DATE OF OPERATION: MM/DD/YYYY
1. Sick sinus syndrome, status post pacemaker insertion.
1. Sick sinus syndrome, status post pacemaker insertion.
1. Explant of pacemaker generator and two wires under fluoroscopic guidance and xenon laser.
SURGEON: John Doe, MD
ANESTHESIOLOGIST: Jane Doe, MD
DRAINS: One #7 Jackson-Pratt in the subcutaneous space.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and anesthetized without difficulty and prepped and draped in a sterile fashion. Previous incision that had been used to insert the pacemaker was excised and the pacemaker was dissected out from the subcutaneous pocket. Cultures were obtained from the pocket. I had initially planned on making my incision so as to include the area of skin that had been worn through by the pacemaker leads, but this was impracticable because the lead had worn out quite a way below the clavicle and I was concerned about accessing the subclavicular region through this approach. The leads that had eroded through the skin inferiorly was excised separately in an elliptical fashion.
The pacemaker was dissected out. The infected tissue in the subcutaneous space was removed via electrocautery. I disconnected the atrial lead and placed a stylette into it. The screw was withdrawn under direct vision and the lead was removed without difficulty. The ventricular lead was then subsequently removed. Again, I placed a stylette and placed tractional lead. I was not able to remove it. It was transected and sized to a #2 locking device. The locking device was inserted and secured with heavy silk. A 14-French laser and laser sheath were obtained and placed over the locking device. The laser was activated under fluoroscopic guidance. The lead was removed in its entirety without difficulty. Tips of both leads were sent down for culture as well.
At this point, reassessed the transesophageal echocardiography. No pericardial effusion was noted. The patient was well preserved with left ventricular function. The wound was irrigated with saline antibiotic solution. I was somewhat concerned about the thinness of the tissue between the area where the skin eroded through where the lead had been exposed in my primary incision. The skin was somewhat thin here, but it appeared to be viable. I went ahead and placed my drain through the elliptical incision that was used to excise the erosion. Around the drain, I closed the skin with interrupted nylon. The subcutaneous tissues of the primary incision were closed with 2-0 Vicryl and the skin with surgical clips. A sterile pressure dressing was applied.
Needle, sponge and instrument counts were correct at the end of the case. Once again, we rechecked the transesophageal echocardiography and felt no evidence of effusion. The patient was extubated and transferred to the recovery room in satisfactory condition.
Echocardiogram Sample Report:
DATE OF STUDY: MM/DD/YYYY
DATE OF INTERPRETATION OF STUDY:
Echocardiogram was obtained for assessment of left ventricular function. The patient has been admitted with diagnosis of syncope. Overall, the study was suboptimal due to poor sonic window.
1. Aortic root appears normal.
2. Left atrium is mildly dilated. No gross intraluminal pathology is recognized, although subtle abnormalities could not be excluded. Right atrium is of normal dimension.
3. There is echo dropout of the interatrial septum. Atrial septal defects could not be excluded.
4. Right and left ventricles are normal in internal dimension. Overall left ventricular systolic function appears to be normal. Eyeball ejection fraction is around 55%. Again, due to poor sonic window, wall motion abnormalities in the distribution of lateral and apical wall could not be excluded.
5. Aortic valve is sclerotic with normal excursion. Color flow imaging and Doppler study demonstrates trace aortic regurgitation.
6. Mitral valve leaflets are also sclerotic with normal excursion. Color flow imaging and Doppler study demonstrates trace to mild degree of mitral regurgitation.
7. Tricuspid valve is delicate and opens normally. Pulmonic valve is not clearly seen. No evidence of pericardial effusion.
1. Poor quality study.
2. Eyeball ejection fraction is 55%.
3. Trace to mild degree of mitral regurgitation.
4. Trace aortic regurgitation.
PROCEDURE PERFORMED: Left renal artery balloon angioplasty, left renal artery stent, aortogram, and left renal artery catheterization.
DESCRIPTION OF PROCEDURE: The patient was brought to the ER where he was given general MAC anesthesia, which he tolerated well. Both groins were prepped and draped in the usual fashion. A total of 10 mL of 1% plain Xylocaine was locally infiltrated for anesthesia. Right common femoral vein was percutaneously accessed. A 6 French sheath was inserted. An Omni Flush catheter was positioned in the abdominal aorta and diagnostic aortogram performed. This revealed the above noted findings. Given the severe left renal artery stenosis, decision was made to treat with angioplasty and stent. The patient was given 5000 units of IV heparin. I advanced an IM 6-French guiding catheter. I selectively catheterized the left renal artery and advanced a 0.14-inch stabilizing wire. Left renal artery angiogram was performed by injection through the guiding catheter. This confirmed the severe stenosis in the left renal artery, which began about 0.5 cm from its origin. Stenosis over a length of about 1 cm. The distal left renal artery was widely patent, no stenosis. Intermittent boluses of nitroglycerin 100 mcg aliquots were administered through the catheter to minimize vasospasm. Left renal artery balloon angioplasty was performed using a 5 mm x 2 cm balloon. Severe waist was present which effaced with balloon dilation. A Palmaz Blue Genesis stent, 6 x 80 mm was used. It was deployed across the left renal artery stenosis in good position. Just a small portion of the stent extended to the aorta origin. The stent was balloon angioplastied up to nominal pressure, 8 atmospheres. I then retracted the balloon into the aorta and balloon angioplastied the proximal end up to 10 atmospheres. Repeat left renal angiogram showed excellent result with a widely patent left renal artery and no further stenosis. Wires and catheters were removed. Diagnostic right femoral artery angiogram showed a widely patent femoral artery suitable for closure device. StarClose device was used to close the right femoral artery puncture. This provided satisfactory hemostasis. Topical Dermabond was applied to the incision. The patient tolerated the procedure well without complications and was taken to the recovery room in stable condition.
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chronic atrial fibrillation and episodes of bradycardia complicated by syncope.
POSTOPERATIVE DIAGNOSIS: Chronic atrial fibrillation and episodes of bradycardia complicated by syncope.
OPERATION PERFORMED: Insertion of a ventricular pacemaker.
SURGEON: John Doe, MD
ANESTHESIOLOGIST: Jane Doe, MD
DESCRIPTION OF OPERATION: Under sedation and local anesthesia, a diagonal incision was made through the skin and subcutaneous tissue below the left clavicle. A pocket was created between the subcutaneous and muscular layers. Through the medial corner of the wound, the subclavian vein was cannulated and a guidewire was advanced under fluoroscopic control into the superior vena cava. Following the usual sequence, a ventricular wire was put in place, was secured to the muscle at the insertion site with #2-0 silk, was connected to the pulse generator and was carefully coiled underneath it inside the pocket. The wound was closed with interrupted sutures of medium-sized Vicryl for the deeper layers, and metal staples for the skin edges. A bulky dry dressing was applied over the operative site. The blood loss was essentially nil, and the procedure was well tolerated. Fluoroscopic examination of the chest at the end of surgery showed no evidence of complications.
PROCEDURES PERFORMED: Left heart catheterization, selective coronary angiography, left ventricular catheter placement, left ventriculogram, intercoronary nitroglycerin, renal angiography and Angio-Seal closure device.
DESCRIPTION OF PROCEDURE: Informed consent was obtained and the patient was brought to the cardiac catheterization lab in the postabsorptive state. The right groin was draped and prepped in a sterile fashion and the area of vascular access was anesthetized using 10 mL of 2% lidocaine. Access to the right femoral artery was obtained using an 18 gauge cannulation needle via single-wall cannulation without difficulty. A 5 French sheath was placed. A 5 French pigtail catheter was introduced and used across the aortic valve and measured intraventricular pressures, including pressure upon pullback across the aortic valve. A left ventriculogram was performed via power injection. This catheter was removed and exchanged for a 5 French JL4 catheter which was used to selectively engage and image the left coronary system in multiple views. This catheter was exchanged for a 5 French JR4 catheter, which was used to selectively engage and image the right coronary system in multiple views. This catheter was exchanged for a 5 French 3DRC catheter, which was also used to engage the right coronary system and visualize the vessel in multiple views as well as give intercoronary nitroglycerin. The 5 French 3DRC catheter was then used to selectively engage and image the bilateral renal arteries. This catheter was removed and angiography was performed in the right femoral artery through the sheath side port. Following this, the sheath was removed and a 6 French Angio-Seal device was placed per standard protocol and there were no problems with the Angio-Seal device placement. There was no evidence of vascular complication at the access site following the procedure and the patient was transferred to the cardiovascular recovery area.
HEMODYNAMIC FINDINGS: Aortic pressure 162/80. LV 156/2 and LVEDP (post A) 17. There was no gradient upon pullback across the aortic valve.
1. Left main coronary artery was free of angiographically significant disease.
2. Left anterior descending artery gives off two moderate-sized diagonal branches, one proximal and one mid vessel. The LAD extends around the ventricular apex to supply the apical portion of the inferior wall. The LAD and its branches are free of angiographically significant disease.
3. Circumflex coronary artery gives off a large proximal oblique marginal branch and a smaller second mid vessel oblique marginal. It also gives off posterior descending artery distally. The left circumflex system is free of angiographically significant disease.
4. Right coronary artery is small and nondominant with no significant stenoses.
5. Renal arteries were free of angiographically significant stenosis bilaterally.
6. Left ventriculogram performed in the RAO projection shows hyperdynamic LV function with an estimated ejection fraction of 70% and no significant mitral regurgitation.
ASSESSMENT AND RECOMMENDATIONS:
1. Angiographically normal coronary arteries.
2. Angiographically normal renal arteries.
3. Normal to hyperdynamic LV systolic function.
4. Successful Angio-Seal closure device placement.
5. Previous IVC filter visualized under fluoroscopy appears to be in stable position.
PROCEDURES PERFORMED: Left heart catheterization, left ventriculography, selective coronary angiography, selective left internal mammary artery bypass graft angiography, selective saphenous vein bypass graft angiography, nonselective right iliac angiography.
INDICATIONS FOR PROCEDURE: Progressive angina and known history of coronary artery disease, status post coronary artery bypass grafting.
DESCRIPTION OF PROCEDURE: The patient was brought to the cardiac catheterization lab in fasting state. Informed consent had been obtained prior to presentation in the cardiac catheterization lab. The patient was prepped and draped in sterile fashion and mild sedation was administered via IV Versed and fentanyl. The right common femoral region was then anesthetized via 15 mL of 2% lidocaine. The right common femoral artery was accessed via single-wall puncture technique and a 4-French femoral arterial sheath was advanced over a guidewire using modified Seldinger technique. Next, a 4-French angled pigtail catheter was advanced over guidewire to the level of the ascending aorta. This catheter was used to cross the aortic valve and enter the left ventricle where hemodynamic measurements were obtained and left ventriculography was performed in the RAO projection via power injection of 26 mL of dye at 13 mL per second. The pigtail catheter was then used to obtain hemodynamic measurement upon pullback across the aortic valve into the ascending aorta. The pigtail catheter was subsequently withdrawn over guidewire. Next, a 4-French 3DRC catheter was advanced over a guidewire to the level of the ascending aorta. This catheter was used to selectively engage the right coronary artery. The right coronary artery was then imaged in multiple planes and views. This catheter was then used to selectively engage the saphenous vein grafts. The saphenous vein bypass grafts were then imaged in multiple planes and views. The 3DRC was subsequently withdrawn to the level of the aortic arch and advanced over a guidewire into the left subclavian artery. The catheter was then used to selectively engage the left internal mammary artery bypass graft. The LIMA bypass graft and the native LAD post anastomosis was then imaged in multiple planes and views as well. This 3DRC catheter was then withdrawn over a guidewire. Next, a 4-French JL4 catheter was advanced over guidewire to the level of the ascending aorta. This catheter was used to selectively engage the left main coronary artery. The left main coronary artery and its branches were then imaged in multiple planes and views. The JL4 catheter was subsequently withdrawn over a guidewire. The right common femoral arterial sheath was then visualized via hand injection to perform nonselective right iliac angiography. At the termination of the procedure, the femoral arterial sheath was withdrawn in the cardiac catheterization lab with hemostasis obtained via manual compression, and the patient was transferred to the cardiovascular recovery area for further observation and care.
1. Left main: The left main is noted to bifurcate into the left anterior descending and circumflex coronary artery. It is moderately diffusely diseased without focal significant stenosis.
2. Left anterior descending: The left anterior descending coronary artery is noted to be proximally completely occluded after supplying 2 septal perforators that are also diffusely diseased.
3. Circumflex: The circumflex coronary artery is noted to be proximally completely occluded.
4. Right coronary artery: The right coronary artery is noted to be dominant and demonstrates proximal 40-50% stenosis and a mid vessel 99% stenosis prior to its termination just prior to the crux of the right coronary artery. At this point, the vessel was completely occluded.
5. Left internal mammary artery bypass graft: The LIMA bypass graft is noted to be widely patent without focal significant stenosis. It supplies a small caliber, diffusely diseased left anterior descending coronary artery. It trifurcates in its terminal segment. The LIMA bypass graft and the anastomosed LAD are angiographically free of significant stenosis. There was no note of subclavian stenosis as well.
6. Saphenous vein graft to OM1: The saphenous vein graft is noted to be widely patent and supplies diffusely diseased small-caliber vessels, which are also angiographically free of significant stenosis.
7. SVG to PDA: This bypass graft is noted to be angiographically free of significant disease and also supplies mild to moderately diffusely diseased PDA branch that retrograde fills the posterolateral branch. These arteries are without focal significant stenosis.
8. Left heart catheterization and left ventriculography: Left ventricular end-diastolic pressure pre-A wave was 7 and post-A wave was 14. No significant wall motion abnormality was noted with a visually estimated ejection fraction of 60%. There was no gradient noted on pullback across the aortic valve.
9. Nonselective right iliac angiography: The right common iliac artery is noted to be angiographically free of significant stenosis and bifurcates into the internal and external iliac arteries. These arteries are also noted to be angiographically free of significant disease.
FINAL DIAGNOSIS: Stable 3-vessel coronary artery disease, status post coronary artery bypass grafting.
PLAN: Aggressive medical management.
OPERATION PERFORMED: On-pump beating-heart coronary artery bypass grafting x4 with the left internal mammary artery to the left anterior descending coronary artery and reverse aortocoronary saphenous vein graft sequentially to the right posterior descending, second, and first obtuse marginal branches of the circumflex coronary arteries.
DESCRIPTION OF OPERATION: The patient was placed in the supine position and general endotracheal anesthesia was obtained. Central venous catheter, Swan-Ganz catheter, radial arterial catheter, and Foley catheter were inserted. The patient was prepped and draped in the usual manner. Saphenous vein was harvested from the patient's left thigh down to just below the knee endoscopically. The wound was closed in layers with Vicryl. Simultaneously, a median sternotomy incision was made. The sternum was divided. The left hemisternum was elevated. Then, 2000 units of heparin was administered. The left internal mammary artery was dissected from its bed. The patient was fully heparinized. The mammary artery was ligated and transected. Then, 2 mL of 60 mg of papaverine was injected into the mammary artery and the mammary artery clipped distally. It was wrapped in papaverine-soaked gauze and placed in the left chest. A sternal retractor was placed. The pericardium was opened. The heart was cannulated using aortic and venous cannulae. The patient was placed on cardiopulmonary bypass and kept warm. The right posterior descending coronary artery was exposed, stabilized, and temporarily occluded. The saphenous vein was anastomosed end-to-side to the right posterior descending coronary artery with running 7-0 Prolene. The right coronary artery had been looked at, but was calcified all the way down to its bifurcation. The second obtuse marginal branch of the circumflex coronary artery was exposed, stabilized, and temporarily occluded. The same saphenous vein was anastomosed side-to-side to this artery with running 7-0 Prolene. The first obtuse marginal branch of the circumflex coronary artery was exposed, stabilized, and temporarily occluded. The same saphenous vein was anastomosed side-to-side to this artery with running 7-0 Prolene. The left anterior descending coronary artery was exposed, stabilized, and temporarily occluded. The left internal mammary artery tip was prepared for anastomosis. The left internal mammary artery was anastomosed end-to-side to the left anterior descending coronary artery with running 7-0 Prolene. The mammary artery was tacked to heart with 6-0 Prolene. A side-biting clamp was placed on the ascending aorta and aortotomy was performed with a 4.5 mm punch. The saphenous vein was anastomosed end-to-side to the ascending aorta with running 6-0 Prolene. The vein graft was deaired. All anastomotic sites were inspected and hemostasis assured. The patient was weaned off of cardiopulmonary bypass without any problem on minimal inotropes. The heart was decannulated. The heparin was reversed with protamine. A 40 French right angle mediastinal tube was placed. A 40 French straight mediastinal tube was placed. The pericardial cavity was copiously irrigated and hemostasis was assured. The sternum was reapproximated with wires. The pectoralis fascia was closed with 0 Vicryl. The rectus fascia was closed with #1 Maxon. The subcutaneous tissue was closed with 2-0 Vicryl. The skin was closed with 3-0 Monocryl. All wounds were dressed. The patient tolerated the procedure well.