chronic total occlusion in the right coronary artery at multiple
levels. Right coronary artery is dominant.
b. High-grade 90% ostial circumflex lesion.
c. High-grade ostial ramus/diagonal lesion at least 80% to 90%.
d. Severe disease in the left anterior descending artery at multiple levels.
e. Severe carotid disease on the left side with moderately severe
carotid disease on the right side.
8. Adequate LIMA vessel for use as an in-situ graft.
COMMENTS:
This 83-year-old male is anticipating brachytherapy. He has fairly well-preserved
LV function. Recommendations are for surgical consideration, graftable
vessels include the distal right coronary artery, LAD, major diagonal
branch, and circ marginal branch. The patient’s aortic stenosis is
severe, but not critical. He could be a candidate for a TAVR procedure
in the future if aortic valve replacement is not entertained at the
time of bypass surgery. This patient will need a CT angiogram of the
carotid arteries and will likely need a left carotid endarterectomy
prior to coronary artery bypass grafting surgery.
90051917MC