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Cardiac Cath

PROCEDURE IN DETAIL: The patient was brought to the cath lab and prepped and draped in standard fashion.  The right femoral artery was accessed using a 6-French arterial sheath by Seldinger technique.  The right femoral artery was accessed using an 8-French venous sheath by Seldinger technique.  A Swan-Ganz catheter was advanced under fluoroscopic guidance into the right atrium and pressures were measured.  The Swan-Ganz was advanced to the right ventricle and pulmonary artery in wedge position.  Cardiac output was done and pressures were measured.  The Swan-Ganz catheter was removed.  Intra-arterial heparin, 3000 units, was given.  A JL4 6-French arterial catheter was advanced over the wire under fluoroscopic guidance into the thoracic aorta.  The wire was removed and the left coronary artery was cannulated.  Multiple arteriograms were done.  The catheter was exchanged over a wire to a JR4 6-French diagnostic catheter.  The right coronary artery was cannulated and multiple arteriograms were taken.  The catheter was exchanged over a wire to a 6-French pigtail catheter.  Multiple attempts were made to cross the aortic valve with the pigtail catheter without any success.  The catheter was exchanged over the wire to a 6-French JR4 catheter.  A Softip Wholey wire was used to cross the aortic valve.  Pressures in the left ventricular cavity were measured, but left ventricular angiocardiogram was not done.

PROCEDURE IN DETAIL:  After informed consent was obtained, the patient was premedicated with Benadryl 50 mg p.o. and Zantac 150 mg p.o., brought to the cardiac catheterization lab and prepped and draped in the usual manner.  Under local anesthesia with 2% lidocaine, the right femoral artery was entered with a 6-French arterial sheath by Seldinger technique.  Heparin 3000 units was given intra-arterially. Using  a 6-4-French left coronary Judkins catheter, left coronary angiograms were performed in different views.  With a 6-4-French right coronary Judkins catheter, right coronary angiograms were performed in different views.  With the help of a 6-French pigtail catheter, left ventriculogram was performed in the RAO view.  Hemodynamic data were obtained.  This catheter was withdrawn into the aortic root and aortic root angiogram was performed in the LAO view.  The catheter was withdrawn and removed.  The arterial sheath was removed and pressure was applied.  Hemostasis was secured.  No bleeding was noted.  No hematoma was seen.  Pedal pulses were as before the catheterization.

PROCEDURE IN DETAIL:  After informed consent, the patient was sterilely prepped and draped.  Local anesthetic was administered, and 3000 units of intra-arterial heparin was given following cannulation of the right common femoral artery with a 6-French introducer sheath.  A JL4 diagnostic catheter was placed in the ostium of the left main under fluoroscopy.  Injection revealed somewhat tortuous coronary arteries, but otherwise smooth-walled and no filling defects.  No evidence of stenosis.  Essentially normal appearance. Following this, a JR4 diagnostic catheter was advanced close to the ostium of the right coronary artery.  A nonselective injection revealed a small right coronary artery that had a normal-appearing lumen in orthogonal views.  The right coronary artery gives off the posterior descending coronary artery and is, therefore, a dominant right coronary artery.  Following this, an angled pigtail was placed in the left ventricle.  Left ventricular end-diastolic pressure was 16.  Injection revealed normal wall motion and no mitral regurgitation.  On withdrawal of the catheter across the aortic valve, there was no pressure gradient.

Pacemaker Placement

After informed consent, the patient was taken to the cardiac catheterization and prepped and draped in the usual manner. Under local anesthesia with lidocaine 2%, a sterile field was created in the right subclavian area. Subsequently, the 6-French venous was exchanged to an 8-French venous sheath by Seldinger technique. In similar fashion, an extra wire was introduced through the venous sheath. A ventricular electrode lead, Elox 45BP (serial #23890243) was introduced and advanced under fluoroscopic guidance. With the help of a preshaped stylet, the electrode lead was advanced to the right ventricle. The tip of the lead was placed in the right ventricular apex. The lead was screwed in. Excellent thresholds were obtained. Minimum threshold obtained at the site of implantation was 0.8 volts. R-wave amplitude 16.0. Lead impedance 820 ohms. In similar fashion, the atrial electrode lead was introduced into the venous sheath and advanced under fluoroscopic guidance. With the help of a preshaped stylet, the atrial electrode lead was negotiated to the atrial appendage and screwed in. Excellent thresholds were obtained. Minimum threshold obtained at the site of implantation was 1.4 volts. P-wave amplitude 3.1 millivolts. Lead impedance 940 ohms. As good thresholds were obtained for both the atrial and ventricular leads, they were secured to the deeper tissues by sutures. A pocket was created for the pulse generator by Dr. Doolittle. The electrode leads were connected to the pulse generator, Philos DR, which was placed in the pocket and the pocket closed. A sterile dressing was applied. The patient was returned to the intensive care unit ins table condition. EKG rhythm revealed normal sensing and capture of the AV sequential pacemaker. The temporary transvenous pacemaker was later removed.

PACEMAKER PARAMETERSAtrial output 3.6 volts. Pulse width 0.40 millivolts. Sensitivity 1.0. Ventricular output 3.6 volts. Pulse width 0.40 milliseconds. Sensitivity 2.5.

PTCA

PROCEDURE IN DETAIL: After informed consent was obtained, the patient was premedicated with Benadryl 50 mg p.o. and Zantac 150 mg p.o., brought to the cardiac catheterization lab and prepped and draped in the usual manner.  Under local anesthesia with lidocaine 2%, the right femoral artery was entered with a 6-French arterial sheath by Seldinger technique.  The patient was given 5000 units of heparin intra-arterially.  The ACT was found to be 263.  A ReoPro infusion was started and ReoPro protocol was followed.  The right femoral arterial sheath was entered with an 8-French FL4 Softip Sci-Med guiding catheter.  The catheter was advanced under fluoroscopy guidance and the left coronary artery was selectively cannulated.  Selective coronary angiograms were performed in different views, which served as guide shots for road mapping.  Subsequently, a 0.014 Hi-Torque floppy wire and Ranger 2.5-mm balloon catheter were prepped.  This was introduced into the guiding catheter and advanced under fluoroscopic guidance.  The Hi-Torque floppy wire was advanced into the left main, then into the circumflex coronary artery, across the lesion, and placed distally.  The balloon was advanced across the wire and placed at the site of the lesion.  Position was confirmed on fluoroscopy by dye injection.  The balloon was inflated to 6 atmospheres pressure for 60 seconds.  The balloon was deflated, withdrawn and removed.  An AVE 3-mm x 18-mm stent balloon catheter was advanced across the wire and placed at the site of the lesion.  Position was confirmed on fluoroscopy by dye injection.  The balloon was inflated to 7 atmospheres pressure for 32 seconds.  The balloon was deflated.  The stent was successfully deployed.  The balloon was withdrawn and removed.  An NC Ranger 3-mm x 15-mm balloon catheter was placed within the stent and inflated to 12 atmospheres pressure for a total of 25 seconds.  The balloon was deflated, withdrawn and removed.  Selective coronary angiogram revealed adequate dilatation of the circumflex coronary artery from an initial lesion of 95% to a residual lesion of less than 0%.  During the procedure, the patient received Vasotec 1.25 mg IV, a nitroglycerin drip to control blood pressure, Versed 2 mg in divided doses, and intracoronary nitroglycerin 200 mcg.  At the end of the procedure, the patient was symptomatically stable with stable vital signs.

PROCEDURE IN DETAIL:    After obtaining informed consent and under local anesthesia with strict aseptic precautions, an 8-French arterial sheath was introduced into the left femoral artery by Seldinger technique.  The first ACT was 151 and the patient received 5000 units of IV heparin.  A Sci-Med FR4 8-French guiding catheter was advanced over a 0.035 guide wire and engaged into the right coronary artery.  Guiding shots were taken as a road map prior to PTCA.  A Sci-Med Ranger 3-mm x 20-mm balloon was chosen.  A Hi-Torque floppy wire was threaded into the Ranger balloon, and the balloon and guide wire were advanced through the guiding catheter.  Using a torque-control device, the guide wire was successfully placed into the distal right coronary artery.  The balloon was advanced and inflated at the junction of the proximal and mid right coronary artery at the site of the stenosis to 3 atmospheres pressure for 43 seconds.  The balloon was deflated and withdrawn into the guiding catheter.  The patient received 100 mcg of intracoronary nitroglycerin.  There was persistent stenosis of the right coronary artery with suboptimal results.  The Ranger balloon was removed over the wire and an AVE GFX 4-mm x 12-mm stent was prepared and successfully deployed at the junction of the proximal and mid right coronary artery at 12 atmospheres pressure for 28 seconds.  The stent balloon was deflated and withdrawn into the guiding catheter.  The patient received 100 mcg of intracoronary nitroglycerin.


Sestamibi Myocardial Perfusion Scan

PROCEDURE IN DETAIL:  After informed consent, the patient was hooked up to 12-lead EKG and an IV line was established.  Adenosine infusion was started and protocol was followed.  A total of 65.6 mg of adenosine was given.  Heart rate reached 97 per minute maximum with a peak systolic blood pressure of 185 mmHg.  Sestamibi 28.7 mCi was given and later perfusion images were obtained in different views.  

SPECT sestamibi myocardial images revealed evidence of decreased perfusion at the apex which was reversible.  This was noted on rest scan, suggesting disease in the left anterior descending coronary artery beyond the mid portion.  

FINAL IMPRESSION:  Abnormal adenosine sestamibi myocardial perfusion scan with evidence of reversible ischemia in the apex in the distribution of the left anterior descending coronary artery beyond the mid portion.