bhargavi
Guru
INDICATION
Unremitting chest pain, non ST elevation myocardial infarction, acute coronary
syndrome, history of multivessel bypass and previous percutaneous intervention.
PROCEDURE
Left heart catheterization, coronary angiography, left internal mammary graft
angiography, intra-aortic balloon pump placement and central venous sheath
placement.
DESCRIPTION OF PROCEDURE
After obtaining informed consent from the patient, a 6 French sheath was placed
in the right common femoral artery. Diagnostic four-tipped Judkins left and
right coronary catheter were utilized for selective left and right coronary
angiography as well as left internal mammary graft angiography. The patient's
vein grafts are known to e chronically occluded. Left heart catheterization
was performed however, left ventriculography was not performed. There was
markedly elevated left ventricular end-diastolic pressure. The patient
appeared to have progressive disease at the ostial segment of the dominant
right coronary artery, in comparison to the 2011 catheterization film, as well
as worsening of the left circumflex diffuse coronary disease. A decision was
then made to attempt percutaneous revascularization of the right coronary
artery ostial stenosis. Despite multiple attempts with the use of multiple
guiding catheters, a right coronary guiding catheter, left internal mammary
artery guiding catheter and a right Amplatz guiding catheter, it was never
possible to obtain adequate placement receiving of the guiding catheter at the
ostium of this right coronary artery, which was heavily calcified, to even
allow wire advancement. During this attempt, the patient developed progressive
hypotension. The patient has a dual-chamber pacemaker in place and did
demonstrate progressive ventricular pacing, she early on demonstrated atrial
dysrhythmia, atrial fibrillation and did receive amiodarone bolus in a drip.
Regardless, she developed progressive hypotension and became unresponsive.
Cardiopulmonary resuscitation was begun, intraaortic balloon pump was placed
through the right common femoral access, as well as placement of the central
venous sheath into the right common femoral vein. The patient then developed
ventricular tachycardia, required cardioversion, and support with multiple
pressors as well as balloon counterpulsation. She also developed
unresponsiveness, as noted, she developed hypoxemia and required intubation
with mechanical ventilation, was also noted to have suffered aspiration.
Finally, after placement of endotracheal tube to secure the airway, balloon
counterpulsation intravenous Neo-Synephrine and dobutamine and multiple
administration of bolus epinephrine as well as epinephrine infusion and
amiodarone infusion, the patient did maintain a systolic pressure greater than
100 with counterpulsation, and was transferred to the intensive care unit.
The patient's prognosis is very poor given her previous neurologic status,
given her aspiration unresponsiveness at present, and severe hypotension with
need for balloon and counterpulsation and pressor and ionotropic support.
ANGIOGRAPHY
The left vein was patent. The left anterior descending was occluded proximally.
The left circumflex was essentially subtotally occluded proximally with
multiple small distal vessels visualized either from antegrade flow or
collaterals, all of which were severely diffusely diseased. The right coronary
artery had heavily calcified ostial stenosis which appeared to be up to 90%.
In 2011, this was present, but it did admit engagement of the catheter with
moderate damping in 2011. On this examination, the diagnostic and the guiding
catheter would never actually intubate into the ostium however, heavy
calcification was noted, there was also distal disease in this vessel although
it was a dominant vessel certainly.
The left internal mammary graft to the mid LAD was widely patent, with minimal
collateral filling of the right coronary artery noted. All vein grafts were
occluded.
INTERVENTION
As detailed above, attempted engagement wire passage for planned intervention
of the right coronary ostial stenosis was unsuccessful.
COMPLICATIONS
Progressive and severe hypotension, with cardiopulmonary arrest and requirement
for intraaortic balloon pump placement, pressor support and ventilatory support
following intubation.
SUMMARY/CONCLUSIONS
1. Non ST elevation myocardial infarction ongoing, unremitting chest pain,
refractory to medical therapy and intravenous nitroglycerin.
2. Severe diffuse three-vessel coronary disease, occlusion of all grafts with
the exception of the mammary graft.
3. Progressive severe ostial disease, dominant right coronary artery,
unsuitable for percutaneous revascularization, as detailed above.
4. Hypotension, cardiogenic shock, and ventricular tachycardia, respiratory
arrest requiring pressor support, intraaortic balloon pump placement,
cardioversion and intubation.
RECOMMENDATION
After discussion with the patient's family, given her previous wishes, the
patient will be maintained at this time with ventilatory support and pressor
and balloon pump support. She has a dual-chamber pacemaker in place. Atrial
and ventricular dysrhythmias will be treated with amiodarone as appropriate.
The patient was seen in consultation briefly by cardiothoracic surgery
however, given the patient's age, and comorbidities was felt to be a poor
candidate for surgical revascularization of the right coronary artery. Full
support and medical management will be entertained, pending the patient's
respiratory and neurologic status and outcome. This was discussed in detail
with the patient's family and representative. Of note, the patient's prognosis
at this time is extremely poor and grave.
should I bill 93459-xu, 33967,92950,92960 ?
thanks in advance for help
Unremitting chest pain, non ST elevation myocardial infarction, acute coronary
syndrome, history of multivessel bypass and previous percutaneous intervention.
PROCEDURE
Left heart catheterization, coronary angiography, left internal mammary graft
angiography, intra-aortic balloon pump placement and central venous sheath
placement.
DESCRIPTION OF PROCEDURE
After obtaining informed consent from the patient, a 6 French sheath was placed
in the right common femoral artery. Diagnostic four-tipped Judkins left and
right coronary catheter were utilized for selective left and right coronary
angiography as well as left internal mammary graft angiography. The patient's
vein grafts are known to e chronically occluded. Left heart catheterization
was performed however, left ventriculography was not performed. There was
markedly elevated left ventricular end-diastolic pressure. The patient
appeared to have progressive disease at the ostial segment of the dominant
right coronary artery, in comparison to the 2011 catheterization film, as well
as worsening of the left circumflex diffuse coronary disease. A decision was
then made to attempt percutaneous revascularization of the right coronary
artery ostial stenosis. Despite multiple attempts with the use of multiple
guiding catheters, a right coronary guiding catheter, left internal mammary
artery guiding catheter and a right Amplatz guiding catheter, it was never
possible to obtain adequate placement receiving of the guiding catheter at the
ostium of this right coronary artery, which was heavily calcified, to even
allow wire advancement. During this attempt, the patient developed progressive
hypotension. The patient has a dual-chamber pacemaker in place and did
demonstrate progressive ventricular pacing, she early on demonstrated atrial
dysrhythmia, atrial fibrillation and did receive amiodarone bolus in a drip.
Regardless, she developed progressive hypotension and became unresponsive.
Cardiopulmonary resuscitation was begun, intraaortic balloon pump was placed
through the right common femoral access, as well as placement of the central
venous sheath into the right common femoral vein. The patient then developed
ventricular tachycardia, required cardioversion, and support with multiple
pressors as well as balloon counterpulsation. She also developed
unresponsiveness, as noted, she developed hypoxemia and required intubation
with mechanical ventilation, was also noted to have suffered aspiration.
Finally, after placement of endotracheal tube to secure the airway, balloon
counterpulsation intravenous Neo-Synephrine and dobutamine and multiple
administration of bolus epinephrine as well as epinephrine infusion and
amiodarone infusion, the patient did maintain a systolic pressure greater than
100 with counterpulsation, and was transferred to the intensive care unit.
The patient's prognosis is very poor given her previous neurologic status,
given her aspiration unresponsiveness at present, and severe hypotension with
need for balloon and counterpulsation and pressor and ionotropic support.
ANGIOGRAPHY
The left vein was patent. The left anterior descending was occluded proximally.
The left circumflex was essentially subtotally occluded proximally with
multiple small distal vessels visualized either from antegrade flow or
collaterals, all of which were severely diffusely diseased. The right coronary
artery had heavily calcified ostial stenosis which appeared to be up to 90%.
In 2011, this was present, but it did admit engagement of the catheter with
moderate damping in 2011. On this examination, the diagnostic and the guiding
catheter would never actually intubate into the ostium however, heavy
calcification was noted, there was also distal disease in this vessel although
it was a dominant vessel certainly.
The left internal mammary graft to the mid LAD was widely patent, with minimal
collateral filling of the right coronary artery noted. All vein grafts were
occluded.
INTERVENTION
As detailed above, attempted engagement wire passage for planned intervention
of the right coronary ostial stenosis was unsuccessful.
COMPLICATIONS
Progressive and severe hypotension, with cardiopulmonary arrest and requirement
for intraaortic balloon pump placement, pressor support and ventilatory support
following intubation.
SUMMARY/CONCLUSIONS
1. Non ST elevation myocardial infarction ongoing, unremitting chest pain,
refractory to medical therapy and intravenous nitroglycerin.
2. Severe diffuse three-vessel coronary disease, occlusion of all grafts with
the exception of the mammary graft.
3. Progressive severe ostial disease, dominant right coronary artery,
unsuitable for percutaneous revascularization, as detailed above.
4. Hypotension, cardiogenic shock, and ventricular tachycardia, respiratory
arrest requiring pressor support, intraaortic balloon pump placement,
cardioversion and intubation.
RECOMMENDATION
After discussion with the patient's family, given her previous wishes, the
patient will be maintained at this time with ventilatory support and pressor
and balloon pump support. She has a dual-chamber pacemaker in place. Atrial
and ventricular dysrhythmias will be treated with amiodarone as appropriate.
The patient was seen in consultation briefly by cardiothoracic surgery
however, given the patient's age, and comorbidities was felt to be a poor
candidate for surgical revascularization of the right coronary artery. Full
support and medical management will be entertained, pending the patient's
respiratory and neurologic status and outcome. This was discussed in detail
with the patient's family and representative. Of note, the patient's prognosis
at this time is extremely poor and grave.
should I bill 93459-xu, 33967,92950,92960 ?
thanks in advance for help