bennieyoung
Guru
In coding the diagnosis for this case I used Z95.5 because I thought it was the better choice because of the intracoronary stents. I'm being asked if Z95.1 would be a better choice because CABG was documented. Can someone look and give me their thoughts? I would appreciate the input. Thanks so much!
PREPROCEDURE DIAGNOSIS: Severe symptomatic aortic stenosis/coronary artery disease.
POSTPROCEDURE DIAGNOSIS: Severe symptomatic aortic stenosis/coronary artery disease.
PROCEDURE:
1. Nonselective left groin sheathogram.
2. 7-French sheath, left common iliac vein.
3. Heart catheterization using a Swan-Ganz catheter.
4. Bilateral coronary angiography.
5. Abdominal aortogram.
HISTORY: Briefly, this is an 89-year-old male with a history of known coronary disease and aortic stenosis. The patient has been having more dyspnea on exertion and fatigue as an outpatient. Patient underwent a DSE recently, which showed clear elevation of pressure across his aortic valve with minimal heart rate elevation reflecting severe aortic stenosis. Given these findings, patient consented for right and left heart catheterization in anticipation for an eventual TAVR.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to BCH where the patient was prepped and draped in a normal sterile fashion. Using lidocaine and a 6-French sheath, the left common femoral artery was verified angiographically. A 7-French sheath was placed in the left common iliac vein. Swan-Ganz catheter was then advanced. Wedge pressure was a mean of 11, A-wave 15, V-wave 17. PA pressure systolic 34, diastolic 10, mean of 20. RV pressure systolic 37, diastolic 4, end of 9. RA pressure mean of 6, A-wave 9, V-wave 8. Cardiac output was 4.4 by Fick with an index of 2.3. Swan-Ganz catheter was then removed. A JL4 catheter was then advanced to the left coronary artery. Images of the left coronary artery showed normal left main. Left circumflex artery with 100% occluded after its ostial takeoff, which is a known finding. The patient had extensive stents in the LAD. The stents appeared to be widely patent with only minimal in-stent restenosis in the midportion. There was a medium-sized diagonal artery coming off the midbody, which had a stent in its proximal aspect. The stent appeared to be widely patent. Distal LAD appeared to be widely patent and free of disease. After these images were obtained, the JL4 catheter was removed. The JR4 catheter was advanced to the right coronary artery. Images of the right coronary artery revealed normal ostial with 20% plaque in the proximal aspect. There was plaque disease throughout the course of the mid RCA. The RPDA and RPS appeared to be healthy and free of disease. There appeared to be a right-dominant circulation. The JR4 catheter was then removed. A pigtail catheter was advanced into the descending aorta. Abdominal aortogram showed widely patent distal aorta, widely patent bilateral common, external, internal iliac arteries and CFAs bilaterally. The pigtail catheter was removed over the 0.035 wire. The left groin was closed with manual pressure. Patient tolerated the procedure well with no complications.
IMPRESSION: Coronary artery disease, namely in the form of:
1. 100% occluded proximal left circumflex artery, which is a chronic finding.
2. Patent stents in the LAD with minimal in-stent restenosis.
3. Right coronary artery with noncritical disease.
4. Normal pulmonic pressures.
5. Widely patent aortoiliac arterial conduits.
PLAN: The patient will have 3 hours bed rest; CTAs of the chest, abdomen, and pelvis, and a carotid ultrasound. The patient will follow up with CT Surgery for discussion about a TAVR. Potentially, we will plan this procedure within the next few weeks.
PREPROCEDURE DIAGNOSIS: Severe symptomatic aortic stenosis/coronary artery disease.
POSTPROCEDURE DIAGNOSIS: Severe symptomatic aortic stenosis/coronary artery disease.
PROCEDURE:
1. Nonselective left groin sheathogram.
2. 7-French sheath, left common iliac vein.
3. Heart catheterization using a Swan-Ganz catheter.
4. Bilateral coronary angiography.
5. Abdominal aortogram.
HISTORY: Briefly, this is an 89-year-old male with a history of known coronary disease and aortic stenosis. The patient has been having more dyspnea on exertion and fatigue as an outpatient. Patient underwent a DSE recently, which showed clear elevation of pressure across his aortic valve with minimal heart rate elevation reflecting severe aortic stenosis. Given these findings, patient consented for right and left heart catheterization in anticipation for an eventual TAVR.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to BCH where the patient was prepped and draped in a normal sterile fashion. Using lidocaine and a 6-French sheath, the left common femoral artery was verified angiographically. A 7-French sheath was placed in the left common iliac vein. Swan-Ganz catheter was then advanced. Wedge pressure was a mean of 11, A-wave 15, V-wave 17. PA pressure systolic 34, diastolic 10, mean of 20. RV pressure systolic 37, diastolic 4, end of 9. RA pressure mean of 6, A-wave 9, V-wave 8. Cardiac output was 4.4 by Fick with an index of 2.3. Swan-Ganz catheter was then removed. A JL4 catheter was then advanced to the left coronary artery. Images of the left coronary artery showed normal left main. Left circumflex artery with 100% occluded after its ostial takeoff, which is a known finding. The patient had extensive stents in the LAD. The stents appeared to be widely patent with only minimal in-stent restenosis in the midportion. There was a medium-sized diagonal artery coming off the midbody, which had a stent in its proximal aspect. The stent appeared to be widely patent. Distal LAD appeared to be widely patent and free of disease. After these images were obtained, the JL4 catheter was removed. The JR4 catheter was advanced to the right coronary artery. Images of the right coronary artery revealed normal ostial with 20% plaque in the proximal aspect. There was plaque disease throughout the course of the mid RCA. The RPDA and RPS appeared to be healthy and free of disease. There appeared to be a right-dominant circulation. The JR4 catheter was then removed. A pigtail catheter was advanced into the descending aorta. Abdominal aortogram showed widely patent distal aorta, widely patent bilateral common, external, internal iliac arteries and CFAs bilaterally. The pigtail catheter was removed over the 0.035 wire. The left groin was closed with manual pressure. Patient tolerated the procedure well with no complications.
IMPRESSION: Coronary artery disease, namely in the form of:
1. 100% occluded proximal left circumflex artery, which is a chronic finding.
2. Patent stents in the LAD with minimal in-stent restenosis.
3. Right coronary artery with noncritical disease.
4. Normal pulmonic pressures.
5. Widely patent aortoiliac arterial conduits.
PLAN: The patient will have 3 hours bed rest; CTAs of the chest, abdomen, and pelvis, and a carotid ultrasound. The patient will follow up with CT Surgery for discussion about a TAVR. Potentially, we will plan this procedure within the next few weeks.