LHC with RCA Stent Placement Report

em2177

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WOULD THIS BE CORRECT: 93458/92980,RC/92973? THANK YOU!!!

REASON FOR EVALUATION: Acute inferior Ml.

HISTORY OF THE PRESENT ILLNESS: This patient is a 54-year-old gentleman with a
history of cigarette smoking and questionable lipids. The patient 1 hour prior
to admission started to develop acute onset of chest discomfort, diaphoresis,
and shortness of breath. He called EMS. There was inferior STEMI. The
patient received nitroglycerin and dropped pressures. The patient came to the
emergency room as a code AMI, where I met the patient on arrival and explained
the complete risks, benefits, and alternatives of left heart catheterization
plus/minus angioplasty and stenting in an emergent fashion to him, and he
agreed to proceed.

PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Lidocaine was placed to the right
common femoral area, and a 7-French sheath was placed to the right common
femoral artery using Seldinger technique. Next a left heart catheterization
was performed with a JL4 with multiple-view angiography. Then a JR4
3.57-French guide catheter engaged the right coronary ostium. Angiography was
performed and Angio-Max was immediately started. A Luge wire was placed into
the distal posterolateral branch. Predilatation was performed with a 2.0 x 15
Apex balloon. At this time we had reestablishment of flow. Total balloon time
was approximately 47 minutes.
At this time thrombectomy was performed over the entire mid segment in serial
fashion. Repeat angiography showed significant resolution of overall thrombus
segment and now establishment of TIMI-3 flow. Repeat angiography was performed.
Next stenting was performed of the mid segment with a 5.0 x 32 VeriFLEX
non-drug-eluting stent and inflated to 14 atmospheres. Repeat angiography was
performed. There was a more-proximal lesion that we were not able to
completely overlap, and thus 5.0 x 12 VeriFLEX non-drug-eluting stent was
placed in overlapping fashion over the proximal segment as well and then
inflated to 14 atmospheres.
Next the STS system was brought slight distal in the overlapping segment and
inflated to 16 atmospheres. Repeat angiography was performed. The STS system
was then placed at the distal portion of the first stent, and serial inflation
over the entire stented segments was completed with 16 atmospheres of pressure.
STS system was removed. Repeat angiography showed some diminished flow. The
patient continued to have ST segments, although was chest pain free and mildly
hypotensive. The patient required normal saline. Thus, due to mild reduction
of flow, we removed the STS, and over the wire we placed the 2.0 x 15 apex
right before the bifurcation of the posterior descending and posterolateral
branch. The wire was removed and serial adenosine was given for a total of 1
mg, which the patient tolerated well.
Repeat angiography now showed 0% residual stenosis and TIMI-3 flow of a very
large RCA vessel. The patient was chest pain free and remained hemodynamically
stable with a heart rate of 69 and a blood pressure of 110/80.

At this point balloon and catheter were removed and a pigtail was placed over
the wire into the left ventricle, measuring an LVEDP of 20. LV angiography was
performed. Pullback revealed no significant aortic valve gradient. Pigtail
was removed. Angiography of the groin was performed. Angio-Seal was placed to
the right common femoral artery with standard protocol with good groin
hemostasis and no evidence of oozing, bruising, or hematoma. The patient
received 600 mg of Plavix in the catheterization laboratory. Prior to
disposition from the catheterization laboratory Angio-Max was discontinued.
The patient currently is hemodynamically stable and chest pain free.
 
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