bennieyoung
Guru
Could someone look at this note and tell me what they would choose to use as diagnosis? Auditor isn't agreeing with me. I used I25.10 and I27.20
INDICATIONS FOR PROCEDURE: Severe symptomatic aortic stenosis.
PROCEDURES PERFORMED:
1. Nonselective left groin sheathogram.
2. 7-French sheath, left common femoral vein.
3. Partial right heart catheterization with Swan-Ganz catheter.
4. Bilateral coronary angiography.
5. Saphenous vein angiography to right posterior descending artery.
6. Saphenous vein angiography to marginal 2 artery.
7. Left internal mammary artery angiography to left anterior descending.
8. Abdominal aortogram.
BRIEF HISTORY: Briefly, this is a 91-year-old female with a history of severe symptomatic aortic stenosis. The patient was consented for a right and left heart catheterization for eventual TAVR.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to BCH, where the left groin was prepped and draped in standard fashion. Using lidocaine, a short 6-French sheath was introduced into the left common femoral artery and verified angiographically. The 7-French sheath was placed into the left common femoral vein. There was significant tortuosity of the left common venous system going into the IVC. We advanced a right heart catheterization with wire and with the significant tortuosity, there was no torque response to the catheter. In order to prevent a kink or twisting of the catheter, which would be difficult to remove, we then placed the catheter in the RV, which was the only place that it could be placed where it could not be advanced to the PA. RV pressure was measured to be systolic 48, diastolic 2, end of 11. RA pressure was measured of 8, A-wave 11, V-wave 11. The Swan-Ganz catheter was then removed, secondary to the fact that we could not advance into the PA system with the excessive tortuosity. At this time, the JL4 catheter was advanced. Images of the left coronary artery showed normal ostial left main. The distal left main had what appeared to be a napkin ring-like lesion. The left circumflex gave off a medium-sized marginal 1 proximally and a marginal 2 artery which appeared to have competitive filling and was a large vessel. The LAD appeared to be 100% occluded after its septal perforator takeoff. There was a moderate to large diagonal artery with only mild 30% to 40% disease proximally. In the AP-cranial view, the distal left main appeared to have 50% to 60% narrowing. After these images were obtained, the JL4 catheter was removed. The JR4 catheter was advanced into right coronary artery. Images of the right coronary artery revealed diffuse disease in the proximal RCA. The RCA and midbody had competitive filling from most likely patent graft. The catheter was pulled back and placed into the first graft, which was a widely patent saphenous vein graft anastomosed to the marginal 2 artery with retrograde filling into the marginal 1 artery. The graft as well as the distal vessel was widely patent. Of note, in the mid-left circumflex artery, before the graft, there was at least 50% lesion. However, again, this was retrograde filling into the marginal 1 artery. The second graft was then found with the same catheter, and it was a widely patent saphenous vein graft anastomosing into a distal RCA. The distal RPDA and RPLS appeared to be healthy and free of disease. The angiography of the right innominate artery showed widely patent RIMA, which was not utilized for the bypass. The LIMA catheter was placed into the left subclavian artery. Angiography of the left internal mammary artery showed a widely patent LIMA anastomosing into the mid-LAD. The distal LAD was widely patent. The LIMA catheter was then removed. The pigtail catheter was advanced into the descending aorta. Abdominal aortogram showed a widely patent distal aorta, which was calcified. There was significant tortuosity of the external iliac arteries bilaterally. Common iliac arteries and internal iliac arteries appeared to be patent, and the CFAs appeared to be patent bilaterally. The pigtail catheter was removed over the 0.0345 wire. The left groin was closed with manual pressure. The patient tolerated the procedure well with no complications.
IMPRESSION:
1. Severe native coronary artery disease.
2. Widely patent bypass grafts in the form of saphenous vein graft to right coronary artery, saphenous vein graft to marginal 2 artery, and left internal mammary artery to left anterior descending artery.
3. Mild pulmonary hypertension, based on the right ventricular pressures.
PLAN: The patient will have 3 hours of bedrest. Discharge later this morning. Follow up for TAVR evaluation as an outpatient.
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INDICATIONS FOR PROCEDURE: Severe symptomatic aortic stenosis.
PROCEDURES PERFORMED:
1. Nonselective left groin sheathogram.
2. 7-French sheath, left common femoral vein.
3. Partial right heart catheterization with Swan-Ganz catheter.
4. Bilateral coronary angiography.
5. Saphenous vein angiography to right posterior descending artery.
6. Saphenous vein angiography to marginal 2 artery.
7. Left internal mammary artery angiography to left anterior descending.
8. Abdominal aortogram.
BRIEF HISTORY: Briefly, this is a 91-year-old female with a history of severe symptomatic aortic stenosis. The patient was consented for a right and left heart catheterization for eventual TAVR.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to BCH, where the left groin was prepped and draped in standard fashion. Using lidocaine, a short 6-French sheath was introduced into the left common femoral artery and verified angiographically. The 7-French sheath was placed into the left common femoral vein. There was significant tortuosity of the left common venous system going into the IVC. We advanced a right heart catheterization with wire and with the significant tortuosity, there was no torque response to the catheter. In order to prevent a kink or twisting of the catheter, which would be difficult to remove, we then placed the catheter in the RV, which was the only place that it could be placed where it could not be advanced to the PA. RV pressure was measured to be systolic 48, diastolic 2, end of 11. RA pressure was measured of 8, A-wave 11, V-wave 11. The Swan-Ganz catheter was then removed, secondary to the fact that we could not advance into the PA system with the excessive tortuosity. At this time, the JL4 catheter was advanced. Images of the left coronary artery showed normal ostial left main. The distal left main had what appeared to be a napkin ring-like lesion. The left circumflex gave off a medium-sized marginal 1 proximally and a marginal 2 artery which appeared to have competitive filling and was a large vessel. The LAD appeared to be 100% occluded after its septal perforator takeoff. There was a moderate to large diagonal artery with only mild 30% to 40% disease proximally. In the AP-cranial view, the distal left main appeared to have 50% to 60% narrowing. After these images were obtained, the JL4 catheter was removed. The JR4 catheter was advanced into right coronary artery. Images of the right coronary artery revealed diffuse disease in the proximal RCA. The RCA and midbody had competitive filling from most likely patent graft. The catheter was pulled back and placed into the first graft, which was a widely patent saphenous vein graft anastomosed to the marginal 2 artery with retrograde filling into the marginal 1 artery. The graft as well as the distal vessel was widely patent. Of note, in the mid-left circumflex artery, before the graft, there was at least 50% lesion. However, again, this was retrograde filling into the marginal 1 artery. The second graft was then found with the same catheter, and it was a widely patent saphenous vein graft anastomosing into a distal RCA. The distal RPDA and RPLS appeared to be healthy and free of disease. The angiography of the right innominate artery showed widely patent RIMA, which was not utilized for the bypass. The LIMA catheter was placed into the left subclavian artery. Angiography of the left internal mammary artery showed a widely patent LIMA anastomosing into the mid-LAD. The distal LAD was widely patent. The LIMA catheter was then removed. The pigtail catheter was advanced into the descending aorta. Abdominal aortogram showed a widely patent distal aorta, which was calcified. There was significant tortuosity of the external iliac arteries bilaterally. Common iliac arteries and internal iliac arteries appeared to be patent, and the CFAs appeared to be patent bilaterally. The pigtail catheter was removed over the 0.0345 wire. The left groin was closed with manual pressure. The patient tolerated the procedure well with no complications.
IMPRESSION:
1. Severe native coronary artery disease.
2. Widely patent bypass grafts in the form of saphenous vein graft to right coronary artery, saphenous vein graft to marginal 2 artery, and left internal mammary artery to left anterior descending artery.
3. Mild pulmonary hypertension, based on the right ventricular pressures.
PLAN: The patient will have 3 hours of bedrest. Discharge later this morning. Follow up for TAVR evaluation as an outpatient.
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