PROCEDURE PERFORMED
1. Cardiac fluoroscopy with radiological supervision and interpretation.
2. Right heart catheterization.
3. Left heart catheterization.
4. Selective right and left coronary artery angiography.
5. Vein graft to diagonal branch angiography, left internal mammary artery
(LIMA) to left anterior descending (LAD) angiography.
6. Left axillary subclavian vein venography.
7. Dobutamine drug challenge with hemodynamic response interpretation.
8. Right iliofemoral angiography and vascular closure device with a 8-French
Angio-Seal.
9. Conscious sedation for a total of 40 minutes of preairway and postairway
examination, evaluations, and continuous cardiopulmonary monitoring.

COMPLICATIONS
None apparent.

INDICATIONS
Caucasian with a prior history of multivessel coronary artery disease and prior CABG 2-vessel, LIMA to LAD and
a vein graft of the diagonal branch, moderately severe endograft stenosis, who has had worsening dyspnea on exertion and shortness of breath. Being evaluated pre-TAVR, for worsening symptoms, NYHA Class III.

BRIEF DESCRIPTION OF PROCEDURE
After written informed consent was obtained, the patient was brought to our
cardiac cath lab, placed supine in the fasting state on the catheterization
table. Bilateral groins and right arm were prepped and draped in the usual
sterile fashion. Lidocaine 1% was used to anesthetize the right antecubital
area and a 6-French radial Glidesheath was exchanged out over IV with sterile
technique. Following this right heart catheterization was then performed
using a 6-French Swan-Ganz catheter advanced up to the right atrium, right
pulmonary artery. Pulmonary capillary wedge pressure was obtained using
serial pressure measurements, cardiac output index utilizing Fick technique.
Of note, there was some difficulty passing the Swan through this axillary
vein. Therefore, selective axillary venography was performed which showed a
patent vessel which showed a tortuous bend.[/U]

At this point the right heart catheter was removed, the sheaths were flushed.
IV fentanyl and Versed were used for conscious sedation. Micropuncture needle
and modified Seldinger technique, the right common femoral artery was
percutaneously entered and a 6-French sheath was used to dilate the right
common femoral vein and a 7 x 23 cm sheath was placed in the distal aorta.
At this point retrograde coronary angiography was then carried out using a
6-French JL4 for left coronary circulation, and a 6-French JR4 for right
coronary circulation, vein graft diagonal branch angiography, and selective
limited LAD angiography. Following this the 6-French JR4 was then used to
cross the aortic valve with an 0.035 straight wire. Simultaneous aortic LV
pressures were obtained. Baseline peak-to-peak gradient was 35 with a mean
of 32. Dobutamine drug challenge at 5 mcg titrated up to 10 mcg/kg/min
showed peak-to-peak gradient of 45 with a mean of 40. The calculated aortic
valve area was 0.64. At this point the dobutamine was discontinued. All
wires and catheters removed from the body. Right iliofemoral angiography
showed vessel anatomy suitable for vascular closure device. An 8-French
Angio-Seal was placed successfully.

FINDINGS
HEMODYNAMICS
RA pressure was 17/14 with a mean of 11 to 12. RV pressure 52/5 with an
RVEDP of 12 to 14. Pulmonary artery pressure 52/17 with a mean of 33 to 35.
Pulmonary capillary wedge pressure of 22/21 with a mean of 19 to 20. LV
pressure was 199/4 with an LVEDP of 22 to 23 mmHg. Aortic pressure 145/56
with a mean of 91. Post dobutamine infusion the peak-to-peak gradient was 45
with a mean of 40. Calculated aortic valve area of 0.64 sq cm per sq meter
with aortic valve index of 0.33. Cardiac output of 4.56. Cardiac index of
2.34 liters per minute per sq meter.

CORONARY ANATOMY
1. Left main: Left main angiographically is a large-caliber-size vessel. It
bifurcates into the left anterior descending artery, the left circumflex and
ramus intermedius. It is widely patent, mild luminal irregularities at the
ostium. Possibly an old stent placed there, difficult to visualize.
However, the vessel is widely patent. TIMI-3 flow.
2. Left anterior descending: The left anterior descending is a
large-caliber-size vessel. It is 99% occluded in its midportion and there is
faint biphasic flow noted in the midportion of the vessel. It gives rise to
a large diagonal 1 branch which has mild luminal irregularities, TIMI-3 flow.
3. Ramus intermedius: Large-caliber-size vessel, has mild ostial luminal
irregularities, less than 10% to 20% stenosis, widely patent. TIMI-3 flow.
4. Left circumflex is a large-caliber-size vessel, widely patent. Single
obtuse marginal wall branch. TIMI-3 flow. Mild luminal irregularities.
5. Right coronary artery: Right coronary artery is a large-caliber-size
vessel. It is a dominant vessel supplying right side posterior structures.
It has a widely patent stent in the midportion with only a very mild in-stent
restenosis. The remainder of the vessel has mild luminal irregularities.
The RPDA is widely patent with mild luminal irregularities.

TOTAL AMOUNT OF CONTRAST
80 mL

TOTAL FLUOROSCOPY TIME
5.2 minutes

CONCLUSION
1. Widely patent left internal mammary artery (LIMA) to left anterior
descending (LAD).
2. Occluded vein graft to diagonal 1 branch.
3. Widely patent left main and diagonal branch.
4. Widely patent left circumflex and ramus intermedius.
5. Widely patent mid right coronary artery stent.
6. Elevated right and left-sided filling pressures.
7. Pulmonary hypertension.
8. Severe aortic valve stenosis with dobutamine drug challenge with a
peak-to-peak gradient of 45 and a mean of 40 mmHg. Calculated aortic valve
area was 0.64, index of 0.33.

PLAN
The patient will be sent to the recovery area and will be monitored for any
postprocedure complications. She received a dose of IV diuretics. We will
optimize medical therapy, continue with TAVR evaluation, likely as an
outpatient.