Not sure about the RCFA angiogram with angio seal placement, is this billable?
INDICATION FOR PROCEDURE: Chest pain and abnormal stress test with
ST depressions in the inferior leads.
PROCEDURE PERFORMED:
1. Selective coronary angiography x3.
2. Retrograde left heart catheterization.
3. Left ventriculogram with power injection.
4. Right common femoral artery angiogram and 6-French AngioSeal
placement.
PROCEDURE DETAILS: After explaining the indications, risks, and
benefits of the procedure to the patient, informed consent was
obtained. The patient was brought to the cardiac cath lab in a
fasting state and sterilely prepped and draped per usual fashion. The
patient was found on preop labs to be hypomagnesemic with a magnesium
level of 1.3 therefore, 1 gram of magnesium sulfate was given IV. 1%
lidocaine was given over the right groin for local anesthesia. Using
a micropuncture needle, the right common femoral artery was accessed
and a 6-French hemostasis sheath was placed. Diagnostic 6-French JL4
and JR4 catheters were then used to selectively engage the left and
right coronary arteries and selective injections performed. The
patient was found to have severe vasospasm of the proximal part of
the right coronary artery which resolved completely with 150 mcg of
intracoronary nitroglycerin. A 6-French pigtail was then advanced
into the LV. LVEDP obtained and power injection performed with LV
obtained in the RAO position. Pullback then performed across the
aortic valve, and right common femoral angiogram was performed, a
6-French Angio-Seal placed successfully. The patient was then
transferred back to the holding area with no immediate
complications.
CORONARY ANGIOGRAPHY:
Left main bifurcates into the LAD and circumflex. Angiographically
normal.
LAD gives off a large diagonal branch then courses towards the apex.
Angiographically normal.
Circumflex is small and gives off about 3 small OM branches,
angiographically normal.
RCA dominant for the posterior circulation with severe vasospasm in
the proximal portion upon engagement that is completely resolved with
intracoronary nitroglycerin. Angiographically normal.
LEFT VENTRICULOGRAM: EF 55% to 60%. LVEDP around 15 mmHg. No
gradient across the aortic valve.
ASSESSMENT:
1. No evidence of coronary atherosclerosis.
2. Severe vasospasm of the right coronary artery, especially the
proximal segment, relieved with intracoronary nitroglycerin.
RECOMMENDATIONS: The patient will be discharged home today. Her
metoprolol was stopped and she was switched to long acting diltiazem.
She will come back to the clinic to reassess her symptoms. If she is
still symptomatic then the options are to either increase her
diltiazem dose, add long acting nitrates, and to reduce or stop some
of her medications that can potentially promote vasoconstriction.
INDICATION FOR PROCEDURE: Chest pain and abnormal stress test with
ST depressions in the inferior leads.
PROCEDURE PERFORMED:
1. Selective coronary angiography x3.
2. Retrograde left heart catheterization.
3. Left ventriculogram with power injection.
4. Right common femoral artery angiogram and 6-French AngioSeal
placement.
PROCEDURE DETAILS: After explaining the indications, risks, and
benefits of the procedure to the patient, informed consent was
obtained. The patient was brought to the cardiac cath lab in a
fasting state and sterilely prepped and draped per usual fashion. The
patient was found on preop labs to be hypomagnesemic with a magnesium
level of 1.3 therefore, 1 gram of magnesium sulfate was given IV. 1%
lidocaine was given over the right groin for local anesthesia. Using
a micropuncture needle, the right common femoral artery was accessed
and a 6-French hemostasis sheath was placed. Diagnostic 6-French JL4
and JR4 catheters were then used to selectively engage the left and
right coronary arteries and selective injections performed. The
patient was found to have severe vasospasm of the proximal part of
the right coronary artery which resolved completely with 150 mcg of
intracoronary nitroglycerin. A 6-French pigtail was then advanced
into the LV. LVEDP obtained and power injection performed with LV
obtained in the RAO position. Pullback then performed across the
aortic valve, and right common femoral angiogram was performed, a
6-French Angio-Seal placed successfully. The patient was then
transferred back to the holding area with no immediate
complications.
CORONARY ANGIOGRAPHY:
Left main bifurcates into the LAD and circumflex. Angiographically
normal.
LAD gives off a large diagonal branch then courses towards the apex.
Angiographically normal.
Circumflex is small and gives off about 3 small OM branches,
angiographically normal.
RCA dominant for the posterior circulation with severe vasospasm in
the proximal portion upon engagement that is completely resolved with
intracoronary nitroglycerin. Angiographically normal.
LEFT VENTRICULOGRAM: EF 55% to 60%. LVEDP around 15 mmHg. No
gradient across the aortic valve.
ASSESSMENT:
1. No evidence of coronary atherosclerosis.
2. Severe vasospasm of the right coronary artery, especially the
proximal segment, relieved with intracoronary nitroglycerin.
RECOMMENDATIONS: The patient will be discharged home today. Her
metoprolol was stopped and she was switched to long acting diltiazem.
She will come back to the clinic to reassess her symptoms. If she is
still symptomatic then the options are to either increase her
diltiazem dose, add long acting nitrates, and to reduce or stop some
of her medications that can potentially promote vasoconstriction.
