PROCEDURES PERFORMED:
1. Left heart
catheterization.
2. Selective coronary
angiography.
INDICATION FOR PROCEDURE:
Non-ST elevation MI.
DESCRIPTION OF PROCEDURE:
The patient was brought to the cardiac catheterization lab in fasting
state, informed consent was obtained and the patient was prepped and draped in
sterile fashion. Mild sedation was administered via IV Versed and fentanyl with
attending present during administration of sedation. The right common femoral
region was then anesthetized via 10 mL of 2% lidocaine and the right common
femoral artery was accessed via single wall puncture technique and a 4-French
femoral arterial sheath was advanced over a guidewire using modified Seldinger
technique. Next, a 4-French angled pigtail catheter was advanced over a
guidewire to the level of the ascending aorta. This catheter was used to cross
the aortic valve and enter the left ventricle where hemodynamic measurements
were obtained. Due to significantly elevated left ventricular end-diastolic
pressures, no left ventriculography was performed. The pigtail catheter was
then used to obtain hemodynamic measurements upon pullback across the aortic
valve into the ascending aorta. This pigtail catheter was then subsequently
withdrawn over a guidewire. Next, a 4-French 3DRC catheter was advanced over a
guidewire to the level of the ascending aorta. This catheter was used to
selectively engage the right coronary artery. The right coronary artery and its
branches were then imaged in multiple planes and views. The 3DRC catheter was
then withdrawn over a guidewire. Next, a 4-French JL4.5 catheter was advanced
over the guidewire to the level of the ascending aorta. This catheter was used to
selectively engage the left main coronary artery. The left main coronary artery
and its branches were then imaged in multiple planes and views. The JL4.5
catheter was then withdrawn over the guidewire. At the conclusion of the
procedure, the patient had the femoral arterial sheaths removed in the cardiac
catheterization lab with hemostasis obtained via manual compression, and the
patient was transferred to the coronary care unit for further observation and
care.
SELECTIVE CORONARY ANGIOGRAPHY:
1. Left main: The left main bifurcates into the left
anterior descending and circumflex coronary artery. The left main is
angiographically free of significant stenosis.
2. Left anterior
descending: The left anterior descending
coronary artery is noted to provide two diagonal branches and terminates as the
apical recurrent branch. The proximal LAD after this first small caliber
diagonal branch is noted to have a 90-95% stenosis.
3. Circumflex: The circumflex coronary artery is noted to
provide four obtuse marginal branches with OM2 being largest caliber obtuse
marginal branch. This OM2 branch is noted to have subtotal occlusion
proximally.
4. Right coronary
artery: The right coronary artery is
dominant and is noted to be completely occluded in its mid segment after
supplying an acute marginal branch. Also noted is the presence of bridging collaterals
that faintly fill the distal vessel. Additionally, during left coronary
injections, the presence of left to right collaterals from the apical LAD
supplying the distal right coronary artery is also noted.
LEFT HEART CATHETERIZATION:
Left ventricular end-diastolic pressure 27 pre-A wave and 40
post-A wave. There was no gradient noted upon pullback.
FINAL DIAGNOSIS:
1. Severe
three-vessel coronary artery disease in a diabetic patient.
2. Significantly
elevated left ventricular end-diastolic pressures.
PLAN: The patient was
referred for coronary artery bypass grafting and received IV Lasix in the
cardiac catheterization lab given his significantly elevated left ventricular
end-diastolic pressures.
