Cats3
Contributor
So I have 93459 and 33990 for this procedure, but I am not sure what else I'm missing. Any help would be appreciated. Thank you!
INDICATIONS/DIAGNOSIS:
1. Non-ST-elevated myocardial infarction.
2. Severe left main multivessel coronary artery disease with remote four-vessel coronary artery bypass graft.
3. Acute systolic heart failure.
4. Cardiogenic shock.
5. Diabetes mellitus type 2.
COMPLICATIONS:
None immediate.
ESTIMATED BLOOD LOSS:
50 mL.
FLUORO TIME:
10.9.
CONTRAST:
86 mL.
CONSCIOUS SEDATION:
IV Versed, IV fentanyl. Please refer to sedation narrator. Level of conscious sedation was mild due to acuity of illness. The patient was continuously monitored.
DESCRIPTION OF PROCEDURE:
, patient with known history of severe left main multivessel coronary artery disease with remote CABG. The patient presented with non-STEMI with acute CHF. The patient was referred for cardiac catheterization.
After informed consent was obtained, the patient was sterilely prepped and draped in the usual manner. Patient was provided IV sedation and local anesthesia. Under direct ultrasound guidance using micropuncture technique, the right common femoral artery was accessed. We then exchanged for a 6-French mid-size Cordis sheath. This sheath was then advanced over the wire without difficulty. Beyond this, all catheter exchanges were done over an exchange length wire. On presentation to cath lab pt noted to be visibly dyspneic/orthopneic.
Selective angiogram of the LCA was obtained using a 6-French FL4 diagnostic catheter. Selective angiograms of the native RCA was obtained using a 6-French FR4 diagnostic catheter. We then obtained selective angiograms of the SVG to the obtuse marginal branch. The catheter was then repositioned to the left subclavian and selective angiograms of the LIMA graft to the distal LAD was obtained using the IM diagnostic catheter. We then exchanged over the wire to a multipurpose A1 catheter and obtained selective angiograms of the SVG to the right coronary artery. During the course of care, patient was noted to be hypotensive. The patient was provided with IV pressors and initiated a Levophed drip. At that time, we sterilely prepped and draped the right internal jugular access site and then under direct ultrasound guidance, accessed the right internal jugular vein with micropuncture technique. Then, with serial dilation with a 6-French dilator, we advanced a 9-French sheath over the wire without difficulty. We then advanced the 8-French CCO Swan under direct fluoroscopic guidance, right-sided hemodynamics were recorded. Saturation samples were drawn. Wedge pressure was recorded. At that time, given the findings of the hemodynamic assessment we then prepped for Impella CP placement and insertion. Angiogram of the right femoral access site was obtained. We then used an 8-French MANTA depth measuring tool. Depth was measured at 4 + 1. Then, using serial dilators, we were able to advance a 14-French Impella sheath over the stiff wire. We then advanced a 6-French angled pigtail catheter over the wire into the left ventricle. During that time, patient had pulseless electrical activity at which time transient CPR was performed for less than 2 minutes with restoration of rhythm and blood pressure. At that point, we were able to advance the Impella CP catheter over the wire. The Impella CP was positioned into the LV, wire was removed and we initiated support. There was adequate flow rate approximately 3.5 L at that point with sheath and Impella catheter were secured with sutures. We then sterilely prepped the left radial arterial access site and under ultrasound guidance left radial artery access was obtained and an arterial line was inserted over the wire and secured. We did advance a 6-French IM guiding catheter and angiograms revealed a small LIMA graft to a very small caliber distal LAD with severe diffuse disease. The final angiograms revealed severe diffuse stenosis of the very small caliber IMA with occlusion distally. There was TIMI-3 flow on final injection. We confirmed placement of the Impella CP catheter and confirmed adequate flow rate, which was approximately 3.5 L and at that point, all of the sheaths were secured with sutures. At that point, patient was then transported to the critical care unit in stable condition.
FINDINGS:
HEMODYNAMICS: Initial central aortic systolic pressure was 89, diastolic of 63, mean of 76, following IV pressors and Impella CP arterial systolic pressure was 120, diastolic of 65, mean of 83.
RA pressure was 16/17/16, RV was 41/18/19. PA pressure was 43/28/35. Pulmonary capillary wedge pressure was 32/28/25. PA saturation was 48. AO saturation was 97. Cardiac output was 3.01. Cardiac index was 1.64, PAPi was 1.62, CPO was 0.51, consistent with cardiogenic shock.
CORONARY ANATOMY:
1. Injection of the left main reveals a calcified left main, 100% occluded proximally. There is no antegrade flow.
2. Angiogram of the native RCA reveals the right coronary artery to be 100% occluded at its origin/ostium after conus branch.
3. Very small caliber SVG to an obtuse marginal branch is patent. There was normal TIMI-3 flow. There is a stent within the proximal segment of the SVG with mild-to-moderate in-stent diffuse stenosis. Proximal to the stent there also appears to be a focal in-stent restenosis, which appears moderate. There is good TIMI-3 flow into the distal OM target. There is left-to-left collaterals to what appears to be a diagonal branch.
4. LIMA to the LAD is small caliber. Initial angiograms revealed TIMI 2 flow. The distal LAD target is very small caliber. There is diffuse disease. There is diffuse segment of 70% to 80% stenosis. Then, the distal LAD beyond that at the apex appears occluded. As noted above, engagement with the IM guide and final angiogram revealed TIMI-3 flow.
5. SVG to the RCA is widely patent. There is a focal ostial proximal stenosis which appears approximately 50%, but this is similar to the prior study in 2017. The mid segment of the SVG prior to the anastomosis has a diffuse segment of moderate stenosis. There is TIMI-3 flow beyond the anastomosis. Also visualized was right-to-left collaterals.
FINAL IMPRESSIONS:
1. Severe left main multivessel coronary artery disease.
2. Left main is now 100% occluded. Previous study revealed severely calcified left main stenosis greater than 95% supplying the proximal diagonal branch.
3. Native right coronary artery 100% occluded at its ostium, similar to prior study.
4. Patent left internal mammary artery to a very small atretic, diffusely diseased distal left anterior descending with diffuse 70% to 80% stenosis with TIMI-3 flow on final angiogram with the internal mammary guide. The terminal distal left anterior descending is 100% occluded.
5. Patent saphenous vein graft to the obtuse marginal with mild-moderate diffuse proximal segment disease with a patent stent with mild-moderate focal in-stent restenosis with normal TIMI-3 flow with left-to-left collaterals likely to the diagonal branch.
6. Patent saphenous vein graft to the right coronary artery with proximal and mid segment stenosis but with normal TIMI-3 flow with right-to-left collaterals.
7. Elevated pulmonary capillary wedge pressure with a mean of 25 mmHg.
8. Cardiogenic shock with cardiac index of 1.64 and cardiac power output of 0.51.
9. Successful insertion of Impella CP with adequate flow rate of approximately 3.5 L.
10. Placement of 8-French CCO Swan for continued hemodynamic monitoring.
11. Placement of left radial arterial line for hemodynamic monitoring.
12. Severe native left main right coronary artery disease with 100% occlusion as noted above.
RECOMMENDATIONS:
1. Full supportive care.
2. TTE for Impella insertion and monitoring and q.a.m. while in place.
3. Guideline directed medical therapy for non-STEMI and CHF.
4. Critical care team consultation.
5. Would recommend palliative care consult.
6. Poor prognosis.
INDICATIONS/DIAGNOSIS:
1. Non-ST-elevated myocardial infarction.
2. Severe left main multivessel coronary artery disease with remote four-vessel coronary artery bypass graft.
3. Acute systolic heart failure.
4. Cardiogenic shock.
5. Diabetes mellitus type 2.
COMPLICATIONS:
None immediate.
ESTIMATED BLOOD LOSS:
50 mL.
FLUORO TIME:
10.9.
CONTRAST:
86 mL.
CONSCIOUS SEDATION:
IV Versed, IV fentanyl. Please refer to sedation narrator. Level of conscious sedation was mild due to acuity of illness. The patient was continuously monitored.
DESCRIPTION OF PROCEDURE:
, patient with known history of severe left main multivessel coronary artery disease with remote CABG. The patient presented with non-STEMI with acute CHF. The patient was referred for cardiac catheterization.
After informed consent was obtained, the patient was sterilely prepped and draped in the usual manner. Patient was provided IV sedation and local anesthesia. Under direct ultrasound guidance using micropuncture technique, the right common femoral artery was accessed. We then exchanged for a 6-French mid-size Cordis sheath. This sheath was then advanced over the wire without difficulty. Beyond this, all catheter exchanges were done over an exchange length wire. On presentation to cath lab pt noted to be visibly dyspneic/orthopneic.
Selective angiogram of the LCA was obtained using a 6-French FL4 diagnostic catheter. Selective angiograms of the native RCA was obtained using a 6-French FR4 diagnostic catheter. We then obtained selective angiograms of the SVG to the obtuse marginal branch. The catheter was then repositioned to the left subclavian and selective angiograms of the LIMA graft to the distal LAD was obtained using the IM diagnostic catheter. We then exchanged over the wire to a multipurpose A1 catheter and obtained selective angiograms of the SVG to the right coronary artery. During the course of care, patient was noted to be hypotensive. The patient was provided with IV pressors and initiated a Levophed drip. At that time, we sterilely prepped and draped the right internal jugular access site and then under direct ultrasound guidance, accessed the right internal jugular vein with micropuncture technique. Then, with serial dilation with a 6-French dilator, we advanced a 9-French sheath over the wire without difficulty. We then advanced the 8-French CCO Swan under direct fluoroscopic guidance, right-sided hemodynamics were recorded. Saturation samples were drawn. Wedge pressure was recorded. At that time, given the findings of the hemodynamic assessment we then prepped for Impella CP placement and insertion. Angiogram of the right femoral access site was obtained. We then used an 8-French MANTA depth measuring tool. Depth was measured at 4 + 1. Then, using serial dilators, we were able to advance a 14-French Impella sheath over the stiff wire. We then advanced a 6-French angled pigtail catheter over the wire into the left ventricle. During that time, patient had pulseless electrical activity at which time transient CPR was performed for less than 2 minutes with restoration of rhythm and blood pressure. At that point, we were able to advance the Impella CP catheter over the wire. The Impella CP was positioned into the LV, wire was removed and we initiated support. There was adequate flow rate approximately 3.5 L at that point with sheath and Impella catheter were secured with sutures. We then sterilely prepped the left radial arterial access site and under ultrasound guidance left radial artery access was obtained and an arterial line was inserted over the wire and secured. We did advance a 6-French IM guiding catheter and angiograms revealed a small LIMA graft to a very small caliber distal LAD with severe diffuse disease. The final angiograms revealed severe diffuse stenosis of the very small caliber IMA with occlusion distally. There was TIMI-3 flow on final injection. We confirmed placement of the Impella CP catheter and confirmed adequate flow rate, which was approximately 3.5 L and at that point, all of the sheaths were secured with sutures. At that point, patient was then transported to the critical care unit in stable condition.
FINDINGS:
HEMODYNAMICS: Initial central aortic systolic pressure was 89, diastolic of 63, mean of 76, following IV pressors and Impella CP arterial systolic pressure was 120, diastolic of 65, mean of 83.
RA pressure was 16/17/16, RV was 41/18/19. PA pressure was 43/28/35. Pulmonary capillary wedge pressure was 32/28/25. PA saturation was 48. AO saturation was 97. Cardiac output was 3.01. Cardiac index was 1.64, PAPi was 1.62, CPO was 0.51, consistent with cardiogenic shock.
CORONARY ANATOMY:
1. Injection of the left main reveals a calcified left main, 100% occluded proximally. There is no antegrade flow.
2. Angiogram of the native RCA reveals the right coronary artery to be 100% occluded at its origin/ostium after conus branch.
3. Very small caliber SVG to an obtuse marginal branch is patent. There was normal TIMI-3 flow. There is a stent within the proximal segment of the SVG with mild-to-moderate in-stent diffuse stenosis. Proximal to the stent there also appears to be a focal in-stent restenosis, which appears moderate. There is good TIMI-3 flow into the distal OM target. There is left-to-left collaterals to what appears to be a diagonal branch.
4. LIMA to the LAD is small caliber. Initial angiograms revealed TIMI 2 flow. The distal LAD target is very small caliber. There is diffuse disease. There is diffuse segment of 70% to 80% stenosis. Then, the distal LAD beyond that at the apex appears occluded. As noted above, engagement with the IM guide and final angiogram revealed TIMI-3 flow.
5. SVG to the RCA is widely patent. There is a focal ostial proximal stenosis which appears approximately 50%, but this is similar to the prior study in 2017. The mid segment of the SVG prior to the anastomosis has a diffuse segment of moderate stenosis. There is TIMI-3 flow beyond the anastomosis. Also visualized was right-to-left collaterals.
FINAL IMPRESSIONS:
1. Severe left main multivessel coronary artery disease.
2. Left main is now 100% occluded. Previous study revealed severely calcified left main stenosis greater than 95% supplying the proximal diagonal branch.
3. Native right coronary artery 100% occluded at its ostium, similar to prior study.
4. Patent left internal mammary artery to a very small atretic, diffusely diseased distal left anterior descending with diffuse 70% to 80% stenosis with TIMI-3 flow on final angiogram with the internal mammary guide. The terminal distal left anterior descending is 100% occluded.
5. Patent saphenous vein graft to the obtuse marginal with mild-moderate diffuse proximal segment disease with a patent stent with mild-moderate focal in-stent restenosis with normal TIMI-3 flow with left-to-left collaterals likely to the diagonal branch.
6. Patent saphenous vein graft to the right coronary artery with proximal and mid segment stenosis but with normal TIMI-3 flow with right-to-left collaterals.
7. Elevated pulmonary capillary wedge pressure with a mean of 25 mmHg.
8. Cardiogenic shock with cardiac index of 1.64 and cardiac power output of 0.51.
9. Successful insertion of Impella CP with adequate flow rate of approximately 3.5 L.
10. Placement of 8-French CCO Swan for continued hemodynamic monitoring.
11. Placement of left radial arterial line for hemodynamic monitoring.
12. Severe native left main right coronary artery disease with 100% occlusion as noted above.
RECOMMENDATIONS:
1. Full supportive care.
2. TTE for Impella insertion and monitoring and q.a.m. while in place.
3. Guideline directed medical therapy for non-STEMI and CHF.
4. Critical care team consultation.
5. Would recommend palliative care consult.
6. Poor prognosis.