bhargavi
Guru
REASON FOR PROCEDURE
Severe aortic stenosis.
HISTORY
This 88 years old white female has hypertension, hyperlipidemia, coronary
artery disease status post coronary artery bypass graft surgery times three at
Christiana Hospital in 1998 and severe aortic stenosis. She was admitted with
palpitations and chest pain. The patient was noted to have critical aortic
stenosis. She was ruled out for a myocardial infarction with negative cardiac
biomarkers. Considering her symptomatic aortic valve stenosis, Cardiac Surgery
was consulted and the patient was seen by Dr. Marelli the cardiac surgeon.
Considering the patient's previous open heart bypass surgery and sternal wound
infection requiring muscle flap, she is being considered for transcatheter
aortic valve replacement. The patient had a cardiac catheterization as part of
the preoperative work-up before possible upcoming aortic valve replacement.
PROCEDURES PERFORMED
1. Selective left and right coronary angiograms.
2. Right heart cardiac catheterization.
3. Graft angiogram.
4. Right ileofemoral angiogram.
5. Six French Angio-Seal closure for right femoral artery puncture.
PROCEDURE NOTE
Informed consent was obtained after explanation of the risks and benefits to
the patient. The right groin was prepped in the sterile fashion. The patient
was premedicated with 1.5 milligrams of Versed and 75 micrograms of Fentanyl
intravenously during the procedure. A six femoral sheath was inserted in the
right femoral artery using the micropuncture needle without any difficulty. A
seven French femoral sheath was inserted in the right femoral vein without any
difficulty. A seven French Swan-Ganz catheter was advanced into the right side
of the heart and oxygen saturation and pressures were measured. The cardiac
output was calculated using the FICK method. Subsequently the FL3.5 catheter
was used to cannulate the left coronary artery. Multiple attempts were made
using a different catheter to find the right coronary artery which was
unsuccessful initially. For the same reason, a six French angle pigtail
catheter was advanced and the ascending aortogram was performed and the right
coronary artery was identified which had a very anterior take off.
Subsequently using a six French Williams right catheter, the right coronary
artery was selectively cannulated. A six French FR4 catheter was also used to
engage the left internal mammary artery graft. The FR4 catheter was also
advanced initially using a procedure wire to the right innominate artery to
engage the right inferior mammary artery graft which unsuccessful as the
innominate artery extremely tortuous. After multiple attempts using a 0.035 Zip
wire, the FR4 catheter was advanced through the right subclavian artery. Even
the right ( ) mammary artery could not be successfully
cannulated due to extreme tortuosity of the vessel and steep angle of origin.
Using nonselective angiogram, the right internal mammary bypass graft was
assessed which was apparently patent. Multiple attempts were made using a
straight procedure wire to cross the aortic valve which was not successful and
considering known history of critical aortic stenosis, further attempts were
not made. The patient remained hemodynamically stable and tolerated the
procedure well. A right ileofemoral angiogram was performed and a six French
Angio-Seal closure was deployed with good hemostasis.
COMPLICATIONS
None.
RIGHT HEART CARDIAC CATHETERIZATION
The right atrial pressure was 4/3 millimeters of mercury.
The right ventricular pressure was 32/4 millimeters of mercury.
The pulmonary artery pressure was 26/8/14 millimeters of mercury.
The pulmonary capillary wedge pressure was 10 millimeters of mercury.
The cardiac output was 4.34 liters per minute using the FICK method.
The cardiac index was 2.43 liters per minute per meter squared using the FICK
method.
CORONARY ANGIOGRAM
1. The left main was patent and mildly calcified. Mild to moderate osteal
stenosis was noted in the left main artery. There was 60 percent distal
stenosis noted before the bifurcation.
2. The left anterior descending artery was medium size in caliber and wrapped
around the apex. The proximal left anterior descending artery had a 70 percent
diffuse calcified stenosis. Retrograde flow was noted in the left internal
mammary artery at the mid left anterior descending level which was widely
patent with no evidence of disease at the anastomosis. The mid and distal left
anterior descending were, otherwise, angiographically did not have significant
disease.
3. The left circumflex artery was large in caliber. The proximal right
circumflex artery had 70 percent diffuse disease. The first and second obtuse
marginal branches were medium to large in caliber and widely patent. The
comparative flow was noted in the left internal mammary artery without any
disease at the anastomosis.
4. The right coronary artery was anatomically dominant artery but somewhat
smaller in caliber. The right coronary artery also had a very anterior take
off with osteal 70 percent calcified stenosis. The flow in the right coronary
artery was normal. Otherwise, the right coronary artery did not have any
significant disease.
GRAFT ANGIOGRAM
1. The left internal mammary artery graft to the obtuse marginal to the
branch of the circumflex artery was widely patent with good run off.
2. The right internal mammary artery graft to the left anterior descending
was not selectively cannulated even though it was patent without any evidence
of disease at the anastomosis, with good distal run off.
3. The saphenous venous graft to the right coronary artery was 100percent
occluded at the origin.
LEFT HEART CARDIAC CATHETERIZATION
Multiple attempts were made to cross the aortic valve which could not be
crossed.
RIGHT ILEOFEMORAL ANGIOGRAM
The right common femoral artery was patent. The sheath insertion was above the
bifurcation and below the origin of the inferior epigastric artery.
IMPRESSION
1. Three vessels native coronary disease.
2. Patent left internal mammary artery graft to the obtuse marginal branch of
the circumflex artery.
3. Patent right internal mammary artery graft to the left anterior descending.
4. One hundred percent occluded saphenous venous graft to the right coronary
artery.
5. Minimally elevated pulmonary artery pressures.
6. Critical aortic stenosis by history even though the aortic valve could not
be crossed.
RECOMMENDATIONS
The patient is going to be observed in the intermediate care unit and she is
going to be on bed rest for a few hours. She does have a history of critical
aortic stenosis and she is symptomatic. She is being considered for possible
trans catheter aortic valve replacement at the University of Pennsylvania in
the near future.
i was going to bill 93457. question is can i do 93458 with 74 modifier ?
--------------------------------------------------------------------------------
Severe aortic stenosis.
HISTORY
This 88 years old white female has hypertension, hyperlipidemia, coronary
artery disease status post coronary artery bypass graft surgery times three at
Christiana Hospital in 1998 and severe aortic stenosis. She was admitted with
palpitations and chest pain. The patient was noted to have critical aortic
stenosis. She was ruled out for a myocardial infarction with negative cardiac
biomarkers. Considering her symptomatic aortic valve stenosis, Cardiac Surgery
was consulted and the patient was seen by Dr. Marelli the cardiac surgeon.
Considering the patient's previous open heart bypass surgery and sternal wound
infection requiring muscle flap, she is being considered for transcatheter
aortic valve replacement. The patient had a cardiac catheterization as part of
the preoperative work-up before possible upcoming aortic valve replacement.
PROCEDURES PERFORMED
1. Selective left and right coronary angiograms.
2. Right heart cardiac catheterization.
3. Graft angiogram.
4. Right ileofemoral angiogram.
5. Six French Angio-Seal closure for right femoral artery puncture.
PROCEDURE NOTE
Informed consent was obtained after explanation of the risks and benefits to
the patient. The right groin was prepped in the sterile fashion. The patient
was premedicated with 1.5 milligrams of Versed and 75 micrograms of Fentanyl
intravenously during the procedure. A six femoral sheath was inserted in the
right femoral artery using the micropuncture needle without any difficulty. A
seven French femoral sheath was inserted in the right femoral vein without any
difficulty. A seven French Swan-Ganz catheter was advanced into the right side
of the heart and oxygen saturation and pressures were measured. The cardiac
output was calculated using the FICK method. Subsequently the FL3.5 catheter
was used to cannulate the left coronary artery. Multiple attempts were made
using a different catheter to find the right coronary artery which was
unsuccessful initially. For the same reason, a six French angle pigtail
catheter was advanced and the ascending aortogram was performed and the right
coronary artery was identified which had a very anterior take off.
Subsequently using a six French Williams right catheter, the right coronary
artery was selectively cannulated. A six French FR4 catheter was also used to
engage the left internal mammary artery graft. The FR4 catheter was also
advanced initially using a procedure wire to the right innominate artery to
engage the right inferior mammary artery graft which unsuccessful as the
innominate artery extremely tortuous. After multiple attempts using a 0.035 Zip
wire, the FR4 catheter was advanced through the right subclavian artery. Even
the right ( ) mammary artery could not be successfully
cannulated due to extreme tortuosity of the vessel and steep angle of origin.
Using nonselective angiogram, the right internal mammary bypass graft was
assessed which was apparently patent. Multiple attempts were made using a
straight procedure wire to cross the aortic valve which was not successful and
considering known history of critical aortic stenosis, further attempts were
not made. The patient remained hemodynamically stable and tolerated the
procedure well. A right ileofemoral angiogram was performed and a six French
Angio-Seal closure was deployed with good hemostasis.
COMPLICATIONS
None.
RIGHT HEART CARDIAC CATHETERIZATION
The right atrial pressure was 4/3 millimeters of mercury.
The right ventricular pressure was 32/4 millimeters of mercury.
The pulmonary artery pressure was 26/8/14 millimeters of mercury.
The pulmonary capillary wedge pressure was 10 millimeters of mercury.
The cardiac output was 4.34 liters per minute using the FICK method.
The cardiac index was 2.43 liters per minute per meter squared using the FICK
method.
CORONARY ANGIOGRAM
1. The left main was patent and mildly calcified. Mild to moderate osteal
stenosis was noted in the left main artery. There was 60 percent distal
stenosis noted before the bifurcation.
2. The left anterior descending artery was medium size in caliber and wrapped
around the apex. The proximal left anterior descending artery had a 70 percent
diffuse calcified stenosis. Retrograde flow was noted in the left internal
mammary artery at the mid left anterior descending level which was widely
patent with no evidence of disease at the anastomosis. The mid and distal left
anterior descending were, otherwise, angiographically did not have significant
disease.
3. The left circumflex artery was large in caliber. The proximal right
circumflex artery had 70 percent diffuse disease. The first and second obtuse
marginal branches were medium to large in caliber and widely patent. The
comparative flow was noted in the left internal mammary artery without any
disease at the anastomosis.
4. The right coronary artery was anatomically dominant artery but somewhat
smaller in caliber. The right coronary artery also had a very anterior take
off with osteal 70 percent calcified stenosis. The flow in the right coronary
artery was normal. Otherwise, the right coronary artery did not have any
significant disease.
GRAFT ANGIOGRAM
1. The left internal mammary artery graft to the obtuse marginal to the
branch of the circumflex artery was widely patent with good run off.
2. The right internal mammary artery graft to the left anterior descending
was not selectively cannulated even though it was patent without any evidence
of disease at the anastomosis, with good distal run off.
3. The saphenous venous graft to the right coronary artery was 100percent
occluded at the origin.
LEFT HEART CARDIAC CATHETERIZATION
Multiple attempts were made to cross the aortic valve which could not be
crossed.
RIGHT ILEOFEMORAL ANGIOGRAM
The right common femoral artery was patent. The sheath insertion was above the
bifurcation and below the origin of the inferior epigastric artery.
IMPRESSION
1. Three vessels native coronary disease.
2. Patent left internal mammary artery graft to the obtuse marginal branch of
the circumflex artery.
3. Patent right internal mammary artery graft to the left anterior descending.
4. One hundred percent occluded saphenous venous graft to the right coronary
artery.
5. Minimally elevated pulmonary artery pressures.
6. Critical aortic stenosis by history even though the aortic valve could not
be crossed.
RECOMMENDATIONS
The patient is going to be observed in the intermediate care unit and she is
going to be on bed rest for a few hours. She does have a history of critical
aortic stenosis and she is symptomatic. She is being considered for possible
trans catheter aortic valve replacement at the University of Pennsylvania in
the near future.
i was going to bill 93457. question is can i do 93458 with 74 modifier ?
--------------------------------------------------------------------------------
