I would really love any feedback or breakdown anyone is willing to give as I am learning to code these notes.
Thank you!
PROCEDURES PERFORMED:
Left heart catheterization, left ventricular angiography in biplane projections,
selective right and left coronary angiography, saphenous vein graft
angiography x2, left internal mammary angiography with attempted PCI
of an infarct-related totally occluded LAD through the internal mammary
graft and the procedure was unsuccessful as we were not able to establish
antegrade flow after dilating the entire mid and distal third of the
LAD.
CLINICAL DATA:
68-year-old male, presenting the emergency room with
chest pain, evidence of an anterior wall infarct, has a history of bypass
surgery. The diagnostic part of the procedure was performed with a
6-French multipurpose catheter.
HEMODYNAMIC DATA:
Blood pressure 200/90. Mean of 130. LV pressure 200. LVEDP of 12 to 14.
Left ventricular angiography was performed at the end of the case. Left
ventricle is fairly well opacified with dye. Chamber size is moderately
enlarged. There is akinesis of the anterior and inferior apical segments.
No mitral regurgitation is noted. Septal wall motion was well preserved.
Posterior lateral wall motion was well preserved.
Coronary angiography is performed in multiple projections.
A. The right coronary artery appears to have been the dominant artery,
totally occluded right after an RV branch. The vessel is very small.
B. The left main coronary artery is a moderate size vessel arising from
the left cusp ending in a bifurcation. There is moderate nonobstructive
disease in the left main coronary artery. The vessel is heavily calcified.
C. The circumflex totally occluded arising from the left from the left main.
D. The LAD is totally occluded, right at the first septal perforator.
Saphenous vein graft angiography is performed in multiple projections.
A. The saphenous vein graft to the posterior marginal branch of the
circumflex. Selectively visualized. Graft body excellent. Distal
insertion site excellent. This fills retrograde and antegrade in the
posterior marginal branch.
B. The saphenous vein graft to the RCA. Selectively visualized. The
graft body excellent. Runoff good. Distal insertion site excellent.
Inserts into the crux of the PDA. The native vessels are extremely
small.
C. saphenous vein graft to a ramus/diagonal branch. Selectively visualized.
Graft body excellent. Distal insertion site is widely patent. This
also fills briskly in anterograde and retrograde fashion.
Left internal mammary angiography was performed in multiple projections.
The graft is small, has been utilized as an LAD graft. It is totally
occluded at its insertion site into the left anterior descending artery.
COMMENTS:
Plans for ad hoc angioplasty had been made. The patient was given 10,000
heparin. He had been on Xarelto for chronic atrial fibrillation. We
selected a LIMA guiding catheter. We were unable to cross the lesion
with an extra-support wire. We put a 2 x 20 angioplasty balloon and
we were still unable to totally advance the wire. We exchanged the
extra-support wire for a pro via 12 weight wire, we were able to pass
the wire into the apical segment of the LAD. Multiple insufflations
of a 2 x 20 and a 2.5 x 30 balloon were performed. We were unable to
establish antegrade flow into the vessel. We gave multiple doses of
nitroglycerin to no avail. After approximately 1 hour of attempted
PCI, the procedure was terminated.
IMPRESSION:
Unsuccessful infarct-related PCI of an LAD as we had no flow situation
and were unable to establish TIMI-3 flow into the LAD. The patient
will be treated as a completed acute myocardial infarction.