dtruelson
Guest
Any help on this would be greatly appreciated. These are not my favorites--does anyone know of any coding books where congenital heart coding is taught?
INDICATIONS FOR CARDIAC CATHETERIZATION: Hemodynamic and angiographic evaluation of complex tetralogy of Fallot with pulmonary atresia, hypoplastic native branch pulmonary arteries and multiple aorto-pulmonary collateral arteries.
PROCEDURE: A timeout was performed to verify correct patient, procedure, and access sites. Deep sedation was administered by the pediatric anesthesiologist. The patient was prepped and draped in the usual sterile fashion. Following the infiltration of 1% buffered lidocaine in the bilateral groins, a 6 French sheath was inserted in the right femoral vein and a 4 French sheath was inserted in the left femoral artery by modified Seldinger technique under ultrasound guidance. 70 units/kg of heparin were given. ACTs were checked every 30 minutes and additional heparin given as needed to maintain ACT 200-250 seconds.
A baseline LFA blood gas and pressure were measured. A 6 French balloon wedge catheter was advanced through the venous sheath to the SVC. Saturations were measured in the SVC and IVC. Saturation and pressure were measured in the RA, RV, MPA, and LPA wedge. A 4 French pigtail catheter was advanced through the arterial sheath retrograde over a 0.035" straight wire to the RV. Pullback pressures were measured from RV to AAO to DAO.
The pigtail was advanced over the straight wire retrograde into the RV and a right ventriculogram obtained by power injection of contrast. The pigtail was withdrawn into the proximal DAO and a descending aortogram obtained with power injection of contrast. The pigtail was withdrawn more distally in the DAO and a descending aortogram obtained with power injection. A 6 French Berman angiographic catheter was advanced through the venous sheath and into the MPA and a pulmonary arteriogram was performed with power injection.
The pigtail was withdrawn over the straight wire, and a 4 French JR catheter advanced over a 0.035" straight wire, and a right sided aorto-pulmonary collateral was engaged, and an angiogram obtained by hand injection of contrast. A tiny left sided bronchial artery was also selectively engaged and an angiogram obtained by hand injection of contrast. The JR catheter was exchanged for a 4 French Cobra #2 glide catheter over the Wholey wire though additional collaterals could not be engaged with this catheter. The Cobra catheter was then exchanged for a 4 French IM catheter advanced over the straight wire to selectively engage another right sided AP collateral artery.
The IM catheter was removed over straight wire. The pigtail was advanced over the 0.035" straight wire retrograde into the AAO and an ascending aortogram with power injection obtained. This was withdrawn into the proximal DAO and a descending aortogram was repeated by power injection. The pigtail was removed over the straight wire. The Cobra catheter was advanced through the arterial sheath over the Wholey wire to search for further collaterals.
With the procedure concluded, all wires and catheters were removed. Additional 1% buffered lidocaine was infiltrated around the sheaths and the sheaths were removed. Hemostasis was obtained by manual pressure. Pressure dressings were applied to the bilateral groins. Emma was extubated uneventfully and transported to the recovery area in good condition.
ESTIMATED BLOOD LOSS: 20 ml
FLUOROSCOPY TIME: 24.8 min
RADIATION DOSE: 99 mGy
DOSE AREA PRODUCT: 1181 uGy x M2
TOTAL CONTRAST: 185 ml Omnipaque 350
COMPLICATIONS: None
HEMODYNAMIC DATA: (For pressures and saturations, please see heart diagram)
1. Oximetry data summary
All saturations were measured with the patient in deep sedation and spontaneously breathing receiving FiO2 30%. The MPA sat (which was 52%) was taken as the systemic venous saturation and pulmonary arterial saturation. There was no oximetric step up to suggest left to right shunt. The systemic arterial saturation was 75%. The pulmonary venous saturation was assumed to equal 95%. Using an assumed indexed VO2 of 133 ml/min/m2 (from Lafarge) and measured hemoglobin of 16 gm/dL, the cardiac index by Fick principle was normal at 2.7 L/min/m2. The Qp:Qs was 0.53:1.
2. Pressure data summary
Right heart filling pressures were normal (RA mean 6 mmHg, RVEDP 8 mmHg). There was no tricuspid valve inflow gradient (RA A-wave 8 mmHg, RVEDP 8 mmHg). The RV systolic pressure was essentially equal to systemic pressure. There was no gradient from the RV to the distal RV-PA conduit. There was no coarctation of the aorta. (AAO-DAO PSEG 8 mmHg). The pulmonary vascular resistance could not be determined due to multiple sources of pulmonary blood flow.
ANGIOGRAPHY:
1. Right ventriculogram. Power injection of contrast (30 ml, 15 ml/sec, 800 PSI, 1.0 rate rise) with cameras RAO-20 and LAO-70 demonstrated mildly diminished RV function, moderate right ventricular hypertrophy and dilation, and right to left shunting across a large ventricular septal defect. There was mild tricuspid regurgitation. The left ventricle systolic function was mildly diminished.
2. Proximal descending aorta. Power injection of contrast (30 ml, 21 ml/sec, 1200 PSI, no rise) with cameras straight AP and lateral demonstrated a widely patent descending aorta giving rise to multiple aorto-pulmonary collaterals, nearly all of which perfuse the right lung, with unobstructed right-sided pulmonary venous return.
3. Distal descending aorta. Power injection of contrast (21ml, 21 ml/sec, 1200 PSI, no rise) with cameras straight AP and lateral demonstrated the majority of the aorto-pulmonary collaterals arising from the thoracic descending aorta and perfusing the right lung.
4. Main pulmonary artery. Power injection of contrast (18 ml, 18 ml/sec, 500 PSI, 0.1 rate rise) with cameras LAO-20/CRA-20 and lateral demonstrated an unobstructed RV-PA conduit providing flow to the LPA and upper and middle lobes of the left lung. The distal branches were pulsatile with abnormal distal arborization. There was no perfusion to the right lung or left lower lobe. There was unobstructed pulmonary venous return from the left upper pulmonary vein. The conduit to RV connection was markedly aneurysmal.
5. Aorto-pulmonary collateral #1. Hand injection of contrast with cameras straight AP and lateral demonstrated a small collateral perfusing the right upper lobe of the lung arising rightward from the proximal descending aorta at the level of the most superior sternal wire with unobstructed right upper pulmonary venous return on levophase.
6. Aorto-pulmonary collateral #2. Hand injection of contrast demonstrated a tiny bronchial arterial branch off the left posterior side of the descending aorta with flow to the left lung.
7. Aorto-pulmonary collateral #3. Hand injection of contrast reveals a small aorto-pulmonary collateral arising rightward and anterior off the proximal descending aorta and perfusing the right milld and right lower lobes.
8 Ascending aorta. Power injection of contrast (20 ml, 20 ml/sec, 1200 PSI, no rise) with cameras straight AP and lateral demonstrated a right dominant aortic arch with the left carotid and left subclavian artery arising off the proximal remnant of the left aortic arch. There was no supravalvar aortic stenosis or coarctation. The proximal ascending aorta was moderately dilated. There was mild aortic regurgitation. Coronary artery origins were normal and unobstructed.
9. Descending aorta. Power injection of contrast (30 ml, 21 ml/sec, 1200 PSI, no rise) with cameras RAO-20 and LAO-68 demonstrated multiple small aorto-pulmonary collaterals arising off the descending aorta mostly perfusing the right lung.
DIAGNOSIS:
1. Pulmonary atresia, ventricular septal defect with hypoplastic pulmonary arteries supplied by aortopulmonary collaterals
A. S/P Waterston shunt, 5/10/2013
B. S/P Waterston shunt takedown, 10 mm valveless Gore-Tex RV-Pa conduit and unifocalization of AP collateral from right subclavian artery, 10/15/2014
2. Normal CI 2.7 L/min/m2
3. Qp:Qs 0.53:1, assuming pulmonary venous saturation 95%
4. Normal RV filling pressure (RVEDP 8 mmHg)
5. Unobstructed RV-PA conduit
6. No flow from distal RV-PA conduit to right lung
7. Multiple aorto-pulmonary collaterals (described in the full report), supplying the entire right lung. Tiny collaterals to left upper lobe.
8. Double aortic arch status post distal ligation of the small left aortic arch, 5/10/2013
A. Dominant right aortic arch by angiography
INDICATIONS FOR CARDIAC CATHETERIZATION: Hemodynamic and angiographic evaluation of complex tetralogy of Fallot with pulmonary atresia, hypoplastic native branch pulmonary arteries and multiple aorto-pulmonary collateral arteries.
PROCEDURE: A timeout was performed to verify correct patient, procedure, and access sites. Deep sedation was administered by the pediatric anesthesiologist. The patient was prepped and draped in the usual sterile fashion. Following the infiltration of 1% buffered lidocaine in the bilateral groins, a 6 French sheath was inserted in the right femoral vein and a 4 French sheath was inserted in the left femoral artery by modified Seldinger technique under ultrasound guidance. 70 units/kg of heparin were given. ACTs were checked every 30 minutes and additional heparin given as needed to maintain ACT 200-250 seconds.
A baseline LFA blood gas and pressure were measured. A 6 French balloon wedge catheter was advanced through the venous sheath to the SVC. Saturations were measured in the SVC and IVC. Saturation and pressure were measured in the RA, RV, MPA, and LPA wedge. A 4 French pigtail catheter was advanced through the arterial sheath retrograde over a 0.035" straight wire to the RV. Pullback pressures were measured from RV to AAO to DAO.
The pigtail was advanced over the straight wire retrograde into the RV and a right ventriculogram obtained by power injection of contrast. The pigtail was withdrawn into the proximal DAO and a descending aortogram obtained with power injection of contrast. The pigtail was withdrawn more distally in the DAO and a descending aortogram obtained with power injection. A 6 French Berman angiographic catheter was advanced through the venous sheath and into the MPA and a pulmonary arteriogram was performed with power injection.
The pigtail was withdrawn over the straight wire, and a 4 French JR catheter advanced over a 0.035" straight wire, and a right sided aorto-pulmonary collateral was engaged, and an angiogram obtained by hand injection of contrast. A tiny left sided bronchial artery was also selectively engaged and an angiogram obtained by hand injection of contrast. The JR catheter was exchanged for a 4 French Cobra #2 glide catheter over the Wholey wire though additional collaterals could not be engaged with this catheter. The Cobra catheter was then exchanged for a 4 French IM catheter advanced over the straight wire to selectively engage another right sided AP collateral artery.
The IM catheter was removed over straight wire. The pigtail was advanced over the 0.035" straight wire retrograde into the AAO and an ascending aortogram with power injection obtained. This was withdrawn into the proximal DAO and a descending aortogram was repeated by power injection. The pigtail was removed over the straight wire. The Cobra catheter was advanced through the arterial sheath over the Wholey wire to search for further collaterals.
With the procedure concluded, all wires and catheters were removed. Additional 1% buffered lidocaine was infiltrated around the sheaths and the sheaths were removed. Hemostasis was obtained by manual pressure. Pressure dressings were applied to the bilateral groins. Emma was extubated uneventfully and transported to the recovery area in good condition.
ESTIMATED BLOOD LOSS: 20 ml
FLUOROSCOPY TIME: 24.8 min
RADIATION DOSE: 99 mGy
DOSE AREA PRODUCT: 1181 uGy x M2
TOTAL CONTRAST: 185 ml Omnipaque 350
COMPLICATIONS: None
HEMODYNAMIC DATA: (For pressures and saturations, please see heart diagram)
1. Oximetry data summary
All saturations were measured with the patient in deep sedation and spontaneously breathing receiving FiO2 30%. The MPA sat (which was 52%) was taken as the systemic venous saturation and pulmonary arterial saturation. There was no oximetric step up to suggest left to right shunt. The systemic arterial saturation was 75%. The pulmonary venous saturation was assumed to equal 95%. Using an assumed indexed VO2 of 133 ml/min/m2 (from Lafarge) and measured hemoglobin of 16 gm/dL, the cardiac index by Fick principle was normal at 2.7 L/min/m2. The Qp:Qs was 0.53:1.
2. Pressure data summary
Right heart filling pressures were normal (RA mean 6 mmHg, RVEDP 8 mmHg). There was no tricuspid valve inflow gradient (RA A-wave 8 mmHg, RVEDP 8 mmHg). The RV systolic pressure was essentially equal to systemic pressure. There was no gradient from the RV to the distal RV-PA conduit. There was no coarctation of the aorta. (AAO-DAO PSEG 8 mmHg). The pulmonary vascular resistance could not be determined due to multiple sources of pulmonary blood flow.
ANGIOGRAPHY:
1. Right ventriculogram. Power injection of contrast (30 ml, 15 ml/sec, 800 PSI, 1.0 rate rise) with cameras RAO-20 and LAO-70 demonstrated mildly diminished RV function, moderate right ventricular hypertrophy and dilation, and right to left shunting across a large ventricular septal defect. There was mild tricuspid regurgitation. The left ventricle systolic function was mildly diminished.
2. Proximal descending aorta. Power injection of contrast (30 ml, 21 ml/sec, 1200 PSI, no rise) with cameras straight AP and lateral demonstrated a widely patent descending aorta giving rise to multiple aorto-pulmonary collaterals, nearly all of which perfuse the right lung, with unobstructed right-sided pulmonary venous return.
3. Distal descending aorta. Power injection of contrast (21ml, 21 ml/sec, 1200 PSI, no rise) with cameras straight AP and lateral demonstrated the majority of the aorto-pulmonary collaterals arising from the thoracic descending aorta and perfusing the right lung.
4. Main pulmonary artery. Power injection of contrast (18 ml, 18 ml/sec, 500 PSI, 0.1 rate rise) with cameras LAO-20/CRA-20 and lateral demonstrated an unobstructed RV-PA conduit providing flow to the LPA and upper and middle lobes of the left lung. The distal branches were pulsatile with abnormal distal arborization. There was no perfusion to the right lung or left lower lobe. There was unobstructed pulmonary venous return from the left upper pulmonary vein. The conduit to RV connection was markedly aneurysmal.
5. Aorto-pulmonary collateral #1. Hand injection of contrast with cameras straight AP and lateral demonstrated a small collateral perfusing the right upper lobe of the lung arising rightward from the proximal descending aorta at the level of the most superior sternal wire with unobstructed right upper pulmonary venous return on levophase.
6. Aorto-pulmonary collateral #2. Hand injection of contrast demonstrated a tiny bronchial arterial branch off the left posterior side of the descending aorta with flow to the left lung.
7. Aorto-pulmonary collateral #3. Hand injection of contrast reveals a small aorto-pulmonary collateral arising rightward and anterior off the proximal descending aorta and perfusing the right milld and right lower lobes.
8 Ascending aorta. Power injection of contrast (20 ml, 20 ml/sec, 1200 PSI, no rise) with cameras straight AP and lateral demonstrated a right dominant aortic arch with the left carotid and left subclavian artery arising off the proximal remnant of the left aortic arch. There was no supravalvar aortic stenosis or coarctation. The proximal ascending aorta was moderately dilated. There was mild aortic regurgitation. Coronary artery origins were normal and unobstructed.
9. Descending aorta. Power injection of contrast (30 ml, 21 ml/sec, 1200 PSI, no rise) with cameras RAO-20 and LAO-68 demonstrated multiple small aorto-pulmonary collaterals arising off the descending aorta mostly perfusing the right lung.
DIAGNOSIS:
1. Pulmonary atresia, ventricular septal defect with hypoplastic pulmonary arteries supplied by aortopulmonary collaterals
A. S/P Waterston shunt, 5/10/2013
B. S/P Waterston shunt takedown, 10 mm valveless Gore-Tex RV-Pa conduit and unifocalization of AP collateral from right subclavian artery, 10/15/2014
2. Normal CI 2.7 L/min/m2
3. Qp:Qs 0.53:1, assuming pulmonary venous saturation 95%
4. Normal RV filling pressure (RVEDP 8 mmHg)
5. Unobstructed RV-PA conduit
6. No flow from distal RV-PA conduit to right lung
7. Multiple aorto-pulmonary collaterals (described in the full report), supplying the entire right lung. Tiny collaterals to left upper lobe.
8. Double aortic arch status post distal ligation of the small left aortic arch, 5/10/2013
A. Dominant right aortic arch by angiography