DATE OF PROCEDURE: MM/DD/YYYY
PREPROCEDURE DIAGNOSES: PROCEDURE: Electrophysiology study. DETAILS OF PROCEDURE: The patient was brought to the electrophysiology lab where ECG and vital signs were continuously monitored. The right groin was meticulously prepared with Betadine solution and was draped in the usual sterile fashion. Lidocaine 1% was administered subcutaneously for local anesthetic. Using modified Seldinger technique, two #6 French introducer sheaths were inserted into the right femoral vein. Two quadripolar EP catheters were inserted into the sheaths and advanced under fluoroscopic guidance. One was positioned in the area of the high right atrium and one in the area of the His bundle. The high right atrial catheter was later moved to the RV apex for ventricular stimulation. Endocardial potentials were recorded and baseline measurements were performed. The sinus cycle length was 1195 milliseconds. The AH interval was 115 milliseconds. The HV interval was 45 milliseconds with a pacing cycle length of 800 milliseconds. The sinus node recovery time was 1430 milliseconds with the pacing cycle length of 700 milliseconds. The sinus node recovery time was 1465 milliseconds with a pacing cycle length of 600 milliseconds. The sinus node recovery time was 1570 milliseconds. AV Wenckebach recorded an atrial pacing cycle length of 450 milliseconds. The AV node effective refractory period was 320 milliseconds with the pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 600 milliseconds. The pacing threshold from the right ventricular apex was 0.5 milliamps, 1:1 VA conduction was present at a ventricular pacing cycle length of 600 milliseconds. The ventricular effective refractory period was 240 milliseconds with a pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 400 milliseconds. After single, double and triple extrastimuli were performed at two pacing cycle lengths from the RV apex, Isuprel was started at 2 mcg per minute. This was gradually increased to 4 mcg per minute in order to achieve a good heart rate response. The ventricular effective refractory period was 220 milliseconds with the pacing cycle length of 400 milliseconds. All ventricular pacing was performed from the RV apex. After completion of programmed electrical stimulation, catheters were removed. Good hemostasis was achieved using manual compression. The patient was then transferred to the recovery room in good condition. IMPRESSION: RECOMMENDATIONS: The patient will be continued on beta blocker, which should be increased as tolerated. If the patient has recurrent symptoms, despite medications, an ablation procedure may be considered. However, given the differing morphologies of the nonsustained VT, this may make ablation difficult. --------------------------------------------------------------------------------------------------------------------- DATE OF PROCEDURE: MM/DD/YYYY PREPROCEDURE DIAGNOSIS: Status post ICD lead revision. PROCEDURE: Testing of implantable cardioverter-defibrillator. DETAILS OF PROCEDURE: The patient was brought to the electrophysiology lab where she was continuously monitored and blood pressure was monitored basically every 10 minutes. The patient's defibrillator, St. Jude model # XXXX was interrogated. The R wave was greater than 12 millivolts. The ventricular pacing threshold was 0.5 volts at 0.5 milliseconds. The ventricular pacing impedance was 550 ohms. After administration of anesthesia, ventricular fibrillation was induced via DC. Adequate sensing was noted and a 20-joule shock was delivered by the device with successful conversion to sinus rhythm. The shock impedance was 51 ohms and the charge time was 4 seconds. The patient was then transferred to the recovery room in good condition. IMPRESSION:
1. Normal pacing/implantable cardioverter-defibrillator function. 2. Defibrillation threshold less than or equal to 20 joules. ---------------------------------------------------------------------------------------------------------------------
DATE OF CATHETERIZATION: MM/DD/YYYY
PROCEDURES PERFORMED: Left heart catheterization, left ventriculography.
REASON FOR PROCEDURE: Unstable angina and abnormal stress test.
FINDINGS:
1. The left main coronary artery was short and patent.
2. The left anterior descending coronary artery had total occlusion in the proximal and mid portion. 3. The circumflex coronary artery had 95% lesion in the proximal portion. 4. The right coronary artery had 90% proximal and 100% total occlusion in the mid. GRAFTS: The left internal mammary artery graft to the left anterior descending coronary artery was patent. The saphenous vein graft to the diagonal vessel was also patent. The saphenous vein graft to the obtuse marginal was not located and was not selectively engaged.
COLLATERALS: There were collaterals noted from the left anterior descending, septal and obtuse marginal to the right side.
Left ventriculography revealed an overall ejection fraction of around 40% with inferobasal akinesis and mid anterior and septal hypokinesis. End-diastolic pressure was normal at 13 mmHg. There was no gradient across aortic valve on pullback.
At the end of the procedure, the decision to proceed with angioplasty and stent placement of the critical circumflex lesion was made. --------------------------------------------------------------------------------------------------------------------- PROCEDURE PERFORMED: Left heart catheterization, selective coronary angiography, left ventriculography. DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was brought to the cath lab premedicated. The right radial was attempted, but because of vasospasm, we could not enter the vessel so we switched out to the right groin. The right femoral artery was cannulated and a 6 French sheath was placed. The coronaries were identified using standard Judkins left and right size 4 catheters and serial views were obtained. There was no evidence of disease in the right coronary to explain the infarct pattern. The previous area of stenting in the right coronary was widely patent. A pigtail was placed into the left ventricular cavity and RAO ventriculogram was obtained. Then the femoral sheath was injected and the vessel was appropriate for a closure device so a 6-French Angio-Seal was deployed and the patient was returned to the ward in stable condition. FINDINGS: 1. The left ventricular end-diastolic pressure is 16. No gradient across the aortic valve. 2. The left ventricle is dilated and globally hypokinetic. The inferior wall is basically akinetic. The ejection fraction is calculated at 30%. No mitral regurgitation. 3. The left main coronary is normal. 4. The left anterior descending has luminal irregularities but nothing high grade. It gives rise to a large diagonal branch, which also has some encroachment in its proximal portion but not critical. A smaller second diagonal branch is identified. 5. The circumflex distribution gives rise to one major obtuse marginal branch, which bifurcates distally. Again, there are some luminal irregularities but nothing high grade noted. 6. The right coronary artery is dominant. It has luminal irregularities throughout its course, but again, there is nothing high grade. Posterior descending is identified. Posterolateral branches are noted. At the crux, a previously deployed stent is widely patent.. --------------------------------------------------------------------------------------------------------------------- PROCEDURE PERFORMED: Left heart catheterization with coronary angioplasty and double stent placement for right coronary artery. DESCRIPTION OF PROCEDURE: The left groin was prepped and draped in the usual manner. After infiltration with 1% lidocaine, a #6 French Hemaquet sheath was introduced percutaneously into the left femoral artery. Heparin was administered through the side arm of the sheath. A #6 French Judkins right coronary guiding catheter was introduced through the sheath and advanced to the aortic root where the right coronary origin was engaged. A 2 x 15 mm Maverick balloon dilating catheter was introduced through the guiding catheter together with a 0.014-inch Forte Medium Support Marker Wire. The balloon catheter was introduced partly into the right coronary artery and the guidewire advanced to the point of total occlusion. It did not prove possible to readily cross the occluded area and the guidewire was exchanged for a ZIPwire. This wire was readily able to cross the stenotic area and pass into the distal part of the right coronary artery. The balloon catheter was then passed along the wire and withdrawn and a small injection made to confirm that the guidewire was indeed in the distal part of the right coronary artery. The balloon catheter was again advanced into the distal section of the right coronary artery and the guidewire exchanged for the original one. The balloon was positioned within the stenotic area and inflated up to 8 atmospheres. The balloon catheter was withdrawn and exchanged for a 2.75 x 15 mm Vision stent deployment system. Prior to the introduction of this device, nitroglycerin and verapamil were administered intracoronary. The stent was carefully positioned across the previously occluded and now stenotic area and deployed at 9 atmospheres with the pressure carried up to 16 atmospheres. The stent balloon catheter was withdrawn and further angiograms recorded. It was now apparent that there was significant stenosis with an irregular appearance a short distance proximal to the previous point of total occlusion. The previous stent balloon had been difficult to remove from the guidewire and a BMW guidewire was now introduced in "buddy" fashion and passed into the distal part of the right coronary artery and the original guidewire removed. A 2.75 x 12 mm Liberte stent deployment system was introduced and the stent carefully positioned across the more proximal stenotic area. This stent was also inflated up to 9 atmospheres and then the pressure carried up to 16 atmospheres. The stent balloon catheter was then removed and further angiograms recorded. The guidewire and guiding path removed. An injection was made into the femoral artery through the sheath to assess for placement of a closure device but this proved not to be appropriate and the sheath was sutured in place for later removal. The procedure was uneventful and the patient was returned to his room in satisfactory condition. Additional medication given during the procedure included Integrilin by bolus and infusion. 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