Cardiology

Left Heart Catheterization

NAME OF PROCEDURE: 

1.    Left heart catheterization.

2.    Left ventricular cineangiography.

3.    Selective coronary arteriography. 

IMPRESSION:

1.    Severe native three vessel coronary artery disease. 

2.    Patent left internal mammary artery to the left anterior descending artery. 

3.    Severe left ventricular dysfunction with ejection fraction of 20%. 

4.    Trace mitral regurgitation.

5.    No evidence of aortic stenosis. 

INDICATIONS:

Patient is a 62-year-old male with a history of coronary artery bypass grafting with known previous closure of saphenous vein graft x 3 with known patent left internal mammary artery, who underwent a complex coronary intervention on his native first and second obtuse marginals, including the proximal circumflex, who presented with complaints of substernal chest discomfort, consistent with previous anginal pain.  Patient also has elevated cardiac markers.  Patient was subsequently referred for cardiac catheterization for further evaluation. 

DESCRIPTION OF PROCEDURE:

After discussing the risks, benefits and alternatives with the patient, informed consent was obtained.  The patient was brought to Cardiac Catheterization Lab, prepped and draped in standard sterile fashion.  1% lidocaine was used for anesthesia right groin.  A 6 French sheath was placed in the right femoral artery via modified Seldinger technique.  A 6 French internal mammary artery diagnostic catheter was then inserted through the sheath and cannulate the ostium of left internal mammary artery.  Multiple angiograms performed in multiple views via hand injection technique.  This catheter was exchanged for a 6 French Judkins right 4 diagnostic catheter which was used to cannulate the ostium of the right coronary artery.  Multiple angiograms were performed in multiple views using the hand injection technique.  Then this was exchanged for a 6 French Judkins left 4 diagnostic catheter, which was directed to analyze the ostium of the left main coronary artery.  Multiple angiograms with multiple views via the hand injection technique.  This was exchanged for a 6 French pigtail catheter which was inserted into the left ventricular chamber.  Left ventricular pressure was measured and left ventricular cineangiography was performed in the biplane views.  Post-ventriculography pressure was measured and pull-back pressure was measured.  The pigtail catheter was then removed.  Following review of the angiograms, it was decided that coronary intervention will be performed.  This will be dictated as a separate procedure.  6 French right femoral vein and sheath were placed via modified Seldinger technique.  The patient tolerated the procedure well and there were no complications. 

HEMODYNAMICS:

Opening aortic pressure 103/43, mean of 68.  Left ventricular pressure was 100/8 with left ventricular end diastolic pressure of 20.  There was no aortic graft gradient upon pull-back of then pigtail across the aortic valve. 

CINEANGIOGRAPHY:

1.    Left main - left main had approximately an 80% stenosis in its mid-to-distal portion.  This stenosis also involves the ostium and proximal portion of the circumflex artery.  The left main bifurcated into left anterior descending artery and left circumflex artery.

2.    Left anterior descending artery - left anterior descending artery was moderately calcified.  There was approximately 70% stenosis in the proximal portion and just distal to this stenosis, the left anterior descending artery was 100% occluded.  The left anterior descending artery could be seen filling retrogradely by the left internal mammary artery. 

3.    Left circumflex artery - left circumflex artery had approximately 90% stenosis at its proximal portion, just at the take-off of the first obtuse marginal.  The first obtuse marginal also had an approximately 95% stenosis in its ostium.  The stents placed previously in the proximal and mid portion of the first obtuse marginal were patent with in-stent restenosis.  The distal first obtuse marginal was a very small caliber vessel.  The circumflex artery then gave off a second obtuse marginal branch in its mid portion.  Previously placed stents in this area were widely patent with minimal in-stent restenosis.  The remainder of the circumflex artery had minimal irregularities. 

4.    Right coronary artery - the right coronary artery was 100% occluded in its proximal portion.  Of note, the distal PDA could be seen filling via left-to-right collaterals. 

5.    Left internal mammary artery - the left internal mammary artery was widely patent.  The insertion site to the left anterior descending artery was without any significant stenosis.  The distal left anterior descending artery had mild, diffuse, luminal irregularities.  The distal PDA was seen filling upon injection of the left internal mammary artery. 

6.    Left ventriculogram - the left ventricle appeared moderately-to-severely dilated.  The ejection fraction was 20% with severe global hyperkinesis.  There was trace mitral regurgitation. 

ASSESSMENT AND PLAN:

The patient is a 62-year-old male with previous history of coronary artery bypass grafting, who presents with high risk ACF.  Patient was known to have his saphenous vein grafts to be occluded. This cardiac catheterization revealed that he had significant left main, proximal circumflex and first obtuse marginal disease.  At this time interventional cardiology will be performed, coronary intervention on these vessels.  Again, this will be dictated as a separate procedure.  The patient tolerated the procedure well.  There are no complications. 

Medical Transcription Terms Home Page * Cardiology Home Page