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jlb102780

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Here's what I got from the report (which is very long, so thank you to everyone that reads it ;) )any suggestions or additional comments would be wonderful :D

92980-LC
33970
33971
33210
71090-26
93510-26
93545
93556-2659
93543
93555-2659
93540

NAME OF TEST:
1. Left heart cardiac catheterization.
2. Coronary angiography.
3. Left ventriculography.
4. Saphenous vein bypass graft injection.
5. Rotational atherectomy with subsequent implantation of four overlapping
Promus drug-eluding intracoronary stents into the very proximal aspect
of the left circumflex coronary artery, including its ostium all the
way down into the distal left circumflex coronary artery.
6. Insertion of an intraaortic balloon pump via the left femoral artery.
7. Insertion of a transvenous temporary pacemaker via the left femoral
vein.

HISTORY
The patient is a very pleasant, 62-year-old female with a history of known
atherosclerotic coronary artery disease. She actually underwent coronary
artery bypass surgery back several years ago. She had two bypass grafts
placed at that time. She had a single bypass graft off her aorta which
bifurcated and one limb went to her left anterior descending and second limb
went to the obtuse marginal branch of the left circumflex coronary artery.
At the time of her previous cardiac catheterization two years ago, she was
noted to have the limb to the obtuse marginal branch to be totally occluded.
The graft to the left anterior descending was patent. She has a nondominant
right coronary artery. The patient presented to Baptist Medical Center with
some GI type symptoms. She subsequently developed an episode of severe chest
pain after being in the hospital and was noted to have transient ST segment
elevation in leads 1 and AVL along with marked reciprocal ST segment
depression in her anterior precordial leads as well as in her inferior leads.
After stabilization, she was brought to the cardiac catheterization
laboratory for further evaluation today.

PROCEDURE
The patient was brought to the cardiac catheterization laboratory in very
stable condition. The right groin area was prepped and draped in the usual
sterile fashion. Using 1% Xylocaine, the right femoral area was
anesthetized. Using a Cook needle, the right femoral artery was easily
entered without any difficulty and a 6 French sheath was placed via the
Seldinger technique. This sheath was aspirated and flushed. Diagnostic
coronary angiography was then performed utilizing a 6 French 4 left Judkins 5
French 4 left Judkins catheters in order to inject the patient's left
coronary artery. It should be noted that the patient had marked dampening
of pressure when both catheters were inserted. The right coronary artery was
injected non-selectively with a 4 French 4 Williams right coronary diagnostic
catheter. The patient was noted to have a small, nondominant right coronary
artery which supplies very little myocardium from a previous cardiac
catheterization. Utilizing the same 5 French Williams right coronary
diagnostic catheter, we were able to manipulate the catheter into the bypass
graft to the left anterior descending. This saphenous vein bypass graft to
the left anterior descending was injected.

We then performed a left ventriculogram in the 30 degree RAO projection
utilizing a 6 French angled pigtail catheter. This angled pigtail catheter
was then pulled back across the aortic valve in order to measure any possible
transaortic valve gradient. Upon reviewing the patient's cineangiograms, it
was very obvious that the patient had rather pronounced left ventricular
systolic dysfunction. Her left ventricle appeared to have an ejection
fraction of approximately 25%. This was clearly worse than it had been on
previous cardiac catheterization a couple of years ago. She had a patent
bypass graft to the left anterior descending. Her right coronary artery, as
mentioned earlier, was a small vessel which was nondominant. The patient had
severe disease in her proximal left circumflex coronary artery with an 80%
calcified lesion in the ostial part of the circumflex at its takeoff from the
left main. In the proximal circumflex, further downstream, there was a 70%
narrowing noted. In the mid left circumflex coronary artery, there was a 60%
narrowing noted. In the distal left circumflex coronary artery prior to a
couple of distal obtuse marginal branches and a posterior descending branch,
there is a 60% lesion noted.

After careful review of the patient's cineangiograms, I felt that the best
course of action would be to perform a rotational atherectomy on this very
proximal circumflex which appeared angiographically to be heavily calcified.
I felt this would give the best chance for getting stents to go further down
the proximal and possibly into the mid left circumflex coronary artery. I
felt we should try balloon angioplasty first and see how that went and then
probably plan to switch to a rotoblater. I also felt that the patient had
severe left ventricular systolic dysfunction and also had rather significant
damping of pressure measured with the catheter tip with just diagnostic
catheters for the cardiac catheterization. I therefore felt that we should
use a side hole guide for the intervention and also should place intraaortic
balloon pump. I also felt that we should place a venous sheath in case the
patient needed to have a pacing catheter placed for the rotational
atherectomy part of the procedure.

We therefore turned our attention to the patient's left groin area. The left
femoral area was anesthetized carefully. Using a Cook needle, the left
femoral vein and left femoral artery were easily entered without any
difficulty and a 6 French sheath was placed in the left femoral vein and a 6
French sheath was placed in the left femoral artery. Both sheaths were
aspirated and flushed. I then switched out for a 7.5 French balloon pump
sheath in the patient's left femoral artery. We then advanced a 7.5 French
intraaortic balloon catheter through the left femoral artery up into the
patient's aorta without difficulty. The balloon pump catheter was carefully
aspirated and flushed. It was connected up to the balloon pump console and
excellent diastolic augmentation was obtained.

The patient was then given 5000 units of intravenous heparin. We
subsequently placed a 5 French pacing catheter out into the patient's right
ventricle as well. Adequate pacing thresholds were obtained. The pacemaker
was set in the VVI mode with backup ventricular pacing at a rate of
approximately 50 beats per minute. It should be noted that during the
rotational atherectomy, the patient did require transvenous pacing.

I then placed a 6 French 4 left Judkins angioplasty guiding catheter with
side holes up into the ostium of the patient's left main coronary artery.
There was no damping of pressure measured at the catheter tip since there
were side holes present. I then manipulated a 0.014 inch high-torque Floppy
angioplasty wire down past the lesion out into the patient's proximal to mid
left circumflex coronary artery. A couple of balloon inflations were made to
6 atmospheres of pressure and subsequently to 4 and 5 atmospheres of
pressure. There appeared to be significant waist present on the balloon. I
felt that on the balloon would be insufficient. We therefore removed the
balloon catheter. We switched out for a 2 mm Maverick angioplasty balloon
catheter, the balloon being 9 mm in length. This balloon catheter was
advanced down over the angioplasty wire out into the distal circumflex. We
subsequently manipulated the angioplasty wire down out into the proximal
aspect of the PDA. The balloon catheter was brought down into the PDA. We
subsequently switched out for a 0.009 inch Floppy rotational atherectomy
wire. This roto-wire was placed out into the posterior descending branch of
the left circumflex coronary artery distally. I then removed the balloon
catheter. We selected a 1.5 mm rotational atherectomy burr. This burr was
brought down and tested outside the body at 164,000 RPMs. The rotational
atherectomy burr was then brought down into position in the patient's left
main coronary artery. Prior to every burr run, the patient received
intracoronary injection of 200 micrograms of Verapamil. A total of 10 burr
runs were then performed. We were able to successfully perform rotational
atherectomy on the very proximal left circumflex coronary artery at its
ostium extending into the proximal circumflex. The rotational atherectomy
burr was removed. The guiding catheter, however, had softened somewhat. I
felt that we needed to place a new guiding catheter. We removed the entire
angioplasty system and switched out for a 6 French 3.5 Voda angioplasty
guiding catheter with side holes. This guiding catheter was inserted into
the ostium of the patient's left main coronary artery. I then manipulated a
0.014 inch high-torque Floppy angioplasty wire down past the lesion out into
the distal aspect of the patient's left circumflex coronary artery. When I
was satisfied with the position of the angioplasty wire, we then were able to
bring down a 2.5 mm Maverick angioplasty balloon catheter down into the mid
left circumflex coronary artery. A balloon inflation was made to 9
atmospheres of pressure and held for 24 seconds. I then removed the balloon
catheter. I then selected a 2.75 mm Promus drug-eluding stent catheter with
the stent being 15 mm in length. Prior to doing that, while the balloon
catheter was still down, we switched out for a 0.014 inch Grand Slam
angioplasty exchange wire. This wire is somewhat stiffer and I felt it would
allow better support for placing stents. I then was able to surprisingly
bring the Promus stent catheter down all the way through the proximal
circumflex and all the way down out into the distal circumflex. I felt that
we should stent the most distal lesion since we were able to bring a stent
catheter down this far. The stent catheter was advanced out into the distal
left circumflex coronary artery prior to its bifurcation. When I was
satisfied with the position of the stent catheter, I inflated the stent
catheter very carefully to 9 atmospheres of pressure and held this balloon
inflation for 24 seconds. The stent catheter was then removed. I then
selected another 2.75 mm Promus drug-eluding stent catheter, the stent being
18 mm in length. This stent catheter was then brought down into position in
such a way that it overlapped distally with the proximal aspect of the
previously deployed stent. This stent catheter was placed in position and
was then inflated for 11 atmospheres of pressure and was held for 45 seconds
in order to deploy the stent. We then removed the stent catheter. I then
selected another 2.75 mm Promus drug-eluding stent catheter with the catheter
being 23 mm in length. This stent catheter was again placed in such a
fashion that it overlapped the proximal aspect of the previously deployed
stent. There were essentially overlapping stents from distal to proximal
during this time. When I was satisfied with the position of this stent
catheter, we inflated the catheter to 11 atmospheres of pressure and held
this balloon inflation for 45 seconds as well.

We then deflated the stent catheter and removed it. Serial cineangiograms
really made the proximal and mid to distal left circumflex coronary artery to
look quite good. I selected a 2.75 mm NC Voyager RX angioplasty balloon
catheter. A total of three balloon inflations were made within the
overlapping stented segment in the proximal to distal left circumflex
coronary artery. The first balloon inflation distally was 18 atmospheres of
pressure and the next subsequent two inflations were to 22 atmospheres of
pressure. Each balloon inflation was held for approximately 35 seconds. We
then deflated the NC Voyager high pressure angioplasty balloon catheter and
removed it. I then selected a 3 mm Promus drug-eluding stent catheter, with
the stent being 23 mm in length. This stent catheter was placed in such a
way that the distal aspect of this new stent overlapped with the proximal
aspect of the most recently deployed stent distally. The proximal aspect of
this new stent was placed at the ostium of the left circumflex coronary
artery at its takeoff. When I was satisfied with the position of the stent
catheter, we inflated the stent catheter very carefully to 13 atmospheres of
pressure and held this balloon inflation for 30 seconds. There was some
waist noted in the very proximal aspect of the stent at the ostium at its
takeoff from the left circumflex coronary artery from the left main coronary
artery. We subsequently selected a 3 mm NC Merlin high pressure angioplasty
balloon catheter, the balloon being 20 mm in length. Two balloon inflations
were made within the stented segment proximally. Each balloon inflation was
to 18 atmospheres of pressure and was held for 22 seconds. I then selected a
3 mm Quantum Maverick high pressure angioplasty balloon catheter, the balloon
being 12 mm in length. A high pressure balloon inflation was made in the
very proximal aspect of the stented segment to 20 atmospheres of pressure and
was held for 40 seconds. We then deflated the Quantum Maverick high pressure
angioplasty balloon catheter and removed it. Subsequent cineangiograms
revealed a very nice angiographic result. The stent was widely patent.
There was excellent flow in the distal vessel. There was slight narrowing
noted at the takeoff of the left circumflex coronary artery at its ostium.
This was relatively mild in the 10 to 20% range. The entire overlapping
stented segment, however, appeared widely patent and there was excellent flow
in the distal circumflex. The angioplasty system was then removed. The
pacemaker catheter was removed. The patient was taken upstairs in very
stable condition. She was free of chest pain at the conclusion of the
procedure and was hemodynamically stable. Her balloon pump was at 1 to 1
during the case and was cut down to 1 to 2 when she left the cath lab. It
will be pulled later on today.

RESULTS

ANGIOGRAPHY
1. The left main coronary artery is normal.
2. The left anterior descending coronary artery is totally occluded after
the takeoff of the first septal and first diagonal branches. The
first septal branch is fairly large in size and it has mild plaquing
noted throughout. The first diagonal branch is moderate in size and
has some mild disease present in its proximal aspect. This vessel,
however, is too small for any type of catheter based intervention.
3. The left circumflex coronary artery is a large and dominant vessel. In
the very proximal circumflex, shortly after its takeoff at its ostium,
there was a calcified complex 90% lesion noted. Further down in the
proximal mid left circumflex coronary artery, there is a subsequent
80% narrowing noted. In the mid left circumflex coronary artery more
distally, there is a 60 to 70% lesion noted. At the distal circumflex
prior to the takeoff of the distal obtuse marginal branches and
posterior descending branch, there is a 60% lesion noted.
4. The right coronary artery is a very small vessel which supplies very
little myocardium.
5. The saphenous vein bypass graft to the left anterior descending is
patent with good runoff. The left anterior descending is a relatively
small vessel distally, however.
6. The saphenous vein bypass graft to the obtuse marginal branch of the
left circumflex coronary artery is known to be totally occluded. It
was not selectively injected.
7. A left ventriculogram reveals severe global hypokinesis. The overall
left ventricular ejection fraction was estimated to be approximately
25%. The left ventricle appears mildly dilated. There is very
minimal mitral regurgitation detected.
8. After successful rotational atherectomy with subsequent implantation of
four overlapping Promus drug-eluding stents into the very proximal
left circumflex coronary artery at its ostium and extending down
through the proximal circumflex out into the mid and subsequently the
distal left circumflex coronary artery, the long area of severe
disease with several 60 to 90% lesions preintervention was reduced to
no residual narrowing postintervention. There was excellent flow in
the distal vessel. There was no evidence of dissection.

CONCLUSIONS
1. Severely depressed global left ventricular systolic function as
described above.
2. Normal left main coronary artery.
3. Totally occluded left anterior descending coronary artery after the
first septal and first diagonal branch.
4. Large and dominant left circumflex coronary artery which has a severe,
high grade, complex, calcified lesion present in the very proximal
aspect at its ostium at its takeoff from the left main coronary
artery. There was also severe obstructive narrowing noted in the
proximal mid and even distal left circumflex coronary artery prior to
severe distal obtuse marginal branches as well as a posterior
descending branch.
5. Very small and nondominant right coronary artery which supplies very
little myocardium.
6. Widely patent saphenous vein bypass graft to the left anterior
descending with the left anterior descending distally being a
relatively small vessel.
7. Successful rotational atherectomy of the very proximal left circumflex
coronary artery with subsequent implantation of four overlapping
Promus drug-eluding stents into the ostium of the left circumflex
coronary artery extending throughout the proximal circumflex down into
the mid and subsequently the distal left circumflex coronary artery.
The proximal stent is a 3 mm Promus drug-eluding stent which is 23 mm
in length. The three distal stents are all 2.75 mm Promus
drug-eluding stents which are 23 mm, 18 mm, and 15 mm in length,
respectively. The severely diseased and heavily calcified proximal
left circumflex coronary artery with several severe lesions in the mid
and distal left circumflex coronary artery preintervention was reduced
to less than 10 to 20% residual narrowing in the very ostial part of
the circumflex with no residual narrowing noted throughout the rest of
the left circumflex coronary artery. There was no evidence of
dissection and there was excellent flow in the distal vessel.
8. Successful implantation of the intraaortic balloon pump via the right
femoral artery for the interventional procedure.
9. Successful insertion of a transvenous temporary ventricular pacemaker
from the left femoral vein.
 
Last edited:
Here's what I got from the report (which is very long, so thank you to everyone that reads it ;) )any suggestions or additional comments would be wonderful :D

92980-LD
33970
33971
33210
71090-26
93510-26
93545
93556-2659
93543
93555-2659
93540

NAME OF TEST:
1. Left heart cardiac catheterization.
2. Coronary angiography.
3. Left ventriculography.
4. Saphenous vein bypass graft injection.
5. Rotational atherectomy with subsequent implantation of four overlapping
Promus drug-eluding intracoronary stents into the very proximal aspect
of the left circumflex coronary artery, including its ostium all the
way down into the distal left circumflex coronary artery.
6. Insertion of an intraaortic balloon pump via the left femoral artery.
7. Insertion of a transvenous temporary pacemaker via the left femoral
vein.

HISTORY
The patient is a very pleasant, 62-year-old female with a history of known
atherosclerotic coronary artery disease. She actually underwent coronary
artery bypass surgery back several years ago. She had two bypass grafts
placed at that time. She had a single bypass graft off her aorta which
bifurcated and one limb went to her left anterior descending and second limb
went to the obtuse marginal branch of the left circumflex coronary artery.
At the time of her previous cardiac catheterization two years ago, she was
noted to have the limb to the obtuse marginal branch to be totally occluded.
The graft to the left anterior descending was patent. She has a nondominant
right coronary artery. The patient presented to Baptist Medical Center with
some GI type symptoms. She subsequently developed an episode of severe chest
pain after being in the hospital and was noted to have transient ST segment
elevation in leads 1 and AVL along with marked reciprocal ST segment
depression in her anterior precordial leads as well as in her inferior leads.
After stabilization, she was brought to the cardiac catheterization
laboratory for further evaluation today.

PROCEDURE
The patient was brought to the cardiac catheterization laboratory in very
stable condition. The right groin area was prepped and draped in the usual
sterile fashion. Using 1% Xylocaine, the right femoral area was
anesthetized. Using a Cook needle, the right femoral artery was easily
entered without any difficulty and a 6 French sheath was placed via the
Seldinger technique. This sheath was aspirated and flushed. Diagnostic
coronary angiography was then performed utilizing a 6 French 4 left Judkins 5
French 4 left Judkins catheters in order to inject the patient's left
coronary artery. It should be noted that the patient had marked dampening
of pressure when both catheters were inserted. The right coronary artery was
injected non-selectively with a 4 French 4 Williams right coronary diagnostic
catheter. The patient was noted to have a small, nondominant right coronary
artery which supplies very little myocardium from a previous cardiac
catheterization. Utilizing the same 5 French Williams right coronary
diagnostic catheter, we were able to manipulate the catheter into the bypass
graft to the left anterior descending. This saphenous vein bypass graft to
the left anterior descending was injected.

We then performed a left ventriculogram in the 30 degree RAO projection
utilizing a 6 French angled pigtail catheter. This angled pigtail catheter
was then pulled back across the aortic valve in order to measure any possible
transaortic valve gradient. Upon reviewing the patient's cineangiograms, it
was very obvious that the patient had rather pronounced left ventricular
systolic dysfunction. Her left ventricle appeared to have an ejection
fraction of approximately 25%. This was clearly worse than it had been on
previous cardiac catheterization a couple of years ago. She had a patent
bypass graft to the left anterior descending. Her right coronary artery, as
mentioned earlier, was a small vessel which was nondominant. The patient had
severe disease in her proximal left circumflex coronary artery with an 80%
calcified lesion in the ostial part of the circumflex at its takeoff from the
left main. In the proximal circumflex, further downstream, there was a 70%
narrowing noted. In the mid left circumflex coronary artery, there was a 60%
narrowing noted. In the distal left circumflex coronary artery prior to a
couple of distal obtuse marginal branches and a posterior descending branch,
there is a 60% lesion noted.

After careful review of the patient's cineangiograms, I felt that the best
course of action would be to perform a rotational atherectomy on this very
proximal circumflex which appeared angiographically to be heavily calcified.
I felt this would give the best chance for getting stents to go further down
the proximal and possibly into the mid left circumflex coronary artery. I
felt we should try balloon angioplasty first and see how that went and then
probably plan to switch to a rotoblater. I also felt that the patient had
severe left ventricular systolic dysfunction and also had rather significant
damping of pressure measured with the catheter tip with just diagnostic
catheters for the cardiac catheterization. I therefore felt that we should
use a side hole guide for the intervention and also should place intraaortic
balloon pump. I also felt that we should place a venous sheath in case the
patient needed to have a pacing catheter placed for the rotational
atherectomy part of the procedure.

We therefore turned our attention to the patient's left groin area. The left
femoral area was anesthetized carefully. Using a Cook needle, the left
femoral vein and left femoral artery were easily entered without any
difficulty and a 6 French sheath was placed in the left femoral vein and a 6
French sheath was placed in the left femoral artery. Both sheaths were
aspirated and flushed. I then switched out for a 7.5 French balloon pump
sheath in the patient's left femoral artery. We then advanced a 7.5 French
intraaortic balloon catheter through the left femoral artery up into the
patient's aorta without difficulty. The balloon pump catheter was carefully
aspirated and flushed. It was connected up to the balloon pump console and
excellent diastolic augmentation was obtained.

The patient was then given 5000 units of intravenous heparin. We
subsequently placed a 5 French pacing catheter out into the patient's right
ventricle as well. Adequate pacing thresholds were obtained. The pacemaker
was set in the VVI mode with backup ventricular pacing at a rate of
approximately 50 beats per minute. It should be noted that during the
rotational atherectomy, the patient did require transvenous pacing.

I then placed a 6 French 4 left Judkins angioplasty guiding catheter with
side holes up into the ostium of the patient's left main coronary artery.
There was no damping of pressure measured at the catheter tip since there
were side holes present. I then manipulated a 0.014 inch high-torque Floppy
angioplasty wire down past the lesion out into the patient's proximal to mid
left circumflex coronary artery. A couple of balloon inflations were made to
6 atmospheres of pressure and subsequently to 4 and 5 atmospheres of
pressure. There appeared to be significant waist present on the balloon. I
felt that on the balloon would be insufficient. We therefore removed the
balloon catheter. We switched out for a 2 mm Maverick angioplasty balloon
catheter, the balloon being 9 mm in length. This balloon catheter was
advanced down over the angioplasty wire out into the distal circumflex. We
subsequently manipulated the angioplasty wire down out into the proximal
aspect of the PDA. The balloon catheter was brought down into the PDA. We
subsequently switched out for a 0.009 inch Floppy rotational atherectomy
wire. This roto-wire was placed out into the posterior descending branch of
the left circumflex coronary artery distally. I then removed the balloon
catheter. We selected a 1.5 mm rotational atherectomy burr. This burr was
brought down and tested outside the body at 164,000 RPMs. The rotational
atherectomy burr was then brought down into position in the patient's left
main coronary artery. Prior to every burr run, the patient received
intracoronary injection of 200 micrograms of Verapamil. A total of 10 burr
runs were then performed. We were able to successfully perform rotational
atherectomy on the very proximal left circumflex coronary artery at its
ostium extending into the proximal circumflex. The rotational atherectomy
burr was removed. The guiding catheter, however, had softened somewhat. I
felt that we needed to place a new guiding catheter. We removed the entire
angioplasty system and switched out for a 6 French 3.5 Voda angioplasty
guiding catheter with side holes. This guiding catheter was inserted into
the ostium of the patient's left main coronary artery. I then manipulated a
0.014 inch high-torque Floppy angioplasty wire down past the lesion out into
the distal aspect of the patient's left circumflex coronary artery. When I
was satisfied with the position of the angioplasty wire, we then were able to
bring down a 2.5 mm Maverick angioplasty balloon catheter down into the mid
left circumflex coronary artery. A balloon inflation was made to 9
atmospheres of pressure and held for 24 seconds. I then removed the balloon
catheter. I then selected a 2.75 mm Promus drug-eluding stent catheter with
the stent being 15 mm in length. Prior to doing that, while the balloon
catheter was still down, we switched out for a 0.014 inch Grand Slam
angioplasty exchange wire. This wire is somewhat stiffer and I felt it would
allow better support for placing stents. I then was able to surprisingly
bring the Promus stent catheter down all the way through the proximal
circumflex and all the way down out into the distal circumflex. I felt that
we should stent the most distal lesion since we were able to bring a stent
catheter down this far. The stent catheter was advanced out into the distal
left circumflex coronary artery prior to its bifurcation. When I was
satisfied with the position of the stent catheter, I inflated the stent
catheter very carefully to 9 atmospheres of pressure and held this balloon
inflation for 24 seconds. The stent catheter was then removed. I then
selected another 2.75 mm Promus drug-eluding stent catheter, the stent being
18 mm in length. This stent catheter was then brought down into position in
such a way that it overlapped distally with the proximal aspect of the
previously deployed stent. This stent catheter was placed in position and
was then inflated for 11 atmospheres of pressure and was held for 45 seconds
in order to deploy the stent. We then removed the stent catheter. I then
selected another 2.75 mm Promus drug-eluding stent catheter with the catheter
being 23 mm in length. This stent catheter was again placed in such a
fashion that it overlapped the proximal aspect of the previously deployed
stent. There were essentially overlapping stents from distal to proximal
during this time. When I was satisfied with the position of this stent
catheter, we inflated the catheter to 11 atmospheres of pressure and held
this balloon inflation for 45 seconds as well.

We then deflated the stent catheter and removed it. Serial cineangiograms
really made the proximal and mid to distal left circumflex coronary artery to
look quite good. I selected a 2.75 mm NC Voyager RX angioplasty balloon
catheter. A total of three balloon inflations were made within the
overlapping stented segment in the proximal to distal left circumflex
coronary artery. The first balloon inflation distally was 18 atmospheres of
pressure and the next subsequent two inflations were to 22 atmospheres of
pressure. Each balloon inflation was held for approximately 35 seconds. We
then deflated the NC Voyager high pressure angioplasty balloon catheter and
removed it. I then selected a 3 mm Promus drug-eluding stent catheter, with
the stent being 23 mm in length. This stent catheter was placed in such a
way that the distal aspect of this new stent overlapped with the proximal
aspect of the most recently deployed stent distally. The proximal aspect of
this new stent was placed at the ostium of the left circumflex coronary
artery at its takeoff. When I was satisfied with the position of the stent
catheter, we inflated the stent catheter very carefully to 13 atmospheres of
pressure and held this balloon inflation for 30 seconds. There was some
waist noted in the very proximal aspect of the stent at the ostium at its
takeoff from the left circumflex coronary artery from the left main coronary
artery. We subsequently selected a 3 mm NC Merlin high pressure angioplasty
balloon catheter, the balloon being 20 mm in length. Two balloon inflations
were made within the stented segment proximally. Each balloon inflation was
to 18 atmospheres of pressure and was held for 22 seconds. I then selected a
3 mm Quantum Maverick high pressure angioplasty balloon catheter, the balloon
being 12 mm in length. A high pressure balloon inflation was made in the
very proximal aspect of the stented segment to 20 atmospheres of pressure and
was held for 40 seconds. We then deflated the Quantum Maverick high pressure
angioplasty balloon catheter and removed it. Subsequent cineangiograms
revealed a very nice angiographic result. The stent was widely patent.
There was excellent flow in the distal vessel. There was slight narrowing
noted at the takeoff of the left circumflex coronary artery at its ostium.
This was relatively mild in the 10 to 20% range. The entire overlapping
stented segment, however, appeared widely patent and there was excellent flow
in the distal circumflex. The angioplasty system was then removed. The
pacemaker catheter was removed. The patient was taken upstairs in very
stable condition. She was free of chest pain at the conclusion of the
procedure and was hemodynamically stable. Her balloon pump was at 1 to 1
during the case and was cut down to 1 to 2 when she left the cath lab. It
will be pulled later on today.

RESULTS

ANGIOGRAPHY
1. The left main coronary artery is normal.
2. The left anterior descending coronary artery is totally occluded after
the takeoff of the first septal and first diagonal branches. The
first septal branch is fairly large in size and it has mild plaquing
noted throughout. The first diagonal branch is moderate in size and
has some mild disease present in its proximal aspect. This vessel,
however, is too small for any type of catheter based intervention.
3. The left circumflex coronary artery is a large and dominant vessel. In
the very proximal circumflex, shortly after its takeoff at its ostium,
there was a calcified complex 90% lesion noted. Further down in the
proximal mid left circumflex coronary artery, there is a subsequent
80% narrowing noted. In the mid left circumflex coronary artery more
distally, there is a 60 to 70% lesion noted. At the distal circumflex
prior to the takeoff of the distal obtuse marginal branches and
posterior descending branch, there is a 60% lesion noted.
4. The right coronary artery is a very small vessel which supplies very
little myocardium.
5. The saphenous vein bypass graft to the left anterior descending is
patent with good runoff. The left anterior descending is a relatively
small vessel distally, however.
6. The saphenous vein bypass graft to the obtuse marginal branch of the
left circumflex coronary artery is known to be totally occluded. It
was not selectively injected.
7. A left ventriculogram reveals severe global hypokinesis. The overall
left ventricular ejection fraction was estimated to be approximately
25%. The left ventricle appears mildly dilated. There is very
minimal mitral regurgitation detected.
8. After successful rotational atherectomy with subsequent implantation of
four overlapping Promus drug-eluding stents into the very proximal
left circumflex coronary artery at its ostium and extending down
through the proximal circumflex out into the mid and subsequently the
distal left circumflex coronary artery, the long area of severe
disease with several 60 to 90% lesions preintervention was reduced to
no residual narrowing postintervention. There was excellent flow in
the distal vessel. There was no evidence of dissection.

CONCLUSIONS
1. Severely depressed global left ventricular systolic function as
described above.
2. Normal left main coronary artery.
3. Totally occluded left anterior descending coronary artery after the
first septal and first diagonal branch.
4. Large and dominant left circumflex coronary artery which has a severe,
high grade, complex, calcified lesion present in the very proximal
aspect at its ostium at its takeoff from the left main coronary
artery. There was also severe obstructive narrowing noted in the
proximal mid and even distal left circumflex coronary artery prior to
severe distal obtuse marginal branches as well as a posterior
descending branch.
5. Very small and nondominant right coronary artery which supplies very
little myocardium.
6. Widely patent saphenous vein bypass graft to the left anterior
descending with the left anterior descending distally being a
relatively small vessel.
7. Successful rotational atherectomy of the very proximal left circumflex
coronary artery with subsequent implantation of four overlapping
Promus drug-eluding stents into the ostium of the left circumflex
coronary artery extending throughout the proximal circumflex down into
the mid and subsequently the distal left circumflex coronary artery.
The proximal stent is a 3 mm Promus drug-eluding stent which is 23 mm
in length. The three distal stents are all 2.75 mm Promus
drug-eluding stents which are 23 mm, 18 mm, and 15 mm in length,
respectively. The severely diseased and heavily calcified proximal
left circumflex coronary artery with several severe lesions in the mid
and distal left circumflex coronary artery preintervention was reduced
to less than 10 to 20% residual narrowing in the very ostial part of
the circumflex with no residual narrowing noted throughout the rest of
the left circumflex coronary artery. There was no evidence of
dissection and there was excellent flow in the distal vessel.
8. Successful implantation of the intraaortic balloon pump via the right
femoral artery for the interventional procedure.
9. Successful insertion of a transvenous temporary ventricular pacemaker
from the left femoral vein.

wow, that is a long report...here goes:
92980 LC for the stents
93510 for the LHC
33967 IABP
33210-59 Temp Pacer
93540 Injection of Venous Graft
93545 Injection of Coronary arteries
93543 Injection of LT Ventrical
93555 26,59 Supervision/Interpretation of Lt Ventriculography
93556 26,59 S & I of Coronary Arteries

I would not charge for the removal of the IABP or Temp Pacer, nor the Atherectomy and Angioplasty of the LC (included with stent placement).
I think that is everything...
HTH :)
 
Last edited:
Here's what I got from the report (which is very long, so thank you to everyone that reads it ;) )any suggestions or additional comments would be wonderful :D

92980-LC
33970
33971
33210
71090-26
93510-26
93545
93556-2659
93543
93555-2659
93540


NAME OF TEST:
1. Left heart cardiac catheterization.
2. Coronary angiography.
3. Left ventriculography.
4. Saphenous vein bypass graft injection.
5. Rotational atherectomy with subsequent implantation of four overlapping
Promus drug-eluding intracoronary stents into the very proximal aspect
of the left circumflex coronary artery, including its ostium all the
way down into the distal left circumflex coronary artery.
6. Insertion of an intraaortic balloon pump via the left femoral artery.
7. Insertion of a transvenous temporary pacemaker via the left femoral
vein.

HISTORY
The patient is a very pleasant, 62-year-old female with a history of known
atherosclerotic coronary artery disease. She actually underwent coronary
artery bypass surgery back several years ago. She had two bypass grafts
placed at that time. She had a single bypass graft off her aorta which
bifurcated and one limb went to her left anterior descending and second limb
went to the obtuse marginal branch of the left circumflex coronary artery.
At the time of her previous cardiac catheterization two years ago, she was
noted to have the limb to the obtuse marginal branch to be totally occluded.
The graft to the left anterior descending was patent. She has a nondominant
right coronary artery. The patient presented to Baptist Medical Center with
some GI type symptoms. She subsequently developed an episode of severe chest
pain after being in the hospital and was noted to have transient ST segment
elevation in leads 1 and AVL along with marked reciprocal ST segment
depression in her anterior precordial leads as well as in her inferior leads.
After stabilization, she was brought to the cardiac catheterization
laboratory for further evaluation today.

PROCEDURE
The patient was brought to the cardiac catheterization laboratory in very
stable condition. The right groin area was prepped and draped in the usual
sterile fashion. Using 1% Xylocaine, the right femoral area was
anesthetized. Using a Cook needle, the right femoral artery was easily
entered without any difficulty and a 6 French sheath was placed via the
Seldinger technique. This sheath was aspirated and flushed. Diagnostic
coronary angiography was then performed utilizing a 6 French 4 left Judkins 5
French 4 left Judkins catheters in order to inject the patient's left
coronary artery. It should be noted that the patient had marked dampening
of pressure when both catheters were inserted. The right coronary artery was
injected non-selectively with a 4 French 4 Williams right coronary diagnostic
catheter. The patient was noted to have a small, nondominant right coronary
artery which supplies very little myocardium from a previous cardiac
catheterization. Utilizing the same 5 French Williams right coronary
diagnostic catheter, we were able to manipulate the catheter into the bypass
graft to the left anterior descending. This saphenous vein bypass graft to
the left anterior descending was injected.

We then performed a left ventriculogram in the 30 degree RAO projection
utilizing a 6 French angled pigtail catheter. This angled pigtail catheter
was then pulled back across the aortic valve in order to measure any possible
transaortic valve gradient. Upon reviewing the patient's cineangiograms, it
was very obvious that the patient had rather pronounced left ventricular
systolic dysfunction. Her left ventricle appeared to have an ejection
fraction of approximately 25%. This was clearly worse than it had been on
previous cardiac catheterization a couple of years ago. She had a patent
bypass graft to the left anterior descending. Her right coronary artery, as
mentioned earlier, was a small vessel which was nondominant. The patient had
severe disease in her proximal left circumflex coronary artery with an 80%
calcified lesion in the ostial part of the circumflex at its takeoff from the
left main. In the proximal circumflex, further downstream, there was a 70%
narrowing noted. In the mid left circumflex coronary artery, there was a 60%
narrowing noted. In the distal left circumflex coronary artery prior to a
couple of distal obtuse marginal branches and a posterior descending branch,
there is a 60% lesion noted.

After careful review of the patient's cineangiograms, I felt that the best
course of action would be to perform a rotational atherectomy on this very
proximal circumflex which appeared angiographically to be heavily calcified.
I felt this would give the best chance for getting stents to go further down
the proximal and possibly into the mid left circumflex coronary artery. I
felt we should try balloon angioplasty first and see how that went and then
probably plan to switch to a rotoblater. I also felt that the patient had
severe left ventricular systolic dysfunction and also had rather significant
damping of pressure measured with the catheter tip with just diagnostic
catheters for the cardiac catheterization. I therefore felt that we should
use a side hole guide for the intervention and also should place intraaortic
balloon pump. I also felt that we should place a venous sheath in case the
patient needed to have a pacing catheter placed for the rotational
atherectomy part of the procedure.

We therefore turned our attention to the patient's left groin area. The left
femoral area was anesthetized carefully. Using a Cook needle, the left
femoral vein and left femoral artery were easily entered without any
difficulty and a 6 French sheath was placed in the left femoral vein and a 6
French sheath was placed in the left femoral artery. Both sheaths were
aspirated and flushed. I then switched out for a 7.5 French balloon pump
sheath in the patient's left femoral artery. We then advanced a 7.5 French
intraaortic balloon catheter through the left femoral artery up into the
patient's aorta without difficulty. The balloon pump catheter was carefully
aspirated and flushed. It was connected up to the balloon pump console and
excellent diastolic augmentation was obtained.

The patient was then given 5000 units of intravenous heparin. We
subsequently placed a 5 French pacing catheter out into the patient's right
ventricle as well. Adequate pacing thresholds were obtained. The pacemaker
was set in the VVI mode with backup ventricular pacing at a rate of
approximately 50 beats per minute. It should be noted that during the
rotational atherectomy, the patient did require transvenous pacing.

I then placed a 6 French 4 left Judkins angioplasty guiding catheter with
side holes up into the ostium of the patient's left main coronary artery.
There was no damping of pressure measured at the catheter tip since there
were side holes present. I then manipulated a 0.014 inch high-torque Floppy
angioplasty wire down past the lesion out into the patient's proximal to mid
left circumflex coronary artery. A couple of balloon inflations were made to
6 atmospheres of pressure and subsequently to 4 and 5 atmospheres of
pressure. There appeared to be significant waist present on the balloon. I
felt that on the balloon would be insufficient. We therefore removed the
balloon catheter. We switched out for a 2 mm Maverick angioplasty balloon
catheter, the balloon being 9 mm in length. This balloon catheter was
advanced down over the angioplasty wire out into the distal circumflex. We
subsequently manipulated the angioplasty wire down out into the proximal
aspect of the PDA. The balloon catheter was brought down into the PDA. We
subsequently switched out for a 0.009 inch Floppy rotational atherectomy
wire. This roto-wire was placed out into the posterior descending branch of
the left circumflex coronary artery distally. I then removed the balloon
catheter. We selected a 1.5 mm rotational atherectomy burr. This burr was
brought down and tested outside the body at 164,000 RPMs. The rotational
atherectomy burr was then brought down into position in the patient's left
main coronary artery. Prior to every burr run, the patient received
intracoronary injection of 200 micrograms of Verapamil. A total of 10 burr
runs were then performed. We were able to successfully perform rotational
atherectomy on the very proximal left circumflex coronary artery at its
ostium extending into the proximal circumflex. The rotational atherectomy
burr was removed. The guiding catheter, however, had softened somewhat. I
felt that we needed to place a new guiding catheter. We removed the entire
angioplasty system and switched out for a 6 French 3.5 Voda angioplasty
guiding catheter with side holes. This guiding catheter was inserted into
the ostium of the patient's left main coronary artery. I then manipulated a
0.014 inch high-torque Floppy angioplasty wire down past the lesion out into
the distal aspect of the patient's left circumflex coronary artery. When I
was satisfied with the position of the angioplasty wire, we then were able to
bring down a 2.5 mm Maverick angioplasty balloon catheter down into the mid
left circumflex coronary artery. A balloon inflation was made to 9
atmospheres of pressure and held for 24 seconds. I then removed the balloon
catheter. I then selected a 2.75 mm Promus drug-eluding stent catheter with
the stent being 15 mm in length. Prior to doing that, while the balloon
catheter was still down, we switched out for a 0.014 inch Grand Slam
angioplasty exchange wire. This wire is somewhat stiffer and I felt it would
allow better support for placing stents. I then was able to surprisingly
bring the Promus stent catheter down all the way through the proximal
circumflex and all the way down out into the distal circumflex. I felt that
we should stent the most distal lesion since we were able to bring a stent
catheter down this far. The stent catheter was advanced out into the distal
left circumflex coronary artery prior to its bifurcation. When I was
satisfied with the position of the stent catheter, I inflated the stent
catheter very carefully to 9 atmospheres of pressure and held this balloon
inflation for 24 seconds. The stent catheter was then removed. I then
selected another 2.75 mm Promus drug-eluding stent catheter, the stent being
18 mm in length. This stent catheter was then brought down into position in
such a way that it overlapped distally with the proximal aspect of the
previously deployed stent. This stent catheter was placed in position and
was then inflated for 11 atmospheres of pressure and was held for 45 seconds
in order to deploy the stent. We then removed the stent catheter. I then
selected another 2.75 mm Promus drug-eluding stent catheter with the catheter
being 23 mm in length. This stent catheter was again placed in such a
fashion that it overlapped the proximal aspect of the previously deployed
stent. There were essentially overlapping stents from distal to proximal
during this time. When I was satisfied with the position of this stent
catheter, we inflated the catheter to 11 atmospheres of pressure and held
this balloon inflation for 45 seconds as well.

We then deflated the stent catheter and removed it. Serial cineangiograms
really made the proximal and mid to distal left circumflex coronary artery to
look quite good. I selected a 2.75 mm NC Voyager RX angioplasty balloon
catheter. A total of three balloon inflations were made within the
overlapping stented segment in the proximal to distal left circumflex
coronary artery. The first balloon inflation distally was 18 atmospheres of
pressure and the next subsequent two inflations were to 22 atmospheres of
pressure. Each balloon inflation was held for approximately 35 seconds. We
then deflated the NC Voyager high pressure angioplasty balloon catheter and
removed it. I then selected a 3 mm Promus drug-eluding stent catheter, with
the stent being 23 mm in length. This stent catheter was placed in such a
way that the distal aspect of this new stent overlapped with the proximal
aspect of the most recently deployed stent distally. The proximal aspect of
this new stent was placed at the ostium of the left circumflex coronary
artery at its takeoff. When I was satisfied with the position of the stent
catheter, we inflated the stent catheter very carefully to 13 atmospheres of
pressure and held this balloon inflation for 30 seconds. There was some
waist noted in the very proximal aspect of the stent at the ostium at its
takeoff from the left circumflex coronary artery from the left main coronary
artery. We subsequently selected a 3 mm NC Merlin high pressure angioplasty
balloon catheter, the balloon being 20 mm in length. Two balloon inflations
were made within the stented segment proximally. Each balloon inflation was
to 18 atmospheres of pressure and was held for 22 seconds. I then selected a
3 mm Quantum Maverick high pressure angioplasty balloon catheter, the balloon
being 12 mm in length. A high pressure balloon inflation was made in the
very proximal aspect of the stented segment to 20 atmospheres of pressure and
was held for 40 seconds. We then deflated the Quantum Maverick high pressure
angioplasty balloon catheter and removed it. Subsequent cineangiograms
revealed a very nice angiographic result. The stent was widely patent.
There was excellent flow in the distal vessel. There was slight narrowing
noted at the takeoff of the left circumflex coronary artery at its ostium.
This was relatively mild in the 10 to 20% range. The entire overlapping
stented segment, however, appeared widely patent and there was excellent flow
in the distal circumflex. The angioplasty system was then removed. The
pacemaker catheter was removed. The patient was taken upstairs in very
stable condition. She was free of chest pain at the conclusion of the
procedure and was hemodynamically stable. Her balloon pump was at 1 to 1
during the case and was cut down to 1 to 2 when she left the cath lab. It
will be pulled later on today.

RESULTS

ANGIOGRAPHY
1. The left main coronary artery is normal.
2. The left anterior descending coronary artery is totally occluded after
the takeoff of the first septal and first diagonal branches. The
first septal branch is fairly large in size and it has mild plaquing
noted throughout. The first diagonal branch is moderate in size and
has some mild disease present in its proximal aspect. This vessel,
however, is too small for any type of catheter based intervention.
3. The left circumflex coronary artery is a large and dominant vessel. In
the very proximal circumflex, shortly after its takeoff at its ostium,
there was a calcified complex 90% lesion noted. Further down in the
proximal mid left circumflex coronary artery, there is a subsequent
80% narrowing noted. In the mid left circumflex coronary artery more
distally, there is a 60 to 70% lesion noted. At the distal circumflex
prior to the takeoff of the distal obtuse marginal branches and
posterior descending branch, there is a 60% lesion noted.
4. The right coronary artery is a very small vessel which supplies very
little myocardium.
5. The saphenous vein bypass graft to the left anterior descending is
patent with good runoff. The left anterior descending is a relatively
small vessel distally, however.
6. The saphenous vein bypass graft to the obtuse marginal branch of the
left circumflex coronary artery is known to be totally occluded. It
was not selectively injected.
7. A left ventriculogram reveals severe global hypokinesis. The overall
left ventricular ejection fraction was estimated to be approximately
25%. The left ventricle appears mildly dilated. There is very
minimal mitral regurgitation detected.
8. After successful rotational atherectomy with subsequent implantation of
four overlapping Promus drug-eluding stents into the very proximal
left circumflex coronary artery at its ostium and extending down
through the proximal circumflex out into the mid and subsequently the
distal left circumflex coronary artery, the long area of severe
disease with several 60 to 90% lesions preintervention was reduced to
no residual narrowing postintervention. There was excellent flow in
the distal vessel. There was no evidence of dissection.

CONCLUSIONS
1. Severely depressed global left ventricular systolic function as
described above.
2. Normal left main coronary artery.
3. Totally occluded left anterior descending coronary artery after the
first septal and first diagonal branch.
4. Large and dominant left circumflex coronary artery which has a severe,
high grade, complex, calcified lesion present in the very proximal
aspect at its ostium at its takeoff from the left main coronary
artery. There was also severe obstructive narrowing noted in the
proximal mid and even distal left circumflex coronary artery prior to
severe distal obtuse marginal branches as well as a posterior
descending branch.
5. Very small and nondominant right coronary artery which supplies very
little myocardium.
6. Widely patent saphenous vein bypass graft to the left anterior
descending with the left anterior descending distally being a
relatively small vessel.
7. Successful rotational atherectomy of the very proximal left circumflex
coronary artery with subsequent implantation of four overlapping
Promus drug-eluding stents into the ostium of the left circumflex
coronary artery extending throughout the proximal circumflex down into
the mid and subsequently the distal left circumflex coronary artery.
The proximal stent is a 3 mm Promus drug-eluding stent which is 23 mm
in length. The three distal stents are all 2.75 mm Promus
drug-eluding stents which are 23 mm, 18 mm, and 15 mm in length,
respectively. The severely diseased and heavily calcified proximal
left circumflex coronary artery with several severe lesions in the mid
and distal left circumflex coronary artery preintervention was reduced
to less than 10 to 20% residual narrowing in the very ostial part of
the circumflex with no residual narrowing noted throughout the rest of
the left circumflex coronary artery. There was no evidence of
dissection and there was excellent flow in the distal vessel.
8. Successful implantation of the intraaortic balloon pump via the right
femoral artery for the interventional procedure.
9. Successful insertion of a transvenous temporary ventricular pacemaker
from the left femoral vein.

The way you coded seems to be perfect except that I don't see a code for implantation of the intraaortic ballon pump . Is it inclusive of the angio stent code. I am not sure. Please check on that one. I don't have any of my literature handy now to check on it. In case if you get to know about it let me know. Otherwise everything is good. Also I only wish I get such a descriptive op reports for me to code . Good luck.
skk
 
dpeoples has coded this report correctly, I was in cardiology but am now in pathology but that is not that uncommon of a report and the coding dpeoples gave was exactly what I would use. No codes for removals.

lisa
 
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