PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Coronary angiography.
3. Percutaneous transluminal coronary angioplasty of the right coronary
artery.
4. Left ventriculogram.
5. Temporary balloon pacing catheter placement.
6. Placement of an intraaortic balloon pump.

INDICATIONS FOR PROCEDURE: This is a 79-year-old lady, who presents
approximately 90 minutes into an inferior myocardial infarction. She has
no previous cardiac history. She had a history of some hypertension only.

DESCRIPTION OF PROCEDURE: Informed consent had been obtained and the
patient was brought emergently to the cardiac catheterization lab for ST
elevation myocardial infarction. She was sterilely prepped and draped in
usual fashion. The right femoral artery entered using the modified
Seldinger technique and a 6-French arterial sheath easily established.
Following this, left heart catheterization done. A 6-French JL4 and JR4
catheters were used to perform multiple coronary angiograms in multiple
projections. The right coronary was anomalous and had a high anterior
takeoff. Subsequent to this, we attempted to do angioplasty. The right
coronary proved extraordinarily difficult to engage, unsuccessful cath
included a JR4, AL1, AR1. We did successfully get in with an LCD. Its
support was not overly great. We also subsequently tried a 3.0 and a
hockey stick guide, which were also not effective. In fact, the only
guide that even allowed the passage of a wire was the LCD. The patient
received Angiomax bolus infusion. She had received aspirin in the ER, but
did not receive any other antiplatelet therapy in the lab.

Once we were able to get the LCD guide at least adequately seated, we did
cross the lesion with mild difficulty with a graphics wire. We then
attempted the pass a 2.5 x 15 Trek balloon, but found it would not
negotiate the extremely surfing time like origin of this vessel, which
also appeared to have a significant stenosis in it. With the placement of
a second wire, which was a Whisper ES we were able to get the balloon down
to the distal lesion where it was deployed to 10 atmospheres times about
20 seconds. This did restore some better flow. We also did use this
balloon in the proximal. I attempted to go back and do for the proximal
vessel, but it would not cross. We did get a 2.5 x 15 NC Trek across the
area in the proximal vessel and deployed that at about 10 atmospheres
times 20 seconds. There was no evidence of any sort of waste. At this
point, we did attempt to stent a 2.75 x 15 Xience, did not even remotely
come close to getting into the vessel. There is absolutely no way to
negotiate that proximal area. We did lose our entire system trying to do
this. We went in again to reengage and recross the wire, then we were
able to get a wire again and then this time a 3.0 x 15 Trek balloon down
to the distal vessel. The vessel initially had looked bad after the first
2.5 balloon, but in the interim developed less good flow again and in fact
it was more sluggish and actually she developed some transient heart
block. This did require the placement of the 5-French pacing catheter.
The access had been obtained in the right femoral vein via modified
Seldinger technique and a 5-French sheath was established and the balloon
catheter positioned in place. Adequate pacing parameters were confirmed.
We then again went back to work with the balloon angioplasty. This was
the 3.0 balloon. It was taken out up for about 20 seconds at about 10
atmospheres. The lesion looked quite a bit better. It was better flow
and less area of visible thrombus in that area. We attempted to also do
the ostium with this balloon, but found that it was initially we were not
able to get back far enough to be on the lesion and out of the guide. I
then withdrew the guide and the entire system again was lost. Basically,
the anatomy of this patient’s proximal right coronary being one anomalous,
two extremely serving time in its course and three having significant
plaque present, made passage of a winged balloon or stents absolutely
impossible.

At this point, it became evident that we were not going to be successful
with stenting this lesion. I was concerned that it would not have
durability in terms of staying open. Therefore, at this point, we did opt
to pursue an emergent surgical consult. Dr. Blitz was consulted and he
came by and reviewed the films and agreed to take the patient for emergent
bypass. The anticipated graft will be to the right coronary and to the
LAD. At this point, he did request a balloon pump be in place, which is
certainly reasonable. Therefore, we did go ahead and exchange our sheath
and put in a balloon pump, it was placed on one-to-one support.

As the patient was just living the cath lab, she has her ST segments
considerably better. There is slight residual ST elevation, but it does
look a lot better and also her chest pain is significantly improved. This
patient has been very noncooperative as well, making his case even much
more difficult. She has a lot of chronic back problems and was constantly
moving around her legs and arms and body the entire case. Therefore, we
needed to monitor very carefully with the balloon pump in place.

At this point, the balloon pump was left and of course and also the pacing
catheter, though her transient heart block seems to have resolved at least
at the end of the case that she is no longer requiring the pacemaker, but
nonetheless _____, heart block returned.

The intra-procedure medicines include Angiomax bolus infusion and
sedatives and pain medications per the nursing flow sheets, quite a bit
was used and I did detailed in those notes. No other antiplatelet agents
were added. The contrast and flow amounts were elucidated in the cath lab
report.

STUDY FINDINGS:

HEMODYNAMICS: Central aortic pressure was about 131/66. The LV pressure
measured about 140/17, but did not suspect that there is significant
gradient.

ANGIOGRAPHIC FINDINGS: The left main is a moderate-sized vessel, free of
any significant disease.

Left circumflex is a moderate-sized system, does not appear to be
significant disease. It gives rise to a single tortuous obtuse marginal
branch, which has about a 20 percent proximal lesion.

The LAD has a tubular 80 percent proximal stenosis. This vessel is large
and very tortuous, does reach around the apex.

There is a moderate-sized diagonal branch, free of significant disease.

The right coronary artery is large and dominant vessel with an anomalous
takeoff, it comes off anteriorly. There is likely an 80 to 90 percent
ostial stenosis. The area was 100 percent occluded in the distal vessel
that was opened up and then the final angiogram as a residual stenosis in
the distal vessel of about 50 percent with some thrombus present. Initial
TIMI 0 flow is restored to TIMI 3 flow. The area in the ostium of the
right coronary, where the 89 percent stenosis present is not significantly
changed.

Left ventriculogram was attempted via hand injection; however, contrast
opacification is poor. The patient’s hand came in front and basically it
was not really interpretable.

OVERALL IMPRESSION:

1. Severe 2-vessel disease involving the distal right coronary for her
culprit for the acute inferior myocardial infarction and also
significant high-grade disease in the proximal LAD.
2. Difficult to assess left ventricular systolic function.
3. Successful placement of both the intraaortic balloon pump and
temporary transvenous pacing catheter.

RECOMMENDATIONS: The patient will be supported on her balloon pump. I
should also mention that we did transiently use some dopamine during the
case, she became hypotensive when she had her heart block and her
bradyarrhythmia that was discontinued by the end of the case. At the time
of her leaving the cath lab is on standby. We will continue to support
her temporarily until she goes to the operating room for emergent bypass.