bhargavi
Guru
CLINICAL INDICATIONS
This is a 53 years old noninsulin dependent diabetic, hypertensive,
hyperlipidemic black male who is an active smoker. He was admitted to the
hospital with chest discomfort, palpitations, mild shortness of breath and
dizziness. She was found to have sugar greater than 400 with troponin-I that
had increased from 0.02 to 0.13 in the presence of a baseline abnormal
electrocardiogram. Subsequently, she underwent stress cardiac imaging study
which was suggestive of multivessel coronary disease and she was advised to
have cardiac catheterization.
PROCEDURES PERFORMED
1. Left heart catheterization.
2. Selective coronary angiography.
3. Left ventriculography.
4. Fluoroscopic examination of the heart.
5. Iliac angiography.
PROCEDURES PERFORMED
1. Left heart catheterization.
2. Selective coronary angiography.
3. Left ventriculography.
4. Fluoroscopic examination of the heart.
OPERATIVE PROCEDURE
Complete history and physical, laboratory data, chest x-ray and
electrocardiogram showed the patient to be a suitable candidate for cardiac
catheterization. The patient signed informed consent after appropriately
identifying the patient and complete review of the risks, complications,
benefits and alternative procedures were available. The patient was prepped and
draped in the usual sterile fashion and the right femoral region anesthetized
with 1% Lidocaine.
A 6-French short sheath was introduced in the right femoral artery. Using
standard retrograde technique, cardiac catheterization was performed of the
left and right coronary arteries using 6-French FL4 and FR4 catheters in
multiple LAO and RAO projection. A left ventriculogram was performed in the
RAO projection using a 5 French pigtail catheter. Pressures were measured in
the left ventricle as well as in the ascending aorta.
A total of 20 milliliters of Optiray contrast was used. Pre-procedure
medication included 2 mg Versed and 50 mg Benadryl. The sheaths were kept in
place and the patient was referred to Dr. Scaffidi for percutaneous coronary
intervention. There were no immediate complications. The patient had no
pruritus or skin rash.
HEMODYNAMICS
Left ventricle 160/10
Aorta 160/65, mean 95.
LEFT VENTRICULOGRAPHY
Normal left ventricular systolic function with an estimated ejection fraction
of 55%. Normal wall motion abnormalities were noted. There is no evidence or
mitral regurgitation noted.
CORONARY ANGIOGRAPHY
Severe triple coronary artery disease in a right dominant system.
1. Left main coronary artery is free of significant disease.
2. Left anterior descending coronary artery has 80 percent stenosis in its mid
portion. There is mild to moderate disease in the diagonal system.
3. The circumflex coronary artery is nondominant and has 80 percent stenosis
in its mid portion. There is mild to moderate disease in the circumflex
marginal branches.
4. The right coronary artery is totally occluded in its mid portion. The
distal right and PDA are visualized via right to left and right to right
collaterals.
CONCLUSIONS
1. Severe triple vessel coronary artery disease in a right dominant system.
There is total occlusion of the mid right coronary artery which is consistent
with Cardiolite imaging and may be the culprit vessel. There is also 80
percent stenosis in the mid left anterior descending and 80 percent stenosis in
the mid circumflex. The patient will be referred to Dr. for stage
stenting.
2. Normal left ventriculography with estimated LVF of 55 percent.
3. Moderate systolic hypertension.
CLINICAL INDICATIONS
Severe RCA stenosis.
CLINICAL HISTORY
Tracy Terrell is a 53 years old woman with a history of diabetes and
hypertension as well as tobacco abuse. He presented to the Kent General
Hospital on January 14 with complaints of chest pain. She had borderline
elevation of her cardiac enzymes and underwent stress testing that suggested
mid anterior and inferior ischemia. She underwent coronary angiography today by
Dr. Ramos which revealed a focal mid left anterior descending and mid left
circumflex stenosis with a more lengthy area of subtotal occlusion in the mid
to distal right coronary artery with left to right collateralization. We had
considered referring the patient for coronary bypass surgery but at Dr. Ramos'
request, I attempted to perform percutaneous intervention of the right coronary
artery.
TECHNIQUE
After completion of the diagnostic procedure, we went directly into the
attempted percutaneous intervention. The existing six French sheath was
maintained in place. Angiomax by intravenous bolus and infusion was
administered in order to achieve an activated clotting time in excess of 300
seconds. The right coronary artery was then selectively engaged utilizing a
six French JR4 guide catheter. We then obtained a 180 centimeters Asahi
Prowater straight wire which we attempted to advance into the small residual 99
percent channel in the junction of the middle and distal thirds of the right
coronary artery. Unfortunately, we were unsuccessful in advancing the wire.
We decided to switch this wire for a 190 centimeters 0.014 inch Whisper Wire
hoping that the hydrophilic coating on the Whisper Wire would allow for
successful passage of the wire. Unfortunately, this was not successful despite
utilization of a nondilated 1.5 millimeters balloon as back up. We then
removed the Whisper Wire and balloon and readvanced the Asahi Prowater wire and
attempted to advance it with balloon back up guidance. Again, this was
unsuccessful. At this point, we felt that our likelihood of success was
becoming increasingly low with an increasingly high risk of complications. We
decided to abort any further attempts at intervention. Follow-up angiography
after removal of the guide wire revealed no change in the appearance of the
right coronary artery. We then concluded the attempted angioplasty procedure.
We did utilize our six French guide catheter to perform nonselective injection
of the left internal mammary artery via the left subclavian vessel. This
revealed osteal 20 to 30 percent disease in the left subclavian with widely
patent left anterior mammary artery with good run off.
Nonselective injection of the right ileofemoral system revealed acceptable
positioning of the arterial sheath in the distal right common femoral artery
above the common femoral bifurcation. As there was no angiographic evidence of
disease at the site of sheath insertion, we placed a six French Angio-Seal
device for hemostasis. The patient was then transferred to the recovery area
in stable condition.
IMPRESSION
1. Severe subtotal occlusion in the mid to distal right coronary artery
status post unsuccessful recanalization.
2. Severe three vessel coronary disease.
3. Widely patent IMA.
4. Status post Angio-Seal placement.
I billed only 93458 for 1st doctor as second drs procedure was unsuccessful intervention. my question is second doctor did shoot ima . do I bill anything for the second procedure . this was done in cath lab same day
thanks in advance
This is a 53 years old noninsulin dependent diabetic, hypertensive,
hyperlipidemic black male who is an active smoker. He was admitted to the
hospital with chest discomfort, palpitations, mild shortness of breath and
dizziness. She was found to have sugar greater than 400 with troponin-I that
had increased from 0.02 to 0.13 in the presence of a baseline abnormal
electrocardiogram. Subsequently, she underwent stress cardiac imaging study
which was suggestive of multivessel coronary disease and she was advised to
have cardiac catheterization.
PROCEDURES PERFORMED
1. Left heart catheterization.
2. Selective coronary angiography.
3. Left ventriculography.
4. Fluoroscopic examination of the heart.
5. Iliac angiography.
PROCEDURES PERFORMED
1. Left heart catheterization.
2. Selective coronary angiography.
3. Left ventriculography.
4. Fluoroscopic examination of the heart.
OPERATIVE PROCEDURE
Complete history and physical, laboratory data, chest x-ray and
electrocardiogram showed the patient to be a suitable candidate for cardiac
catheterization. The patient signed informed consent after appropriately
identifying the patient and complete review of the risks, complications,
benefits and alternative procedures were available. The patient was prepped and
draped in the usual sterile fashion and the right femoral region anesthetized
with 1% Lidocaine.
A 6-French short sheath was introduced in the right femoral artery. Using
standard retrograde technique, cardiac catheterization was performed of the
left and right coronary arteries using 6-French FL4 and FR4 catheters in
multiple LAO and RAO projection. A left ventriculogram was performed in the
RAO projection using a 5 French pigtail catheter. Pressures were measured in
the left ventricle as well as in the ascending aorta.
A total of 20 milliliters of Optiray contrast was used. Pre-procedure
medication included 2 mg Versed and 50 mg Benadryl. The sheaths were kept in
place and the patient was referred to Dr. Scaffidi for percutaneous coronary
intervention. There were no immediate complications. The patient had no
pruritus or skin rash.
HEMODYNAMICS
Left ventricle 160/10
Aorta 160/65, mean 95.
LEFT VENTRICULOGRAPHY
Normal left ventricular systolic function with an estimated ejection fraction
of 55%. Normal wall motion abnormalities were noted. There is no evidence or
mitral regurgitation noted.
CORONARY ANGIOGRAPHY
Severe triple coronary artery disease in a right dominant system.
1. Left main coronary artery is free of significant disease.
2. Left anterior descending coronary artery has 80 percent stenosis in its mid
portion. There is mild to moderate disease in the diagonal system.
3. The circumflex coronary artery is nondominant and has 80 percent stenosis
in its mid portion. There is mild to moderate disease in the circumflex
marginal branches.
4. The right coronary artery is totally occluded in its mid portion. The
distal right and PDA are visualized via right to left and right to right
collaterals.
CONCLUSIONS
1. Severe triple vessel coronary artery disease in a right dominant system.
There is total occlusion of the mid right coronary artery which is consistent
with Cardiolite imaging and may be the culprit vessel. There is also 80
percent stenosis in the mid left anterior descending and 80 percent stenosis in
the mid circumflex. The patient will be referred to Dr. for stage
stenting.
2. Normal left ventriculography with estimated LVF of 55 percent.
3. Moderate systolic hypertension.
CLINICAL INDICATIONS
Severe RCA stenosis.
CLINICAL HISTORY
Tracy Terrell is a 53 years old woman with a history of diabetes and
hypertension as well as tobacco abuse. He presented to the Kent General
Hospital on January 14 with complaints of chest pain. She had borderline
elevation of her cardiac enzymes and underwent stress testing that suggested
mid anterior and inferior ischemia. She underwent coronary angiography today by
Dr. Ramos which revealed a focal mid left anterior descending and mid left
circumflex stenosis with a more lengthy area of subtotal occlusion in the mid
to distal right coronary artery with left to right collateralization. We had
considered referring the patient for coronary bypass surgery but at Dr. Ramos'
request, I attempted to perform percutaneous intervention of the right coronary
artery.
TECHNIQUE
After completion of the diagnostic procedure, we went directly into the
attempted percutaneous intervention. The existing six French sheath was
maintained in place. Angiomax by intravenous bolus and infusion was
administered in order to achieve an activated clotting time in excess of 300
seconds. The right coronary artery was then selectively engaged utilizing a
six French JR4 guide catheter. We then obtained a 180 centimeters Asahi
Prowater straight wire which we attempted to advance into the small residual 99
percent channel in the junction of the middle and distal thirds of the right
coronary artery. Unfortunately, we were unsuccessful in advancing the wire.
We decided to switch this wire for a 190 centimeters 0.014 inch Whisper Wire
hoping that the hydrophilic coating on the Whisper Wire would allow for
successful passage of the wire. Unfortunately, this was not successful despite
utilization of a nondilated 1.5 millimeters balloon as back up. We then
removed the Whisper Wire and balloon and readvanced the Asahi Prowater wire and
attempted to advance it with balloon back up guidance. Again, this was
unsuccessful. At this point, we felt that our likelihood of success was
becoming increasingly low with an increasingly high risk of complications. We
decided to abort any further attempts at intervention. Follow-up angiography
after removal of the guide wire revealed no change in the appearance of the
right coronary artery. We then concluded the attempted angioplasty procedure.
We did utilize our six French guide catheter to perform nonselective injection
of the left internal mammary artery via the left subclavian vessel. This
revealed osteal 20 to 30 percent disease in the left subclavian with widely
patent left anterior mammary artery with good run off.
Nonselective injection of the right ileofemoral system revealed acceptable
positioning of the arterial sheath in the distal right common femoral artery
above the common femoral bifurcation. As there was no angiographic evidence of
disease at the site of sheath insertion, we placed a six French Angio-Seal
device for hemostasis. The patient was then transferred to the recovery area
in stable condition.
IMPRESSION
1. Severe subtotal occlusion in the mid to distal right coronary artery
status post unsuccessful recanalization.
2. Severe three vessel coronary disease.
3. Widely patent IMA.
4. Status post Angio-Seal placement.
I billed only 93458 for 1st doctor as second drs procedure was unsuccessful intervention. my question is second doctor did shoot ima . do I bill anything for the second procedure . this was done in cath lab same day
thanks in advance