# Intracardiac shunt study



## Sarzs168 (Mar 16, 2016)

Can someone please help me in coding this? I ve come up with the 93451. thoughts ?????


1.  Right and left heart catheterization.
2.  Coronary arteriography.
3.  Oxygen saturation run for shunt study.

PREOPERATIVE DIAGNOSIS:
Probable intracardiac shunting.

POSTOPERATIVE DIAGNOSIS:
Intracardiac shunting with a Qp:Qs of 2.13:1 at the interatrial level.  Normal coronary arteries.

COMPLICATIONS:
None.

PROCEDURE IN DETAIL:
After informed consent, the patient was taken to the catheterization laboratory.  The left inguinal area was prepped and draped in usual fashion.  Skin was infiltrated with 1% Xylocaine.  A puncture was made in the left femoral artery and left femoral vein.  Six-French and 8-French sheaths were introduced respectively.  A Swan-Ganz catheter was advanced with great difficulty into the pulmonary artery and pulmonary artery wedge position.  Sampling with a Swan-Ganz catheter was obtained in the IVC, high right atrium, low right atrium, right ventricle, PA x2, and PAW x1.  Using a pigtail catheter, the SVC was sampled and using a pigtail, the left ventricle was sampled.  Thermodilution cardiac outputs x3 were measured.  Right-sided pressures were recorded as the Swan-Ganz catheter was pulled back from PAW to PA to RV to RA.  It was then removed from the patient and the venous sleeve left in place.  A 30-degree RAO left ventriculogram using 40 cc of Visipaque at a flow rate of 10 cc/second was performed.  End-diastolic pressures were rerecorded as were the pressures across the aortic valve during the pull-back procedure.  The pigtail catheter was replaced with a 4 left Judkins catheter and the left coronary artery tree was injected in multiple views.  A one right Amplatz catheter was inserted and the right coronary artery was cannulated and injected x1.  A right femoral arteriogram was performed.  The patient was not thought to be a good candidate for a closure device.  The sheaths were left in place.  The patient was transferred to the CRU in good condition.  Sheath protocol was initiated.

HEMODYNAMIC SUMMARY:
PA pressures are elevated at 65 to 72.  The wedge pressure was 15.  This closely related to the left ventricular end-diastolic pressure, which was not documented on the patient's chart.  PA pressure was ______.  Cardiac index was reduced to 2.31 L/minute per meter squared on the thermodilution and 1.84 L/minute per meter squared on the Fick estimated with a slow resolution.

There was a significant oxygen step up at the right atrial level.  IVC O2 sat was 66.2, SVC sat was 57.5, RA sat 80.9, high right atrium 74.7, low right atrium.  The right ventricle was 78.7, PAW 89.4, and LV 90.  This gives a Qp:Qs of 2.13:1 at the atrial level.

LEFT VENTRICULOGRAM:
The left ventricular ejection fraction is normal.  There is an inferior diverticulum, but ejection fraction is preserved at approximately 60%.  No significant mitral regurgitation is noted.

CORONARY ANGIOGRAM:
1.  The left main coronary artery normal.
2.  The left anterior descending coronary artery normal.
3.  The circumflex coronary artery normal.
4.  The right coronary artery, moderate size dominant and normal.

CONCLUSIONS:
1.  Abnormal hemodynamics at rest characterized by reduced cardiac index and moderate pulmonary artery hypertension.
2.  2.13:1 intracardiac shunting at the atrial level.
3.  Unusual LV configuration with preserved ejection fraction.
4.  Normal epicardial arteries.


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