DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURES PERFORMED:
1. Selective coronary angiography.
2. Left heart catheterization.
3. Left ventricular catheter placement.
4. Right heart catheterization.
ATTENDING SURGEON: John Doe , MD
INDICATIONS: Angina, shortness of breath, and dyspnea on exertion.
DETAILS OF PROCEDURE: The patient was brought to the cath lab in an elective fashion. Informed consent was obtained. The right neck was prepped and draped in a sterile fashion. Then, 2% lidocaine was instilled into the area for local anesthesia. A 22-gauge needle was first used to locate the right internal jugular vein. Blood was aspirated. Subsequently, an 18-gauge needle was inserted in the same direction as the finder needle to locate the right internal jugular vein. This was successful. Blood was aspirated without difficulty. A short guidewire was inserted, which could not go fully into the vessel. Thus, the right internal jugular attempt was aborted and pressure was held. Subsequently, the right groin was prepped and draped in a sterile fashion. Lidocaine 2% was instilled into the area for local anesthesia. An 18-gauge needle connected to a syringe was used to locate the right femoral vein. Subsequently, a short guidewire was inserted into the vessel and the needle was removed.
Next, an 18-gauge needle was used to locate the right femoral artery. Upon pulsatile flow, a short guidewire was inserted without difficulty. Then, a 5-French sheath was inserted over the guidewire into the right femoral artery and an 8-French sheath was inserted over the guidewire leading to the right femoral vein. The catheters were then aspirated and flushed without difficulty. Subsequently, a Swan-Ganz catheter was inserted into the sheath located in the right femoral vein. At 20 cm, the balloon was inflated and directed into the heart under fluoroscopic guidance. Pressures were obtained in the appropriate cardiac chambers. Cardiac output and index were also taken.
Upon pulmonary capillary wedge pressure, the balloon was deflated and pulmonary arterial saturations were obtained. The Swan-Ganz catheter was subsequently removed. Next, a JL4 catheter was inserted into the sheath located in the right femoral artery over the guidewire. The guidewire and catheter were advanced to the aortic cusp. The guidewire was then removed and the catheter was connected to a manifold and was aspirated and flushed without difficulty. Using fluoroscopic guidance, the JL4 catheter was engaged into the left coronary artery system. Various angiographic projections were taken under fluoroscopic guidance. Next, the JL4 catheter was removed over the guidewire and a JR4 catheter was inserted into the sheath over the guidewire. The guidewire was removed. The catheter was aspirated and flushed without difficulty. The catheter was then engaged into the right coronary artery system.
Multiple angiographic images were taken under fluoroscopic guidance. Next, the JR4 catheter was used to locate three saphenous vein grafts. Multiple fluoroscopic views were taken of these vessels and subsequently the JR4 catheter was then used to cross the aortic valve to obtain end-diastolic pressures. A pullback was then performed with the JR4 catheter and the JR4 catheter was then removed.
RIGHT HEART CATHETERIZATION FINDINGS:
RA pressure 4 mmHg, right ventricular pressure 25/5 mmHg, PA pressure 25/15 with the mean of 12 mmHg, pulmonary capillary wedge pressure 10 mmHg, cardiac output 5.4 L/minute, cardiac index 2.5, PA saturation 66%, PVR 222, SVR 1190.
LEFT HEART CATHETERIZATION HEMODYNAMIC FINDINGS:
End-diastolic pressure was 20 mmHg.
ANGIOGRAPHIC FINDINGS:
1. Left main was angiographically normal.
2. LAD was ostially occluded.
3. Circumflex artery had luminal irregularities. The obtuse marginal arteries appeared to be occluded.
4. Right coronary artery had a chronic total occlusion in the proximal segment. In the mid to distal segment, there was a subtotal occlusion with bridging collaterals, and left to right collaterals were seen filling the distal vessel in that region.
5. Saphenous vein graft to right coronary artery occluded.
6. Saphenous vein graft to LAD showed a 99% occlusion in the anastomotic site with the LAD.
7. Saphenous vein jump graft to two successive obtuse marginal arteries was angiographically normal.
IMPRESSION:
1. Normal right heart pressures with adequate filling pressures and normal cardiac index.
2. Coronary artery disease with stenotic, flow-limiting lesion of the saphenous vein graft to left anterior descending at the anastomotic site.
3. The patient was admitted to the cardiac step-down unit for overnight observation following the procedure.
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