DATE OF PROCEDURE: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe , MD
PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Coronary angioplasty.
PREOPERATIVE DIAGNOSES:
1. Angina.
2. History of coronary artery disease, status post coronary artery bypass graft.
POSTOPERATIVE DIAGNOSES:
1. Three-vessel coronary artery disease.
2. Low normal left ventricular systolic function.
3. Known chronically occluded saphenous vein graft to the right coronary artery.
4. Mild mitral regurgitation.
5. Successful percutaneous transluminal coronary angioplasty and stent of the proximal left anterior descending artery with Cypher drug-eluting stents.
DESCRIPTION OF PROCEDURE: Informed consent was obtained prior to the procedure. The patient was prepped and draped in the usual sterile fashion. The right groin was anesthetized with 2% lidocaine. A 6 French sheath was introduced in the right femoral artery via modified Seldinger technique. A 6 French angled pigtail was used for left ventriculography and aortic valve pullback. The 6 French JL4 and JR4 catheters were used for selective coronary angiography. Multiple views were obtained.
FINDINGS: The coronary circulation was right dominant.
Left main artery: Normal
Left anterior descending artery: The vessel was diffusely diseased along its entire length. The proximal vessel had an eccentric 60% to 70% stenosis, which was best appreciated in the cranial views. This was followed by a 50% to 60% narrowing in the mid vessel. The proximal lesion appeared worse than in the prior angiogram. The distal left anterior descending had 60% diffuse stenosis toward the apex. There was a large first diagonal branch, which bifurcated early and had mild to moderate diffuse disease but no critical stenoses. The left anterior descending did supply extensive grade 3 collaterals to the right coronary artery, posterior descending artery, and posterolateral circulation.
Left circumflex artery: There was 80% stenosis in the distal aspect of the vessel, jeopardizing only a very small caliber terminal portion of the vessel subtending a small distribution.
Right coronary artery: The proximal vessel was 100% occluded. This was unchanged from the prior angiogram.
Saphenous vein graft to right coronary artery: Occluded at the aorta.
Left ventricle: Ejection fraction 50%. There was mild hypokinesis of the inferior wall. There was mild 1+ mitral regurgitation. There was no aortic valve gradient. The left ventricular end diastolic pressure was 6.
INTERVENTIONAL PROCEDURE:
The findings of the diagnostic procedure were discussed with the patient, who agreed to proceed with angioplasty. The decision was made based on the progression of the disease in the left anterior descending accompanied by the patient's extensive class III anginal symptoms. The 6 French sheath was exchanged for a 7 French sheath over a wire. Angiomax was administered intravenously. ACT was determined to be therapeutic during the procedure. A 7 French JL4 guiding catheter was advanced to the left coronary ostium. A Prowater wire was advanced from the guide into the distal left anterior descending. The proximal left anterior descending was predilated with a 2.5 mm noncompliant balloon. A 3.5 x 18 mm Cypher drug-eluting stent was then deployed at 18 atmospheres in the proximal vessel. A 2.5 x 28 mm Cypher drug-eluting stent was then deployed beyond the first stent in overlapping fashion in the mid vessel. The stent was deployed at 9 atmospheres and the stent deployment balloon was then withdrawn 2 mm and reinflated to 15 atmospheres. The stents were then postdilated with noncompliant balloons, a 2.5 mm Quantum Maverick balloon distally to 14 atmospheres and a 3.5 mm Quantum Maverick balloon proximally to 18 atmospheres. Multiple views were obtained with and without the wire following conclusion of the procedure.
INTERVENTIONAL FINDINGS:
1. Proximal left anterior descending 70% reduced to 0%.
2. Mid left anterior descending 50% reduced to 0%.
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