Cardiac Cath

PART I

PROCEDURE
Cardiac catheterization.

INDICATIONS
Coronary artery disease.

Positive cardiovascular stress test.

PROCEDURE PERFORMED
Selective coronary angiogram.

Left heart catheterization.

COMPLICATIONS
None.

DESCRIPTION OF THE PROCEDURE
Prior to the test, risk, benefit and alternatives were discussed with the patient and informed consent were obtained.  Patient brought to the cath laboratory in stable condition.  He was prepped and draped in the usual sterile fashion.  We used Versed and fentanyl for conscious sedation and lidocaine for local anesthesia.  We accessed the right radial artery and 5-French sheath was placed and we advanced 5-French JL3.5 catheter over the wire and engaged the left main, images obtained.  Then, we advanced 5-French JR5 over the wire and engaged to the RCA, images obtained.  With the JR catheter we brought the aortic valve and pressure obtained and the gradient across the valve obtained with pullback technique.  Catheter removed from the wire and the TR placed over radial artery have been removed and sheath and complete hemostasis obtained.

FINDINGS
A. Hemodynamics:  The left ventricular end-diastolic pressure was 10. There was no significant gradient across the aortic valve.

B. Coronary angiogram:

Left main:  Left main originates from the left cusp in usual fashion and gives small left circumflex and then it bifurcates large ramus and no disease.

Left circumflex:  Left circumflex is a small artery and showed just mild luminal irregularity.

Ramus:  Ramus is a large caliber artery acting like the circumflex and showed just mild luminal irregularity.

LAD:  LAD is a large caliber artery, wrapped around the apex and showed mild luminal irregularity.  It gives moderate-sized diagonal branches and showed ______ luminal irregularity.

RCA:  Originates from the right cusp in usual fashion. It is a dominant artery.  It showed mild disease in the proximal RCA about 30% to 40%.  There is a stent in the mid RCA, which showed mild luminal disease and distal RCA and PDA showed mild luminal irregularity.

FINAL IMPRESSION
Moderate coronary artery disease as described above with patent mid right coronary artery stent which showed mild in-stent restenosis 30% to 40% mid proximal right coronary artery and the rest of arteries showed just mild luminal irregularity. 

RECOMMENDATIONS
Continue risk factor modification.  Continue Plavix, given the ______ we will add Lipitor 40 mg.  Followup in two weeks after discharge.

Thank you so much for the consultation.  We will continue to follow with you.  Please call us if you have any questions.



INDICATIONS
This is a gentleman with dyspnea on exertion, has positive stress test with lateral wall ischemia.

PROCEDURE PERFORMED
Please see doctor diagnostic catheterization report.

Successful percutaneous coronary intervention to the mid left circumflex with 3.5 x 12 Synergy DES stent, post dilated by 4 x 8 noncompliant balloon to 12 atmospheres.

COMPLICATIONS
None.

DESCRIPTION OF THE PROCEDURE
Please refer to Doctor for diagnostic part of this procedure.  Formal consents were obtained before the procedure.  The patient prepped and draped in the usual sterile fashion and we use right radial access and sheath were placed.  I advanced 3.5 CLS guide catheter engaged to the left main.  The patient got heparin for anticoagulation and his ACT was 283 and got 1000 extra during the procedure of heparin.  We advanced Prowater guidewire over the wire across the lesion and the tip placed distally.  Then, we advanced a 3.5 x 12 Synergy DES stent positioned across the lesion and deployed successfully.  Then, we advanced a 4 x 8 noncompliant balloon, placed successfully inside the stent and inflated to 12 atmospheres.  Images obtained and showed no dissection or residual stenosis, wire removed, and final images obtained, showed no dissection, no residual stenosis and TIMI-3 flow.  The catheter removed and TR band placed and complete hemostasis obtained.  Patient is getting aspirin and he got 180 mg of Brilinta and he will continue 90 mg b.i.d. for at least one year.  The patient to continue risk factor modification and he will continue to follow up with Doctor.

PART II

INDICATION
Cardiomyopathy, abnormal stress test.

COMPLICATIONS
None.

DESCRIPTION OF PROCEDURE
Please refer to Doctor for diagnostic part of this procedure.  A formal consent obtained prior to the test.  Radial access was obtained and diagnostic catheter was done by Doctor.  Patient has mid LAD lesion, which is 50% to 60% and Doctor requested iFR for this lesion.  Patient got already 3000 of heparin and ACT was 221.  Patient got another 2000 of heparin.  We used a CLS 3.5 guide catheter over the wire and engaged to the left main.  Then, we advanced the iFR wire and placed in the left main and normalization obtained.  Then, we advanced the wire to the distal LAD beyond the mid LAD lesion.  The iFR obtained and it was 0.93, which is considered normal.  Wire removed.  More images obtained, showed no complication.  Then, the catheters were removed over the wire.  The sheath was removed and TR band placed and complete hemostasis obtained.  Patient left cath lab in a stable condition.

FINAL IMPRESSION
50% to 60% mid left anterior descending lesion, which is hemodynamically insignificant as proven by iFR with a value of 0.93.  Diagnostic catheter as per Doctor.

PART III

INDICATION
Cardiomyopathy.

COMPLICATIONS
None.

DESCRIPTION OF THE PROCEDURE
This is the interventional part of this procedure.  Please refer to Doctor for diagnostic cath report.  Formal consent were obtained prior to the test.  The patient was prepped and draped in the usual sterile fashion.  diagnostic catheter was done by Doctor with radial axis.  There was concern that the patient has mid LAD lesion  as he has a 50% stenosis.  Also, he has very distal/apical LAD lesion, which is about 90% with a small artery at 1.5 mm.  We used CLS guide catheter and engaged the left main.  Angiomax bolus and drip was started.  We used the IFR wire and normalized in the left main and then advanced to the distal LAD.  IFR came back normal with a number of 0.92.  After that we tried to advance this wire to the distal apical LAD, though I was not able to cross the tight lesion.  I then re-exchanged it with the Choice PT wire with multiple attempts to cross the tight apical lesion without success.  At the end of the procedure, wire was removed.  The final images were obtained showed no dissection, TIMI-3 flow and no complications.  Procedure ended and TR band placed and complete hemostasis was obtained.  Patient left cath lab in stable condition.

FINAL IMPRESSION
Normal IFR to the mid left anterior descending artery lesion calculated as 0.92.

Unsuccessful percutaneous transluminal coronary angioplasty to distal/apical left anterior descending artery, which is 90% and 1.5 mm artery.

RECOMMENDATION
Continue max medical therapy for coronary disease and cardiomyopathy.

PART III

INDICATION
Chest pain and positive stress test.

COMPLICATIONS
None.

DESCRIPTION OF THE PROCEDURE
Prior to the test, risks, benefits, and alternatives were discussed with the patient and informed consent were obtained.  Patient brought in stable condition and he was prepped and draped in the usual sterile fashion.  We accessed right femoral artery and 5-French sheath was placed.  We advanced a 5-French JL4 catheter over the wire and engaged to the left main.  Images obtained.  Then, we advanced a 5-French JR catheter over the wire and engaged to the RCA, images obtained.  Catheter was removed over the wire and the patient has high bifurcation and sheath was removed by manual compression.  The patient left cath lab in stable condition.

FINDINGS
Left main:  Left main originates from the left cusp in usual fashion, showed no disease, bifurcate to the left circumflex and LAD.  Left circumflex is a moderate size artery and showed just mild luminal irregularity and continue mainly as OM1.

LAD:  LAD is a large caliber artery, showed mid LAD stent, which is patent and showed just mild to moderate in-stent restenosis.  Then, patient has another stent in the mid distal LAD and it is patent and showed just mild in-stent stenosis.  Patient has small diagonal branches, which showed no significant disease.

RCA:  RCA originates from the right cusp in usual fashion.  It has two stents in the proximal RCA and distal RCA, and showed just mild luminal irregularity.  The RCA is dominant and the PDA showed mild to moderate disease.

IMPRESSION
Coronary artery disease as described above with patent stent to the mid and mid distal left anterior descending with just mild to moderate in-stent restenosis.

Patent stent to the proximal and distal right coronary artery, which showed mild in-stent stenosis.

The right coronary artery is dominant and the PDA showed just mild to moderate stenosis.

RECOMMENDATION
Continue to maximize medical therapy.