DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Selective coronary angiography.
3. Left ventriculography.
4. Complex PCI of the diagonal/LAD vessels.
5. Intracoronary nitroglycerin use.
SURGEON: John Doe, MD
INDICATIONS FOR PROCEDURE: Acute lateral ST elevation myocardial infarction.
DESCRIPTION OF PROCEDURE: The patient was transferred with complaints of five hours of chest pain. The patient was preloaded with Plavix 600 mg. The right groin was prepped and draped in normal sterile fashion after obtaining informed consent. The right groin was injected with lidocaine. A 6-French sheath was initially placed after obtaining access via Seldinger technique. The sheath was flushed with heparinized solution. Initial AO pressures were obtained. A pigtail catheter was then taken to LV and LVEDP measurements were obtained. The left ventriculogram was performed in a standard RAO view. Then, a JR catheter was used to engage the right coronary ostia and to image the right coronary system in multiple views. Then, JL catheter was used to engage the left main coronary ostium, and the left coronary artery was imaged in multiple views. Then, we proceed with PCI of the second diagonal branch as well as the mid LAD after the diagonal branch.
HEMODYNAMIC FINDINGS: LVEDP was 12 with no pullback gradients.
ANGIOGRAPHIC FINDINGS: The left ventriculogram performed showed preserved LV systolic function with lateral and mild anterior wall hypokinesis. The left main was angiographically patent. The LAD had 60% lesion right after the second diagonal branch. The first diagonal had minor intraluminal irregularities. The second diagonal was occluded proximally with evidence of thrombus. The left circumflex was a codominant vessel. There was a small, tiny ramus intermedius branch. The obtuse marginal branch had proximal 50% lesion. The LAD, after the second diagonal, had mild diffuse disease and distal intraluminal irregularities. The RCA was also a codominant vessel. There was a mid 50% lesion right after the RV marginal branch.
COMPLEX PCI OF THE SECOND DIAGONAL/LAD ARTERIES: The 6-French sheath was exchanged to an 8-French introducer sheath. XBLAD 8-French guiding catheter was used to engage the left main. Heparin was already running, and ACT was optimal for intervention. Integrilin was used for antiplatelet therapy. The patient was already loaded with 600 mg of Plavix. A Luge wire was then used to cross the second diagonal lesion and then BMW wire was used to place in the LAD to protect. Then, a 2.0 x 8 mm Voyager balloon was used to dilate the proximal and the mid diagonal vessel. The vessel was about 2 mm in size, and the mid lesion was dilated several times to 9 atmospheres but with still 10% residual stenosis. The second diagonal branch; the vessel has a hole, was not a large vessel to which a stent could be placed. Just distal to the second diagonal, the LAD had an ulcerated 60-65% lesion. This lesion was then primarily stented with a Taxus 3.0 x 12 mm drug-eluting stent. This resulted in 0% residual stenosis of the LAD lesion and no compromise of the ostium of the second diagonal branch. Multiple images obtained revealed TIMI III flow, no evidence of thrombus or dissection.
IMPRESSION:
1. Successful PCI with Plano balloon angioplasty.
2. The second diagonal branch was below the 2.0 mm vessel.
3. Successful PCI with one Taxus drug-eluting stent, primarily to the LAD.
4. Moderate obtuse marginal 1 and RCA disease to be managed medically.
5. Preserved LV systolic function with borderline LVEDP.
RECOMMENDATIONS:
1. Aspirin and Plavix.
2. Aggressive risk factor modification.
3. Aggressive diabetes control.
4. The patient is to follow up with us. The patient will be instructed to call the office and make an appointment.
5. The patient will be arranged for cardiac rehabilitation thereafter.
