CARDIAC CATHETERIZATION REPORT
DATE OF PROCEDURE: 05/16/2012
REFERRING PHYSICIAN:
PROCEDURE:
1. Right heart catheterization.
2. Left heart catheterization.
3. Right iliofemoral angiogram.
4. Supravalvular aortogram.
5. Angio-Seal closure device placement.
BRIEF HISTORY AND INDICATION:
Patient is a 75-year-old male with a history of aortic
insufficiency. I have been asked to perform right and left heart
catheterization as well as aortography prior to consideration for
cardiac surgery.
All risks, benefits, and alternatives were discussed at length with
the patient. Patient refuses anything other than diagnostic testing
today. Refuses intervention. Refuses intracoronary evaluation.
RIGHT HEART CATHETERIZATION FINDINGS:
1. Right atrium - mean 11 mmHg.
2. Right ventricle - 32/10.
3. Pulmonary artery - 32/19 with a mean 23 mmHg.
4. Pulmonary capillary wedge - mean 19 mmHg.
5. Cardiac output - 4.6 L/minute.
LEFT HEART CATHETERIZATION FINDINGS:
1. Left main - the left main coronary artery has luminal
irregularities and minor eccentric plaque at the origin with no
significant focal stenosis.
2. Left anterior descending - the LAD is a moderately calcified
vessel in its proximal segment. This proximal segment has an
approximate 60 percent stenosis. This is an ectatic diffusely
diseased vessel with sluggish flow distal to the lesion. The main
diagonal branch has luminal irregularities only and no significant
focal obstruction.
3. Left circumflex - the left circumflex artery and its marginal
branches have luminal irregularities throughout but no significant
focal obstruction.
4. Right coronary artery - the RCA has luminal irregularities
throughout its course and is also an ectatic vessel in its
proximal segment, but has no significant focal stenosis. The RCA
is the dominant vessel.
5. Left ventricle -
a. End diastolic pressure 17 mmHg.
b. Ejection fraction visually estimated at 50-55 percent.
c. No aortic stenosis.
d. No significant mitral regurgitation is seen.
6. Supravalvular aortogram - normal system. No aneurysm. No
dissection. No significant aortic insufficiency seen.
7. Right iliofemoral angiogram - normal visualized system. Minimal
atherosclerosis. Sheath enters at an appropriate level. An
Angio-Seal closure device was placed achieving hemostasis.
ASSESSMENT:
1. Essentially normal intracardiac pressures.
2. Coronary artery disease with borderline stenosis in the proximal
to mid left anterior descending (LAD).
3. No significant valvular abnormalities seen.
Can someone please give me an insight on how to code this report .
thx
DATE OF PROCEDURE: 05/16/2012
REFERRING PHYSICIAN:
PROCEDURE:
1. Right heart catheterization.
2. Left heart catheterization.
3. Right iliofemoral angiogram.
4. Supravalvular aortogram.
5. Angio-Seal closure device placement.
BRIEF HISTORY AND INDICATION:
Patient is a 75-year-old male with a history of aortic
insufficiency. I have been asked to perform right and left heart
catheterization as well as aortography prior to consideration for
cardiac surgery.
All risks, benefits, and alternatives were discussed at length with
the patient. Patient refuses anything other than diagnostic testing
today. Refuses intervention. Refuses intracoronary evaluation.
RIGHT HEART CATHETERIZATION FINDINGS:
1. Right atrium - mean 11 mmHg.
2. Right ventricle - 32/10.
3. Pulmonary artery - 32/19 with a mean 23 mmHg.
4. Pulmonary capillary wedge - mean 19 mmHg.
5. Cardiac output - 4.6 L/minute.
LEFT HEART CATHETERIZATION FINDINGS:
1. Left main - the left main coronary artery has luminal
irregularities and minor eccentric plaque at the origin with no
significant focal stenosis.
2. Left anterior descending - the LAD is a moderately calcified
vessel in its proximal segment. This proximal segment has an
approximate 60 percent stenosis. This is an ectatic diffusely
diseased vessel with sluggish flow distal to the lesion. The main
diagonal branch has luminal irregularities only and no significant
focal obstruction.
3. Left circumflex - the left circumflex artery and its marginal
branches have luminal irregularities throughout but no significant
focal obstruction.
4. Right coronary artery - the RCA has luminal irregularities
throughout its course and is also an ectatic vessel in its
proximal segment, but has no significant focal stenosis. The RCA
is the dominant vessel.
5. Left ventricle -
a. End diastolic pressure 17 mmHg.
b. Ejection fraction visually estimated at 50-55 percent.
c. No aortic stenosis.
d. No significant mitral regurgitation is seen.
6. Supravalvular aortogram - normal system. No aneurysm. No
dissection. No significant aortic insufficiency seen.
7. Right iliofemoral angiogram - normal visualized system. Minimal
atherosclerosis. Sheath enters at an appropriate level. An
Angio-Seal closure device was placed achieving hemostasis.
ASSESSMENT:
1. Essentially normal intracardiac pressures.
2. Coronary artery disease with borderline stenosis in the proximal
to mid left anterior descending (LAD).
3. No significant valvular abnormalities seen.
Can someone please give me an insight on how to code this report .
thx