LOVE2CODE
Expert
Please help me code this case.....
PROCEDURES PERFORMED:
1. Selective injection of left and right coronary arteries.
2. Right heart catheterization with measurement of right-sided pressures.
3. Left heart catheterization with left ventricular angiogram.
4. Right femoral arteriotomy site closure with Mynx vascular closure device.
5. Aortic Root Angiogram
INDICATIONS FOR PROCEDURE:
1. Congestive heart failure.
2. Valvular heart disease.
DESCRIPTION OF PROCEDURE: After explaining the risks and benefits of cardiac
catheterization to the patient, informed consent was obtained. The patient was
brought to the cardiac catheterization laboratory in the postabsorptive state. The
right femoral region was prepped and draped in the usual sterile fashion. The
right femoral vein was cannulated and an 7-French femoral venous sheath was
introduced via the modified Seldinger technique. The right femoral artery was
subsequently cannulated and a 6-French femoral arterial sheath was introduced via
the modified Seldinger technique. Right heart catheterization was performed by
means of an 8-French Swan-Ganz catheterization with measurement of pressures in the
right atrium, right ventricle, mean pulmonary artery and the pulmonary capillary
wedge pressure. Oxygen saturation was also measured in the wedge position and the
mean pulmonary artery. After right heart catheterization, the ventricular was
catheterized by means of a 6-French Langston catheter with measurement of
simultaneous pressures in the left ventricle and the aorta. Left and right
coronaries were selectively engaged by means of 6-French JL4 and 6-French JR4
catheters respectively. Cineangiograms were taken in multiple projections.
At the end of the procedure, all of the catheters were removed and the right
femoral arteriotomy site was closed by means of Mynx vascular closure device. The
right femoral sheath was removed and hemostasis secured by manual pressure for 10
to 15 minutes.
The patient tolerated the procedure very well without any adverse outcomes. The
patient was transported back to the floor for routine ongoing monitoring.
DIAGNOSTIC FINDINGS:
HEMODYNAMICS:
1. Right atrial pressure 25 mmHg.
2. RV pressure 43/21 mmHg- pressure tracing showed giant V-waves.
3. PA pressure 48/23 mmHg.
4. Mean pulmonary artery pressure 31 mmHg.
5. Left ventricular end-diastolic pressure 20 mmHg.
6. Left ventricular pressure 114/20 mmHg.
7. Pulmonary capillary wedge pressure 21 mmHg.
8. Aortic pressure 116/67 mmHg.
9. Cardiac output 3.11 l/m by FICK method and cardiac index 1.9.
10. Pulmonary capillary wedge saturation 96%.
11. Aortic saturation 92%.
12. PA saturation 36%.
13. There was no LV AO gradient on simultaneous LV AO pressure recording and also
on LV AO pullback.
LEFT VENTRICULAR ANGIOGRAPHY:
1. LV angiogram revealed normal ejection fraction with no wall motion
abnormality. LVEF is estimated at 60%. (limited -Hand Injection)
2. Mild mitral regurgitation.
3. Mild aortic regurgitation noted Aortic Root injection. The rest of the
ascending aorta appeared to be normal other than the fact that she has mid
calcification (limited- Hand Injection).
CORONARY ANGIOGRAPHY:
1. Left main coronary artery: The left main coronary artery is a moderate-caliber
vessel with mild disease with mild to moderate calcification.
2. Left anterior descending artery: The left anterior descending artery is
heavily calcified. The LAD has 2 tandem lesions, 40% stenosis in the proximal
segment and 40% stenosis in the mid segment.
3. Left circumflex artery: The left circumflex artery gives rise to a large
obtuse marginal, which has mild diffuse disease and is also calcified.
4. Right coronary artery: The right coronary artery is 100% in the proximal
segment. The right coronary artery has collaterals from the left side. It
appears that the right coronary artery is a dominant vessel.
CONCLUSIONS:
1. Completely occluded RCA with left sided collaterals.
2. Elevated left ventricular end-diastolic pressure.
3. Moderate passive pulmonary hypertension.
RECOMMENDATIONS:
1. Recommend medical treatment for coronary artery disease.
2. If the patient is considering surgery for the valve she may need TEE. If not
treat medically. (At this point the patient did not want any surgical
intervention.
Thanks so much.....
PROCEDURES PERFORMED:
1. Selective injection of left and right coronary arteries.
2. Right heart catheterization with measurement of right-sided pressures.
3. Left heart catheterization with left ventricular angiogram.
4. Right femoral arteriotomy site closure with Mynx vascular closure device.
5. Aortic Root Angiogram
INDICATIONS FOR PROCEDURE:
1. Congestive heart failure.
2. Valvular heart disease.
DESCRIPTION OF PROCEDURE: After explaining the risks and benefits of cardiac
catheterization to the patient, informed consent was obtained. The patient was
brought to the cardiac catheterization laboratory in the postabsorptive state. The
right femoral region was prepped and draped in the usual sterile fashion. The
right femoral vein was cannulated and an 7-French femoral venous sheath was
introduced via the modified Seldinger technique. The right femoral artery was
subsequently cannulated and a 6-French femoral arterial sheath was introduced via
the modified Seldinger technique. Right heart catheterization was performed by
means of an 8-French Swan-Ganz catheterization with measurement of pressures in the
right atrium, right ventricle, mean pulmonary artery and the pulmonary capillary
wedge pressure. Oxygen saturation was also measured in the wedge position and the
mean pulmonary artery. After right heart catheterization, the ventricular was
catheterized by means of a 6-French Langston catheter with measurement of
simultaneous pressures in the left ventricle and the aorta. Left and right
coronaries were selectively engaged by means of 6-French JL4 and 6-French JR4
catheters respectively. Cineangiograms were taken in multiple projections.
At the end of the procedure, all of the catheters were removed and the right
femoral arteriotomy site was closed by means of Mynx vascular closure device. The
right femoral sheath was removed and hemostasis secured by manual pressure for 10
to 15 minutes.
The patient tolerated the procedure very well without any adverse outcomes. The
patient was transported back to the floor for routine ongoing monitoring.
DIAGNOSTIC FINDINGS:
HEMODYNAMICS:
1. Right atrial pressure 25 mmHg.
2. RV pressure 43/21 mmHg- pressure tracing showed giant V-waves.
3. PA pressure 48/23 mmHg.
4. Mean pulmonary artery pressure 31 mmHg.
5. Left ventricular end-diastolic pressure 20 mmHg.
6. Left ventricular pressure 114/20 mmHg.
7. Pulmonary capillary wedge pressure 21 mmHg.
8. Aortic pressure 116/67 mmHg.
9. Cardiac output 3.11 l/m by FICK method and cardiac index 1.9.
10. Pulmonary capillary wedge saturation 96%.
11. Aortic saturation 92%.
12. PA saturation 36%.
13. There was no LV AO gradient on simultaneous LV AO pressure recording and also
on LV AO pullback.
LEFT VENTRICULAR ANGIOGRAPHY:
1. LV angiogram revealed normal ejection fraction with no wall motion
abnormality. LVEF is estimated at 60%. (limited -Hand Injection)
2. Mild mitral regurgitation.
3. Mild aortic regurgitation noted Aortic Root injection. The rest of the
ascending aorta appeared to be normal other than the fact that she has mid
calcification (limited- Hand Injection).
CORONARY ANGIOGRAPHY:
1. Left main coronary artery: The left main coronary artery is a moderate-caliber
vessel with mild disease with mild to moderate calcification.
2. Left anterior descending artery: The left anterior descending artery is
heavily calcified. The LAD has 2 tandem lesions, 40% stenosis in the proximal
segment and 40% stenosis in the mid segment.
3. Left circumflex artery: The left circumflex artery gives rise to a large
obtuse marginal, which has mild diffuse disease and is also calcified.
4. Right coronary artery: The right coronary artery is 100% in the proximal
segment. The right coronary artery has collaterals from the left side. It
appears that the right coronary artery is a dominant vessel.
CONCLUSIONS:
1. Completely occluded RCA with left sided collaterals.
2. Elevated left ventricular end-diastolic pressure.
3. Moderate passive pulmonary hypertension.
RECOMMENDATIONS:
1. Recommend medical treatment for coronary artery disease.
2. If the patient is considering surgery for the valve she may need TEE. If not
treat medically. (At this point the patient did not want any surgical
intervention.
Thanks so much.....