Still need help with this one:
PROCEDURES:
1. PTCA of the retrograde limb of the LAD beyond the area od touchdown grom the left internal mammary artery graft, upstream.
2. Intra-aortic balloon pump insertion.
3. Temporary pacemaker.
4. Cardiopulmonary fem-fem bypass.
PREOPERATIVE DIAGNOSES:
Status post bypass surgery and aortic valve replacement in July 2012, recurrent chest pain, unstable, admitted following diagnostic catheterization showing high-grade stenosis in the mid left anterior descending, proximal to the touchdown of the left internal mammary artery supplying the entire left ventricle, both proximal left anterior descending, septals, diagonals, and circumflex obtuse marginal. Presumed iatrogenic occlusion of the left main at the time of valve surgery.
COMPLICATIONS:
Acute cardiogenic shock with hypotension requiring CPS and cardiopulmonary support with fem-fem bypass.
PROCEDURE:
Using modified Seldinger technique, a 7 French sheath was inserted in the right femoral artery. After obtaining arterial access, a JB1 catheter was advanced retrogradely and engaged into the left subclavian. Using an exchange wire, the diagnostic catheter was removed in favor of a 7 French left internal mammary artery with side holes. The catheter was maneuvered and then engaged into the ostium of the tortuous, but patent left internal mammary artery connected to the med to distal LAD. With the guiding catheter in position, a Fielder XT wire was advanced down the tortuous path of the left internal mammary artery and positioned just at the point of the distal anastomosis going down the LAD. A second Fielder XT wire preloaded with 1.5 apex push catheter over the wire, was advanced down the graft and then maneuvered with changing of the tip progressively up the retrograde limb of the LAD beyond the anastomosis, and ultimately down the circumflex artery. With the wire in reasonable position, the balloon was advanced and multiple dilatations with a 1.5mm device was used into the LAD proximal to the area of anastomosis of the left internal mammary artery. After completion of the dilatation, a 2.5mm balloon was advanced at this time a monorail down into the mid LAD proximal to the anastomosis and dilated sequentially using a 2.5 mm balloon. After completion of the dilatation upon removal of the catheter, there appeared to be a dislodgement of the shaft from the balloon segment of the catheter itself, which seems to remain in the LAD proper.
At that point, the pt’s blood pressure started to fall. He complained of check pain and an intra-aortic balloon pump was placed immediately. Despite the counterpulsation, pressures continued to decrease despite also inotropic support. CPR was instituted.
After several mins of CPR, with the pt not recovering, intubation was performed successfully, pacemaker was inserted, and a snare was advanced, but could not reach the area where the balloon was lodged in the LAD. The snare was therefore moved around the wire and the wire was twirled around the catheter, bringing the entire assembly together, dislodging the balloon and retrieving it at the area of the femoral artery. After retrieval of the catheter, pressure remained very low with very ineffective counterpulsation. Therefore, it ws elected to put the patient on cardiopulmonary fem-fem bypass, which was done successfully with a 1 9 mm arterial and 21 mm venous cannula from the right groin. Following institution of the cardiopulmonary support, the pt appeared to stabilize some with a mean arterial pressure in the 50 to 60. O2 saturation 90% and at some point, after multiple DC cardioversion back into sinus rhythm and intermittent afib, the pt started to move his upper extremities and his head and open his eyes.
Given the evidence of still neurological functions with a hymodynamic situation that appeared to be critical but at least stable on CPS with 4 L of flow, and following conversation with the family, it was elected to move the pt to the OR for urgent re-do bypass surgery.
CONCLUSION:
PTCA of the LAD, but with in-situ balloon rupture of a 2.5mm apex balloon retrieval of the balloon, institution of cardiopulmonary bypass and balloon pumping support, as well as temp pacemaker.
92937- Angioplasty thru a bypass graft
33967- Intra aortic balloon pump
37197- Retrieval of foreign body
I believe the temp pacer and cardioversion is inclusive, but
what about the
92950-CPR
and the fem-fem by-pass?
PROCEDURES:
1. PTCA of the retrograde limb of the LAD beyond the area od touchdown grom the left internal mammary artery graft, upstream.
2. Intra-aortic balloon pump insertion.
3. Temporary pacemaker.
4. Cardiopulmonary fem-fem bypass.
PREOPERATIVE DIAGNOSES:
Status post bypass surgery and aortic valve replacement in July 2012, recurrent chest pain, unstable, admitted following diagnostic catheterization showing high-grade stenosis in the mid left anterior descending, proximal to the touchdown of the left internal mammary artery supplying the entire left ventricle, both proximal left anterior descending, septals, diagonals, and circumflex obtuse marginal. Presumed iatrogenic occlusion of the left main at the time of valve surgery.
COMPLICATIONS:
Acute cardiogenic shock with hypotension requiring CPS and cardiopulmonary support with fem-fem bypass.
PROCEDURE:
Using modified Seldinger technique, a 7 French sheath was inserted in the right femoral artery. After obtaining arterial access, a JB1 catheter was advanced retrogradely and engaged into the left subclavian. Using an exchange wire, the diagnostic catheter was removed in favor of a 7 French left internal mammary artery with side holes. The catheter was maneuvered and then engaged into the ostium of the tortuous, but patent left internal mammary artery connected to the med to distal LAD. With the guiding catheter in position, a Fielder XT wire was advanced down the tortuous path of the left internal mammary artery and positioned just at the point of the distal anastomosis going down the LAD. A second Fielder XT wire preloaded with 1.5 apex push catheter over the wire, was advanced down the graft and then maneuvered with changing of the tip progressively up the retrograde limb of the LAD beyond the anastomosis, and ultimately down the circumflex artery. With the wire in reasonable position, the balloon was advanced and multiple dilatations with a 1.5mm device was used into the LAD proximal to the area of anastomosis of the left internal mammary artery. After completion of the dilatation, a 2.5mm balloon was advanced at this time a monorail down into the mid LAD proximal to the anastomosis and dilated sequentially using a 2.5 mm balloon. After completion of the dilatation upon removal of the catheter, there appeared to be a dislodgement of the shaft from the balloon segment of the catheter itself, which seems to remain in the LAD proper.
At that point, the pt’s blood pressure started to fall. He complained of check pain and an intra-aortic balloon pump was placed immediately. Despite the counterpulsation, pressures continued to decrease despite also inotropic support. CPR was instituted.
After several mins of CPR, with the pt not recovering, intubation was performed successfully, pacemaker was inserted, and a snare was advanced, but could not reach the area where the balloon was lodged in the LAD. The snare was therefore moved around the wire and the wire was twirled around the catheter, bringing the entire assembly together, dislodging the balloon and retrieving it at the area of the femoral artery. After retrieval of the catheter, pressure remained very low with very ineffective counterpulsation. Therefore, it ws elected to put the patient on cardiopulmonary fem-fem bypass, which was done successfully with a 1 9 mm arterial and 21 mm venous cannula from the right groin. Following institution of the cardiopulmonary support, the pt appeared to stabilize some with a mean arterial pressure in the 50 to 60. O2 saturation 90% and at some point, after multiple DC cardioversion back into sinus rhythm and intermittent afib, the pt started to move his upper extremities and his head and open his eyes.
Given the evidence of still neurological functions with a hymodynamic situation that appeared to be critical but at least stable on CPS with 4 L of flow, and following conversation with the family, it was elected to move the pt to the OR for urgent re-do bypass surgery.
CONCLUSION:
PTCA of the LAD, but with in-situ balloon rupture of a 2.5mm apex balloon retrieval of the balloon, institution of cardiopulmonary bypass and balloon pumping support, as well as temp pacemaker.
92937- Angioplasty thru a bypass graft
33967- Intra aortic balloon pump
37197- Retrieval of foreign body
I believe the temp pacer and cardioversion is inclusive, but
what about the
92950-CPR
and the fem-fem by-pass?
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