Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: 2-D Doppler
Description: Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.
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2-D STUDY
1. Mild aortic stenosis, widely calcified, minimally restricted.
2. Mild left ventricular hypertrophy but normal systolic function.
3. Moderate biatrial enlargement.
4. Normal right ventricle.
5. Normal appearance of the tricuspid and mitral valves.
6. Normal left ventricle and left ventricular systolic function.
DOPPLER
1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.
2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.
SUMMARY
1. Normal left ventricle.
2. Moderate biatrial enlargement.
3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.
1. Mild aortic stenosis, widely calcified, minimally restricted.
2. Mild left ventricular hypertrophy but normal systolic function.
3. Moderate biatrial enlargement.
4. Normal right ventricle.
5. Normal appearance of the tricuspid and mitral valves.
6. Normal left ventricle and left ventricular systolic function.
DOPPLER
1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.
2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.
SUMMARY
1. Normal left ventricle.
2. Moderate biatrial enlargement.
3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: 2-D Echocardiogram - 1
Description: 2-D M-Mode. Doppler.
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2-D M-MODE:
1. Left atrial enlargement with left atrial diameter of 4.7 cm.
2. Normal size right and left ventricle.
3. Normal LV systolic function with left ventricular ejection fraction of 51%.
4. Normal LV diastolic function.
5. No pericardial effusion.
6. Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.
7. PA systolic pressure is 36 mmHg.
DOPPLER:
1. Mild mitral and tricuspid regurgitation.
2. Trace aortic and pulmonary regurgitation.
1. Left atrial enlargement with left atrial diameter of 4.7 cm.
2. Normal size right and left ventricle.
3. Normal LV systolic function with left ventricular ejection fraction of 51%.
4. Normal LV diastolic function.
5. No pericardial effusion.
6. Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.
7. PA systolic pressure is 36 mmHg.
DOPPLER:
1. Mild mitral and tricuspid regurgitation.
2. Trace aortic and pulmonary regurgitation.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: 2-D Echocardiogram - 2
Description: 2-D Echocardiogram
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COMMENTS:
1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function. There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.
2. The left atrium appears mildly dilated.
3. The right atrium and right ventricle appear normal.
4. The aortic root appears normal.
5. The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.
6. There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.
7. The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension. Estimated pulmonary artery systolic pressure is 49 mmHg. Estimated right atrial pressure of 10 mmHg.
8. The pulmonary valve appears normal with trace pulmonary insufficiency.
9. There is no pericardial effusion or intracardiac mass seen.
10. There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.
11. The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.
1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function. There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.
2. The left atrium appears mildly dilated.
3. The right atrium and right ventricle appear normal.
4. The aortic root appears normal.
5. The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.
6. There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.
7. The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension. Estimated pulmonary artery systolic pressure is 49 mmHg. Estimated right atrial pressure of 10 mmHg.
8. The pulmonary valve appears normal with trace pulmonary insufficiency.
9. There is no pericardial effusion or intracardiac mass seen.
10. There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.
11. The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: 2-D Echocardiogram - 3
Description: 2-D Echocardiogram
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2-D ECHOCARDIOGRAM
Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow. Pulmonary outflow is normal at the valve. Pulmonary venous return is to the left atrium. The interatrial septum is intact. Mitral inflow and ascending aorta flow are normal. The aortic valve is trileaflet. The coronary arteries appear to be normal in their origins. The aortic arch is left-sided and patent with normal descending aorta pulsatility.
Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow. Pulmonary outflow is normal at the valve. Pulmonary venous return is to the left atrium. The interatrial septum is intact. Mitral inflow and ascending aorta flow are normal. The aortic valve is trileaflet. The coronary arteries appear to be normal in their origins. The aortic arch is left-sided and patent with normal descending aorta pulsatility.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: 2-D Echocardiogram - 4
Description: Echocardiogram and Doppler
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DESCRIPTION:
1. Normal cardiac chambers size.
2. Normal left ventricular size.
3. Normal LV systolic function. Ejection fraction estimated around 60%.
4. Aortic valve seen with good motion.
5. Mitral valve seen with good motion.
6. Tricuspid valve seen with good motion.
7. No pericardial effusion or intracardiac masses.
DOPPLER:
1. Trace mitral regurgitation.
2. Trace tricuspid regurgitation.
IMPRESSION:
1. Normal LV systolic function.
2. Ejection fraction estimated around 60%.
1. Normal cardiac chambers size.
2. Normal left ventricular size.
3. Normal LV systolic function. Ejection fraction estimated around 60%.
4. Aortic valve seen with good motion.
5. Mitral valve seen with good motion.
6. Tricuspid valve seen with good motion.
7. No pericardial effusion or intracardiac masses.
DOPPLER:
1. Trace mitral regurgitation.
2. Trace tricuspid regurgitation.
IMPRESSION:
1. Normal LV systolic function.
2. Ejection fraction estimated around 60%.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Abnormal Echocardiogram
Description: Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. The patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.
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REASON FOR CONSULTATION: Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency.
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools. The patient has colitis and also diverticulitis, undergoing treatment. During the hospitalization, the patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion. This consultation is for further evaluation in this regard. As per the patient, she is an 86-year-old female, has limited activity level. She has been having shortness of breath for many years. She also was told that she has a heart murmur, which was not followed through on a regular basis.
CORONARY RISK FACTORS: History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.
FAMILY HISTORY: Nonsignificant.
PAST SURGICAL HISTORY: No major surgery.
MEDICATIONS: Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.
ALLERGIES: AMBIEN, CARDIZEM, AND IBUPROFEN.
PERSONAL HISTORY: She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.
PAST MEDICAL HISTORY: Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.
REVIEW OF SYSTEMS
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: History of cataract, blurred vision, and hearing impairment.
CARDIOVASCULAR: Shortness of breath and heart murmur. No coronary artery disease.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.
GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: Arthritis and severe muscle weakness.
SKIN: Nonsignificant.
NEUROLOGICAL: No TIA or CVA. No seizure disorder.
ENDOCRINE/HEMATOLOGICAL: As above.
PHYSICAL EXAMINATION
VITAL SIGNS: Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.
HEENT/NECK: Head is atraumatic and normocephalic. Neck veins flat. No significant carotid bruits appreciated.
LUNGS: Air entry bilaterally fair. No obvious rales or wheezes.
HEART: PMI displaced. S1, S2 with systolic murmur at the precordium, grade 2/6.
ABDOMEN: Soft and nontender.
EXTREMITIES: Chronic skin changes. Feeble pulses distally. No clubbing or cyanosis.
DIAGNOSTIC DATA: EKG: Normal sinus rhythm. No acute ST-T changes.
Echocardiogram report was reviewed.
LABORATORY DATA: H&H 13 and 39. BUN and creatinine within normal limits. Potassium within normal limits. BNP 9290.
IMPRESSION:
1. The patient admitted for gastrointestinal pathology, under working treatment.
2. History of prior heart murmur with echocardiogram findings as above. Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.
RECOMMENDATIONS:
1. From cardiac standpoint, conservative treatment. Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.
2. After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.
3. Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares. She has a normal LV function.
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools. The patient has colitis and also diverticulitis, undergoing treatment. During the hospitalization, the patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion. This consultation is for further evaluation in this regard. As per the patient, she is an 86-year-old female, has limited activity level. She has been having shortness of breath for many years. She also was told that she has a heart murmur, which was not followed through on a regular basis.
CORONARY RISK FACTORS: History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.
FAMILY HISTORY: Nonsignificant.
PAST SURGICAL HISTORY: No major surgery.
MEDICATIONS: Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.
ALLERGIES: AMBIEN, CARDIZEM, AND IBUPROFEN.
PERSONAL HISTORY: She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.
PAST MEDICAL HISTORY: Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.
REVIEW OF SYSTEMS
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: History of cataract, blurred vision, and hearing impairment.
CARDIOVASCULAR: Shortness of breath and heart murmur. No coronary artery disease.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.
GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: Arthritis and severe muscle weakness.
SKIN: Nonsignificant.
NEUROLOGICAL: No TIA or CVA. No seizure disorder.
ENDOCRINE/HEMATOLOGICAL: As above.
PHYSICAL EXAMINATION
VITAL SIGNS: Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.
HEENT/NECK: Head is atraumatic and normocephalic. Neck veins flat. No significant carotid bruits appreciated.
LUNGS: Air entry bilaterally fair. No obvious rales or wheezes.
HEART: PMI displaced. S1, S2 with systolic murmur at the precordium, grade 2/6.
ABDOMEN: Soft and nontender.
EXTREMITIES: Chronic skin changes. Feeble pulses distally. No clubbing or cyanosis.
DIAGNOSTIC DATA: EKG: Normal sinus rhythm. No acute ST-T changes.
Echocardiogram report was reviewed.
LABORATORY DATA: H&H 13 and 39. BUN and creatinine within normal limits. Potassium within normal limits. BNP 9290.
IMPRESSION:
1. The patient admitted for gastrointestinal pathology, under working treatment.
2. History of prior heart murmur with echocardiogram findings as above. Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.
RECOMMENDATIONS:
1. From cardiac standpoint, conservative treatment. Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.
2. After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.
3. Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares. She has a normal LV function.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 1
Description: Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.
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PROCEDURE: Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.
DETAILS OF THE PROCEDURE: The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed. The patient received topical lidocaine by nebulization. The flexible fiberoptic bronchoscope was introduced orally. The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions. I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe. I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies. Followup fluoroscopy was negative for pneumothorax. I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.
I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions. I performed a bronchial washing after the biopsies in the right upper lobe. I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area. All of these samples were sent for histology and cytology respectively. Estimated blood loss was approximately 5 cc. Good hemostasis was achieved. The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well. Her ASA score was 2.
DETAILS OF THE PROCEDURE: The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed. The patient received topical lidocaine by nebulization. The flexible fiberoptic bronchoscope was introduced orally. The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions. I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe. I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies. Followup fluoroscopy was negative for pneumothorax. I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.
I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions. I performed a bronchial washing after the biopsies in the right upper lobe. I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area. All of these samples were sent for histology and cytology respectively. Estimated blood loss was approximately 5 cc. Good hemostasis was achieved. The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well. Her ASA score was 2.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 2
Description: Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.
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INDICATIONS FOR PROCEDURE: Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.
PREMEDICATION:
1. Demerol 50 mg.
2. Phenergan 25 mg.
3. Atropine 0.6 mg IM.
4. Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.
PROCEDURE DETAILS: With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords. The cords move normally with phonation and ventilation. Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed. Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus. Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted. Upper lobe and lingula were unremarkable. There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem. This had been a change from the prior bronchoscopy of unclear significance. Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection. The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic. The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable. The scope was withdrawn. The patient's saturation remained 93%-95% throughout the procedure. Blood pressure was 103/62. Heart rate at the end of the procedure was about 100. The patient tolerated the procedure well. Samples were sent as follows. Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture. Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture.
PREMEDICATION:
1. Demerol 50 mg.
2. Phenergan 25 mg.
3. Atropine 0.6 mg IM.
4. Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.
PROCEDURE DETAILS: With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords. The cords move normally with phonation and ventilation. Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed. Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus. Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted. Upper lobe and lingula were unremarkable. There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem. This had been a change from the prior bronchoscopy of unclear significance. Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection. The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic. The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable. The scope was withdrawn. The patient's saturation remained 93%-95% throughout the procedure. Blood pressure was 103/62. Heart rate at the end of the procedure was about 100. The patient tolerated the procedure well. Samples were sent as follows. Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture. Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 3
Description: Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.
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PROCEDURE: Fiberoptic bronchoscopy.
PREOPERATIVE DIAGNOSIS: Right lung atelectasis.
POSTOPERATIVE DIAGNOSIS: Extensive mucus plugging in right main stem bronchus.
PROCEDURE IN DETAIL: Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots. The patient was breathing supplemental nasal and mask oxygen throughout the procedure. Saturations and vital signs remained stable throughout. A flexible fiberoptic bronchoscope was passed through the right naris. The vocal cords were visualized. Secretions in the larynx were as aspirated. As before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening. The ports were anesthetized and the trachea entered. There was no cough reflex helping explain the propensity to aspiration and mucus plugging. Tracheal secretions were aspirated. The main carinae were sharp. However, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina. This was gradually lavaged clear. Saline and Mucomyst solution were used to help dislodge remaining plugs. The airways appeared slightly friable, but were patent after the airways were suctioned. O2 saturations remained in the mid-to-high 90s. The patient tolerated the procedure well. Specimens were submitted for microbiologic examination. Despite his frail status, he tolerated bronchoscopy quite well.
PREOPERATIVE DIAGNOSIS: Right lung atelectasis.
POSTOPERATIVE DIAGNOSIS: Extensive mucus plugging in right main stem bronchus.
PROCEDURE IN DETAIL: Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots. The patient was breathing supplemental nasal and mask oxygen throughout the procedure. Saturations and vital signs remained stable throughout. A flexible fiberoptic bronchoscope was passed through the right naris. The vocal cords were visualized. Secretions in the larynx were as aspirated. As before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening. The ports were anesthetized and the trachea entered. There was no cough reflex helping explain the propensity to aspiration and mucus plugging. Tracheal secretions were aspirated. The main carinae were sharp. However, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina. This was gradually lavaged clear. Saline and Mucomyst solution were used to help dislodge remaining plugs. The airways appeared slightly friable, but were patent after the airways were suctioned. O2 saturations remained in the mid-to-high 90s. The patient tolerated the procedure well. Specimens were submitted for microbiologic examination. Despite his frail status, he tolerated bronchoscopy quite well.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 4
Description: Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.
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PREOPERATIVE DIAGNOSIS: Tracheal stenosis and metal stent complications.
POSTOPERATIVE DIAGNOSIS: Tracheal stenosis and metal stent complications.
ANESTHESIA: General endotracheal.
ENDOSCOPIC FINDINGS:
1. Normal true vocal cords.
2. Subglottic stenosis down to 5 mm with mature cicatrix.
3. Tracheal granulation tissue growing through the stents at the midway point of the stents.
5. Three metallic stents in place in the proximal trachea.
6. Distance from the true vocal cords to the proximal stent, 2 cm.
7. Distance from the proximal stent to the distal stent, 3.5 cm.
8. Distance from the distal stent to the carina, 8 cm.
9. Distal airway is clear.
PROCEDURES:
1. Rigid bronchoscopy with dilation.
2. Excision of granulation tissue tumor.
3. Application of mitomycin-C.
4. Endobronchial ultrasound.
TECHNIQUE IN DETAIL: After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done. She had a Dedo laryngoscope placed. Her airways were inspected thoroughly with findings as described above. She was intermittently ventilated with an endotracheal tube placed through the Dedo scope. Her granulation tissue was biopsied and then removed with a microdebrider. Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes. She tolerated the procedure well, was extubated, and brought to the PACU.
POSTOPERATIVE DIAGNOSIS: Tracheal stenosis and metal stent complications.
ANESTHESIA: General endotracheal.
ENDOSCOPIC FINDINGS:
1. Normal true vocal cords.
2. Subglottic stenosis down to 5 mm with mature cicatrix.
3. Tracheal granulation tissue growing through the stents at the midway point of the stents.
5. Three metallic stents in place in the proximal trachea.
6. Distance from the true vocal cords to the proximal stent, 2 cm.
7. Distance from the proximal stent to the distal stent, 3.5 cm.
8. Distance from the distal stent to the carina, 8 cm.
9. Distal airway is clear.
PROCEDURES:
1. Rigid bronchoscopy with dilation.
2. Excision of granulation tissue tumor.
3. Application of mitomycin-C.
4. Endobronchial ultrasound.
TECHNIQUE IN DETAIL: After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done. She had a Dedo laryngoscope placed. Her airways were inspected thoroughly with findings as described above. She was intermittently ventilated with an endotracheal tube placed through the Dedo scope. Her granulation tissue was biopsied and then removed with a microdebrider. Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes. She tolerated the procedure well, was extubated, and brought to the PACU.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 5
Description: Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.
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PREOPERATIVE DIAGNOSIS: Airway stenosis with self-expanding metallic stent complication.
POSTOPERATIVE DIAGNOSIS: Airway stenosis with self-expanding metallic stent complication.
PROCEDURES:
1. Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.
2. Excision of granulation tissue tumor.
3. Bronchial dilation with a balloon bronchoplasty, right main bronchus.
4. Argon plasma coagulation to control bleeding in the trachea.
5. Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.
ENDOSCOPIC FINDINGS:
1. Normal true vocal cords.
2. Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.
3. Multiple stent fractures in the mid portion of the trachea with granulation tissue.
4. High-grade obstruction of the right main bronchus by stent and granulation tissue.
5. Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.
6. All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.
TECHNIQUE IN DETAIL: After informed consent was obtained from the patient, he was brought into the operating field. A rapid sequence induction was done. He was intubated with a rigid scope. Jet ventilation technique was carried out using a rigid and flexible scope. A thorough airway inspection was carried out with findings as described above.
Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal. This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway. It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments. Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope. We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent. It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter. The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length. After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords. The patient tolerated the procedure well and was brought to the recovery room extubated.
POSTOPERATIVE DIAGNOSIS: Airway stenosis with self-expanding metallic stent complication.
PROCEDURES:
1. Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.
2. Excision of granulation tissue tumor.
3. Bronchial dilation with a balloon bronchoplasty, right main bronchus.
4. Argon plasma coagulation to control bleeding in the trachea.
5. Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.
ENDOSCOPIC FINDINGS:
1. Normal true vocal cords.
2. Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.
3. Multiple stent fractures in the mid portion of the trachea with granulation tissue.
4. High-grade obstruction of the right main bronchus by stent and granulation tissue.
5. Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.
6. All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.
TECHNIQUE IN DETAIL: After informed consent was obtained from the patient, he was brought into the operating field. A rapid sequence induction was done. He was intubated with a rigid scope. Jet ventilation technique was carried out using a rigid and flexible scope. A thorough airway inspection was carried out with findings as described above.
Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal. This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway. It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments. Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope. We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent. It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter. The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length. After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords. The patient tolerated the procedure well and was brought to the recovery room extubated.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 6
Description: Bronchoscopy for hypoxia and increasing pulmonary secretions
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PREOPERATIVE DIAGNOSIS: Hypoxia and increasing pulmonary secretions.
POSTOPERATIVE DIAGNOSIS: Hypoxia and increasing pulmonary secretions.
OPERATION: Bronchoscopy.
ANESTHESIA: Moderate bedside sedation.
COMPLICATIONS: None.
FINDINGS: Abundant amount of clear thick secretions throughout the main airways.
INDICATIONS: The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion. This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube. The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray. Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.
OPERATION: The patient was given additional fentanyl, Versed as well as paralytics for the procedure. Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina. There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus. Extensive secretions extended down into the secondary airways. This was lavaged with saline and suctioned dry. There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum. The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned. The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator. Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2. The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.
POSTOPERATIVE DIAGNOSIS: Hypoxia and increasing pulmonary secretions.
OPERATION: Bronchoscopy.
ANESTHESIA: Moderate bedside sedation.
COMPLICATIONS: None.
FINDINGS: Abundant amount of clear thick secretions throughout the main airways.
INDICATIONS: The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion. This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube. The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray. Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.
OPERATION: The patient was given additional fentanyl, Versed as well as paralytics for the procedure. Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina. There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus. Extensive secretions extended down into the secondary airways. This was lavaged with saline and suctioned dry. There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum. The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned. The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator. Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2. The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 7
Description: Diagnostic fiberoptic bronchoscopy.
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PROCEDURE: Diagnostic fiberoptic bronchoscopy.
ANESTHESIA: Plain lidocaine 2% was given intrabronchially for local anesthesia.
PREOPERATIVE MEDICATIONS:
1. Lortab (10 mg) plus Phenergan (25 mg), p.o. 1 hour before the procedure.
2. Versed a total of 5 mg given IV push during the procedure.
INDICATIONS: Right upper lobe lung mass, posterior segment.
Consent obtained from the patient's daughter.
PROCEDURE IN DETAIL: After appropriate sedation was achieved, the bronchoscope was introduced via the right nares and advanced to the upper larynx. Plain lidocaine 2% was used to anesthetize the laryngeal structures. After adequate anesthesia was achieved, close inspection of the laryngeal structures could be performed. Both vocal cords moved appropriately. Under direct visualization, the bronchoscope was advanced past the vocal cords and into the distal trachea. Additional 2% plain lidocaine was used in the trachea and the main stem bronchi for anesthesia. After adequate anesthesia was achieved, close inspection of the airways could be undertaken. The left tracheobronchial tree was inspected closely to the level of the subsegmental bronchi. All bronchi are patent with no endobronchial lesions and no mucosal lesions noted. The right tracheobronchial tree was also patent and intact with the mucosa normal. The bronchoscope was then introduced to the right upper lobe specifically to the posterior segment and washings/brushings and transbronchial lung biopsies were taken from that area. He had quite a bit of coughing during the diagnostic procedures despite lidocaine administration. A total of 5 mg of Versed was used to effect sedation. At one point, the bronchoscope had to be completely withdrawn so that the sample could be appropriately retrieved. Upon reintroduction, there was quite a bit of bleeding in his right nares. The right naris was packed for control of the bleeding. The procedure was completed and all samples were submitted for appropriate studies. A post procedure chest x-ray has been obtained and is still pending. He tolerated the procedure very well other then for the brisk epistaxis from the right nares. Packing to the right nares has been completed.
ANESTHESIA: Plain lidocaine 2% was given intrabronchially for local anesthesia.
PREOPERATIVE MEDICATIONS:
1. Lortab (10 mg) plus Phenergan (25 mg), p.o. 1 hour before the procedure.
2. Versed a total of 5 mg given IV push during the procedure.
INDICATIONS: Right upper lobe lung mass, posterior segment.
Consent obtained from the patient's daughter.
PROCEDURE IN DETAIL: After appropriate sedation was achieved, the bronchoscope was introduced via the right nares and advanced to the upper larynx. Plain lidocaine 2% was used to anesthetize the laryngeal structures. After adequate anesthesia was achieved, close inspection of the laryngeal structures could be performed. Both vocal cords moved appropriately. Under direct visualization, the bronchoscope was advanced past the vocal cords and into the distal trachea. Additional 2% plain lidocaine was used in the trachea and the main stem bronchi for anesthesia. After adequate anesthesia was achieved, close inspection of the airways could be undertaken. The left tracheobronchial tree was inspected closely to the level of the subsegmental bronchi. All bronchi are patent with no endobronchial lesions and no mucosal lesions noted. The right tracheobronchial tree was also patent and intact with the mucosa normal. The bronchoscope was then introduced to the right upper lobe specifically to the posterior segment and washings/brushings and transbronchial lung biopsies were taken from that area. He had quite a bit of coughing during the diagnostic procedures despite lidocaine administration. A total of 5 mg of Versed was used to effect sedation. At one point, the bronchoscope had to be completely withdrawn so that the sample could be appropriately retrieved. Upon reintroduction, there was quite a bit of bleeding in his right nares. The right naris was packed for control of the bleeding. The procedure was completed and all samples were submitted for appropriate studies. A post procedure chest x-ray has been obtained and is still pending. He tolerated the procedure very well other then for the brisk epistaxis from the right nares. Packing to the right nares has been completed.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 8
Description: Bronchoscopy with brush biopsies. Persistent pneumonia, right upper lobe of the lung, possible mass.
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PREOPERATIVE DIAGNOSIS: Persistent pneumonia, right upper lobe of the lung, possible mass.
POSTOPERATIVE DIAGNOSIS: Persistent pneumonia, right upper lobe of the lung, possible mass.
PROCEDURE: Bronchoscopy with brush biopsies.
DESCRIPTION OF PROCEDURE: After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia. A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube. First the trachea and the carina had normal appearance. The scope was passed into the left side and the bronchial system was found to be normal. There were scars and mucoid secretions. Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB. First, the basal lobes were explored and found to be normal. Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated. Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found. Brush biopsy was obtained from one of the segments and sent to Pathology.
The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.
At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.
POSTOPERATIVE DIAGNOSIS: Persistent pneumonia, right upper lobe of the lung, possible mass.
PROCEDURE: Bronchoscopy with brush biopsies.
DESCRIPTION OF PROCEDURE: After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia. A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube. First the trachea and the carina had normal appearance. The scope was passed into the left side and the bronchial system was found to be normal. There were scars and mucoid secretions. Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB. First, the basal lobes were explored and found to be normal. Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated. Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found. Brush biopsy was obtained from one of the segments and sent to Pathology.
The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.
At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CABG
Description: Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.
(Medical Transcription Sample Report)
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TITLE OF PROCEDURE: Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin. Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. The ascending aorta was crossclamped. Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia. The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened. End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture. The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture. A warm antegrade and retrograde cardioplegia were given. The aortic crossclamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventricular and atrial pacing wires were placed. The patient was fully warmed and weaned from cardiopulmonary bypass. The patient was decannulated in the routine fashion and Protamine was given. Good hemostasis was noted. A single mediastinal and left pleural chest tube were placed. The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch. The patient tolerated the procedure well.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin. Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. The ascending aorta was crossclamped. Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia. The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened. End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture. The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture. A warm antegrade and retrograde cardioplegia were given. The aortic crossclamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventricular and atrial pacing wires were placed. The patient was fully warmed and weaned from cardiopulmonary bypass. The patient was decannulated in the routine fashion and Protamine was given. Good hemostasis was noted. A single mediastinal and left pleural chest tube were placed. The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch. The patient tolerated the procedure well.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CABG - 1
Description: Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Coronary occlusive disease.
POSTOPERATIVE DIAGNOSIS: Coronary occlusive disease.
OPERATION PROCEDURE: Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.
INDICATION FOR THE PROCEDURE: The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.
FINDINGS: The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.
Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped. Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route. This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg. The obtuse marginal coronary was identified and opened.
End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventilation was commenced. The patient was fully warm and the patient was then wean from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.
The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well.
POSTOPERATIVE DIAGNOSIS: Coronary occlusive disease.
OPERATION PROCEDURE: Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.
INDICATION FOR THE PROCEDURE: The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.
FINDINGS: The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.
Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped. Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route. This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg. The obtuse marginal coronary was identified and opened.
End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventilation was commenced. The patient was fully warm and the patient was then wean from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.
The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CABG - 2
Description: Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.
(Medical Transcription Sample Report)
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PREOPERATIVE DIAGNOSIS: Angina and coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Angina and coronary artery disease.
NAME OF OPERATION: Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.
ANESTHESIA: General.
PROCEDURE DETAILS: The patient was brought to the operating room and placed in the supine position upon the table. After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner. Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.
A midline sternal skin incision was made and carried down through the sternum which was divided with the saw. Pericardial and thymus fat pad was divided. The left internal mammary artery was harvested and spatulated for anastomosis. Heparin was given.
Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips. The thigh was closed multilayer Vicryl and Dexon technique. A Pulsavac wash was done, drain was placed.
The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors. After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia. Medtronic retractors used to expose the circumflex. Prior to going on pump, we stapled the vein graft in place to the aorta.
Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique. The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique. Deairing procedure was carried out. The bulldogs were removed. The patient maintained good normal sinus rhythm with good mean perfusion. The patient was weaned from cardiopulmonary bypass. The arterial and venous lines were removed and doubly secured. Protamine was delivered. Meticulous hemostasis was present. Platelets were given for coagulopathy. Chest tube was placed and meticulous hemostasis was present. The anatomy and the flow in the grafts was excellent. Closure was begun.
The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique. The skin was closed with subcuticular 4-0 Dexon suture technique. The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.
We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.
POSTOPERATIVE DIAGNOSIS: Angina and coronary artery disease.
NAME OF OPERATION: Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.
ANESTHESIA: General.
PROCEDURE DETAILS: The patient was brought to the operating room and placed in the supine position upon the table. After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner. Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.
A midline sternal skin incision was made and carried down through the sternum which was divided with the saw. Pericardial and thymus fat pad was divided. The left internal mammary artery was harvested and spatulated for anastomosis. Heparin was given.
Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips. The thigh was closed multilayer Vicryl and Dexon technique. A Pulsavac wash was done, drain was placed.
The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors. After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia. Medtronic retractors used to expose the circumflex. Prior to going on pump, we stapled the vein graft in place to the aorta.
Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique. The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique. Deairing procedure was carried out. The bulldogs were removed. The patient maintained good normal sinus rhythm with good mean perfusion. The patient was weaned from cardiopulmonary bypass. The arterial and venous lines were removed and doubly secured. Protamine was delivered. Meticulous hemostasis was present. Platelets were given for coagulopathy. Chest tube was placed and meticulous hemostasis was present. The anatomy and the flow in the grafts was excellent. Closure was begun.
The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique. The skin was closed with subcuticular 4-0 Dexon suture technique. The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.
We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CABG - Redo
Description: Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. Placement of a right femoral intraaortic balloon pump.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
OPERATIVE PROCEDURE:
1. Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.
2. Placement of a right femoral intraaortic balloon pump.
DESCRIPTION: The patient was brought to the operating room and placed in the supine position. After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed. Chest, abdomen an legs were prepped and draped in sterile fashion. The femoral artery on the right was punctured and a guidewire was placed. The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.
The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution. The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.
The old mediastinal incision was opened. The wires were cut and removed. The sternum was divided in the midline. Retrosternal attachments were taken down. The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The heart was dissected free of its adhesions. The patient was fully heparinized and cannulated with a single aorta and single venous cannula. Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene. An antegrade cardioplegia needle sump was placed and secured to the ascending aorta. Cardiopulmonary bypass ensued. The ascending aorta was cross clamped. Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg. It was followed by sumping the ascending aorta. The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture. The vein was cut to length. Antegrade cardioplegia was given, a total of 200 cc. The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture. The vein was cut to length. Antegrade cardioplegia was given. The mammary was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given. The cross clamp was removed. A partial-occlusion clamp was placed. Aortotomies were made. The vein was cut to fit these and sutured in place with running 5-0 Prolene suture. The partial-occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. The patient was fully warmed and ventilation was commenced. The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire. The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well.
1. Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.
2. Placement of a right femoral intraaortic balloon pump.
DESCRIPTION: The patient was brought to the operating room and placed in the supine position. After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed. Chest, abdomen an legs were prepped and draped in sterile fashion. The femoral artery on the right was punctured and a guidewire was placed. The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.
The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution. The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.
The old mediastinal incision was opened. The wires were cut and removed. The sternum was divided in the midline. Retrosternal attachments were taken down. The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The heart was dissected free of its adhesions. The patient was fully heparinized and cannulated with a single aorta and single venous cannula. Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene. An antegrade cardioplegia needle sump was placed and secured to the ascending aorta. Cardiopulmonary bypass ensued. The ascending aorta was cross clamped. Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg. It was followed by sumping the ascending aorta. The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture. The vein was cut to length. Antegrade cardioplegia was given, a total of 200 cc. The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture. The vein was cut to length. Antegrade cardioplegia was given. The mammary was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given. The cross clamp was removed. A partial-occlusion clamp was placed. Aortotomies were made. The vein was cut to fit these and sutured in place with running 5-0 Prolene suture. The partial-occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. The patient was fully warmed and ventilation was commenced. The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire. The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CABG x4
Description: Coronary artery bypass grafting (CABG) x4. Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES: Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.
POSTOPERATIVE DIAGNOSES: Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.
OPERATIVE PROCEDURE: Coronary artery bypass grafting (CABG) x4.
GRAFTS PERFORMED: LIMA to LAD, left radial artery from the aorta to the PDA, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.
INDICATIONS FOR PROCEDURE: The patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina. He had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved LV function. He was advised surgical revascularization of his coronaries.
FINDINGS DURING THE PROCEDURE: The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp. Left internal mammary artery and saphenous vein grafts were good quality conduits. Radial artery graft was a smaller sized conduit, otherwise good quality. All distal targets showed heavy plaque involvement with calcification present. The smallest target was the PDA, which was about 1.5 mm in size. All the other targets were about 2 mm in size or greater. The patient came off cardiopulmonary bypass without any problems. He was transferred on Neo-Synephrine, nitroglycerin, Precedex drips. Cross clamp time was 102 minutes, bypass time was 120 minutes.
DETAILS OF THE PROCEDURE: The patient was brought into the operating room and laid supine on the table. After he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple-lumen catheter and Cordis catheter, right radial A-line, Foley catheter, TEE probes were placed and interfaced appropriately. The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion. Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.
After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed. Left internal mammary artery was taken down. Simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques. Simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques. Subsequent to harvest, the incisions were closed in layers during the course of the procedure.
Heparin was given. Pericardium was opened and suspended. During the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally. Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.
Pericardium was opened and suspended. Pursestring sutures were placed. Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass. With satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia. An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.
PDA was exposed first. The right coronary artery was calcified along its course all the way to its terminal bifurcation. Even in the PDA, calcification was noted in a spotty fashion. Arteriotomy on the PDA was performed in a soft area and 1.5 probe was noted to be accommodated in both directions. End radial to side PDA anastomosis was constructed using running 7-0 Prolene. Next, the posterolateral obtuse marginal was exposed. Arteriotomy was performed. An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 Prolene. This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 Prolene. Next, a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD. LAD was exposed. Arteriotomy was performed. An end LIMA to side LAD anastomosis was constructed using running 7-0 Prolene. LIMA was tacked down to the epicardium securely utilizing its fascial pedicle.
Two stab incisions were made in the ascending aorta and enlarged using 4-mm punch. Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 Prolene. The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed. Following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity. Temporary V-pacing wires were placed. Blake drains were placed in the left chest, the right chest, as well as in the mediastinum. Left chest Blake drain was placed just in the medial section where dissection had been performed. After an adequate period of rewarming during which time, temporary V-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems. With satisfactory hemodynamics, good LV function on TEE and baseline EKG, heparin was reversed using protamine. Decannulation was performed after volume resuscitation. Hemostasis was assured. Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy Vicryl for musculofascial closure, and Monocryl for subcuticular skin closure. Dressings were applied. The patient was transferred to the ICU in stable condition. He tolerated the procedure well. All counts were correct at the termination of the procedure. Cross clamp time was 102 minutes. Bypass time was 120 minutes. The patient was transferred on Neo-Synephrine, nitroglycerin, and Precedex drips.
POSTOPERATIVE DIAGNOSES: Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.
OPERATIVE PROCEDURE: Coronary artery bypass grafting (CABG) x4.
GRAFTS PERFORMED: LIMA to LAD, left radial artery from the aorta to the PDA, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.
INDICATIONS FOR PROCEDURE: The patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina. He had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved LV function. He was advised surgical revascularization of his coronaries.
FINDINGS DURING THE PROCEDURE: The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp. Left internal mammary artery and saphenous vein grafts were good quality conduits. Radial artery graft was a smaller sized conduit, otherwise good quality. All distal targets showed heavy plaque involvement with calcification present. The smallest target was the PDA, which was about 1.5 mm in size. All the other targets were about 2 mm in size or greater. The patient came off cardiopulmonary bypass without any problems. He was transferred on Neo-Synephrine, nitroglycerin, Precedex drips. Cross clamp time was 102 minutes, bypass time was 120 minutes.
DETAILS OF THE PROCEDURE: The patient was brought into the operating room and laid supine on the table. After he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple-lumen catheter and Cordis catheter, right radial A-line, Foley catheter, TEE probes were placed and interfaced appropriately. The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion. Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.
After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed. Left internal mammary artery was taken down. Simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques. Simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques. Subsequent to harvest, the incisions were closed in layers during the course of the procedure.
Heparin was given. Pericardium was opened and suspended. During the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally. Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.
Pericardium was opened and suspended. Pursestring sutures were placed. Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass. With satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia. An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.
PDA was exposed first. The right coronary artery was calcified along its course all the way to its terminal bifurcation. Even in the PDA, calcification was noted in a spotty fashion. Arteriotomy on the PDA was performed in a soft area and 1.5 probe was noted to be accommodated in both directions. End radial to side PDA anastomosis was constructed using running 7-0 Prolene. Next, the posterolateral obtuse marginal was exposed. Arteriotomy was performed. An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 Prolene. This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 Prolene. Next, a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD. LAD was exposed. Arteriotomy was performed. An end LIMA to side LAD anastomosis was constructed using running 7-0 Prolene. LIMA was tacked down to the epicardium securely utilizing its fascial pedicle.
Two stab incisions were made in the ascending aorta and enlarged using 4-mm punch. Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 Prolene. The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed. Following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity. Temporary V-pacing wires were placed. Blake drains were placed in the left chest, the right chest, as well as in the mediastinum. Left chest Blake drain was placed just in the medial section where dissection had been performed. After an adequate period of rewarming during which time, temporary V-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems. With satisfactory hemodynamics, good LV function on TEE and baseline EKG, heparin was reversed using protamine. Decannulation was performed after volume resuscitation. Hemostasis was assured. Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy Vicryl for musculofascial closure, and Monocryl for subcuticular skin closure. Dressings were applied. The patient was transferred to the ICU in stable condition. He tolerated the procedure well. All counts were correct at the termination of the procedure. Cross clamp time was 102 minutes. Bypass time was 120 minutes. The patient was transferred on Neo-Synephrine, nitroglycerin, and Precedex drips.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Allograft Transplant
Description: Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Ischemic cardiomyopathy.
2. Status post redo coronary artery bypass.
3. Status post insertion of intraaortic balloon.
POSTOPERATIVE DIAGNOSES:
1. Ischemic cardiomyopathy.
2. Status post redo coronary artery bypass.
3. Status post insertion of intraaortic balloon.
4. Postoperative coagulopathy.
OPERATIVE PROCEDURE:
1. Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.
2. Open sternotomy covered with Ioban.
3. Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.
ANESTHESIA: General endotracheal.
OPERATIVE PROCEDURE: With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field. A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass. A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle. The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava. A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava. After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium. After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place. A cardiectomy was then performed by starting in the right atrium. The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field. Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed. The right and left atrium, aorta, and pulmonary artery were prepared for the transplant. First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture. The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene. The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood. Air was evacuated and the sutures were tied down. The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass. The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass. Blood factors and factor VII were given to try and correct the coagulopathy. Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture. Hemofiltration was started in the operating room at this time. After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound. The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively. This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy. The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII. Urine output for the procedure was 520 mL. The preservation time of the heart is in the anesthesia sheet. The estimated blood loss was at least 6 L. The patient was taken to the intensive care unit in guarded condition.
1. Ischemic cardiomyopathy.
2. Status post redo coronary artery bypass.
3. Status post insertion of intraaortic balloon.
POSTOPERATIVE DIAGNOSES:
1. Ischemic cardiomyopathy.
2. Status post redo coronary artery bypass.
3. Status post insertion of intraaortic balloon.
4. Postoperative coagulopathy.
OPERATIVE PROCEDURE:
1. Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.
2. Open sternotomy covered with Ioban.
3. Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.
ANESTHESIA: General endotracheal.
OPERATIVE PROCEDURE: With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field. A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass. A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle. The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava. A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava. After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium. After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place. A cardiectomy was then performed by starting in the right atrium. The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field. Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed. The right and left atrium, aorta, and pulmonary artery were prepared for the transplant. First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture. The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene. The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood. Air was evacuated and the sutures were tied down. The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass. The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass. Blood factors and factor VII were given to try and correct the coagulopathy. Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture. Hemofiltration was started in the operating room at this time. After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound. The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively. This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy. The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII. Urine output for the procedure was 520 mL. The preservation time of the heart is in the anesthesia sheet. The estimated blood loss was at least 6 L. The patient was taken to the intensive care unit in guarded condition.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Cath & Coronary Angiography
Description: Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURE: Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.
INDICATIONS: Atherosclerotic coronary artery disease.
PATIENT HISTORY: This is a 55-year-old male. He presented with 3 hours of unstable angina.
PAST CARDIAC HISTORY: History of previous arteriosclerotic cardiovascular disease. Previous ST elevation MI.
REVIEW OF SYSTEMS. The creatinine value is 1.3 mg/dL mg/dL.
PROCEDURE MEDICATIONS:
1. Visipaque 361 mL total dose.
2. Clopidogrel bisulphate (Plavix) 225 mg PO
3. Promethazine (Phenergan) 12.5 mg total dose.
4. Abciximab (Reopro) 10 mg IV bolus
5. Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL
6. Nitroglycerin 300 mcg IC total dose.
DESCRIPTION OF PROCEDURE:
APPROACH: Left heart catheterization via right femoral artery approach.
ACCESS METHOD: Percutaneous needle puncture.
DEVICES USED:
1. Balloon catheter utilized: Manufacturer: Boston Sci Quantum Maverick RX 2.75mm x 20mm.
2. Cordis Vista Brite Tip 6Fr JR 4.0
3. ACS/Guidant Sport .014" (190cm) Wire
4. Stent utilized: Boston Sci Taxus RX Stent 3.0mm x 32mm.
FINDINGS/INTERVENTIONS:
LEFT VENTRICULOGRAPHY: The overall left ventricular systolic function is mildly reduced. Left ventricular ejection fraction is 40% by left ventriculogram. Mild hypokinesis of the anterior wall of the left ventricle. There was no transaortic gradient. Mitral valve regurgitation is not seen.
LEFT MAIN CORONARY ARTERY: There were no obstructing lesions in the left main coronary artery. Blood flow appeared normal.
LEFT ANTERIOR DESCENDING ARTERY: There was a 95%, discrete stenosis in the mid left anterior descending artery. A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm. Post-procedure stenosis was 0%. There was no dissection and no perforation.
LEFT CIRCUMFLEX ARTERY: There was a 50%, diffuse stenosis in the left circumflex artery.
RIGHT CORONARY ARTERY: The right coronary artery is dominant to the posterior circulation. There were no obstructing lesions in the right coronary artery. Blood flow appeared normal.
COMPLICATIONS:
There were no complications during the procedure.
IMPRESSION:
1. Severe two-vessel coronary artery disease.
2. Severe left anterior descending coronary artery disease. There was a 95% mid left anterior descending artery stenosis. The lesion was successfully stented.
3. Moderate left circumflex artery disease. There was a 50% left circumflex artery stenosis. Intervention not warranted.
4. The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%. Mild hypokinesis of the anterior wall of the left ventricle.
RECOMMENDATION:
1. Clopidogrel (Plavix) 75 mg PO daily for 1 year.
2. Aggressive risk factor modification of tobacco abuse, hyperlipidemia and hypertension.
CPT CODE(S):
92980, LD, Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel.
93510, Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous.
93556, 59, Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass).
93555, 59, Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography.
93545, Injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand).
93543, Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography.
ICD CODE(S): 414.01, Coronary atherosclerosis of native coronary artery.
INDICATIONS: Atherosclerotic coronary artery disease.
PATIENT HISTORY: This is a 55-year-old male. He presented with 3 hours of unstable angina.
PAST CARDIAC HISTORY: History of previous arteriosclerotic cardiovascular disease. Previous ST elevation MI.
REVIEW OF SYSTEMS. The creatinine value is 1.3 mg/dL mg/dL.
PROCEDURE MEDICATIONS:
1. Visipaque 361 mL total dose.
2. Clopidogrel bisulphate (Plavix) 225 mg PO
3. Promethazine (Phenergan) 12.5 mg total dose.
4. Abciximab (Reopro) 10 mg IV bolus
5. Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL
6. Nitroglycerin 300 mcg IC total dose.
DESCRIPTION OF PROCEDURE:
APPROACH: Left heart catheterization via right femoral artery approach.
ACCESS METHOD: Percutaneous needle puncture.
DEVICES USED:
1. Balloon catheter utilized: Manufacturer: Boston Sci Quantum Maverick RX 2.75mm x 20mm.
2. Cordis Vista Brite Tip 6Fr JR 4.0
3. ACS/Guidant Sport .014" (190cm) Wire
4. Stent utilized: Boston Sci Taxus RX Stent 3.0mm x 32mm.
FINDINGS/INTERVENTIONS:
LEFT VENTRICULOGRAPHY: The overall left ventricular systolic function is mildly reduced. Left ventricular ejection fraction is 40% by left ventriculogram. Mild hypokinesis of the anterior wall of the left ventricle. There was no transaortic gradient. Mitral valve regurgitation is not seen.
LEFT MAIN CORONARY ARTERY: There were no obstructing lesions in the left main coronary artery. Blood flow appeared normal.
LEFT ANTERIOR DESCENDING ARTERY: There was a 95%, discrete stenosis in the mid left anterior descending artery. A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm. Post-procedure stenosis was 0%. There was no dissection and no perforation.
LEFT CIRCUMFLEX ARTERY: There was a 50%, diffuse stenosis in the left circumflex artery.
RIGHT CORONARY ARTERY: The right coronary artery is dominant to the posterior circulation. There were no obstructing lesions in the right coronary artery. Blood flow appeared normal.
COMPLICATIONS:
There were no complications during the procedure.
IMPRESSION:
1. Severe two-vessel coronary artery disease.
2. Severe left anterior descending coronary artery disease. There was a 95% mid left anterior descending artery stenosis. The lesion was successfully stented.
3. Moderate left circumflex artery disease. There was a 50% left circumflex artery stenosis. Intervention not warranted.
4. The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%. Mild hypokinesis of the anterior wall of the left ventricle.
RECOMMENDATION:
1. Clopidogrel (Plavix) 75 mg PO daily for 1 year.
2. Aggressive risk factor modification of tobacco abuse, hyperlipidemia and hypertension.
CPT CODE(S):
92980, LD, Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel.
93510, Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous.
93556, 59, Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass).
93555, 59, Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography.
93545, Injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand).
93543, Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography.
ICD CODE(S): 414.01, Coronary atherosclerosis of native coronary artery.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Cath & Selective Coronary Angiography
Description: Left cardiac catheterization with selective right and left coronary angiography. Post infarct angina.
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PREOPERATIVE DIAGNOSIS: Post infarct angina.
TYPE OF PROCEDURE: Left cardiac catheterization with selective right and left coronary angiography.
PROCEDURE: After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion. Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated. Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle. Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained. Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged. Cineangiograms were obtained of the left coronary system. This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged. Cineangiograms were obtained, and the catheter and sheath were then withdrawn. The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition. No evidence of hematoma formation or active bleeding.
COMPLICATIONS: None.
TOTAL CONTRAST: 110 cc of Hexabrix.
TOTAL FLUOROSCOPY TIME: 1.8 minutes.
MEDICATIONS: Reglan 10 mg p.o., 5 mg p.o. Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push.
TYPE OF PROCEDURE: Left cardiac catheterization with selective right and left coronary angiography.
PROCEDURE: After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion. Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated. Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle. Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained. Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged. Cineangiograms were obtained of the left coronary system. This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged. Cineangiograms were obtained, and the catheter and sheath were then withdrawn. The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition. No evidence of hematoma formation or active bleeding.
COMPLICATIONS: None.
TOTAL CONTRAST: 110 cc of Hexabrix.
TOTAL FLUOROSCOPY TIME: 1.8 minutes.
MEDICATIONS: Reglan 10 mg p.o., 5 mg p.o. Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization
Description: Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.
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EXAMINATION: Cardiac catheterization.
PROCEDURE PERFORMED: Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.
INDICATION: Syncope with severe aortic stenosis.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state. The right groin was prepped and draped in the usual sterile fashion. After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein. Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg. The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg. The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg. The pulmonary arterial pressures were noted to be 31/14/21 mmHg. Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views. Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter. We were unable to cannulate the right coronary artery. Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views. Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed. Following this, the catheters were removed. Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device. The patient tolerated the procedure well. There were no complications.
DESCRIPTION OF FINDINGS: The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions. The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions. The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches. There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities. The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion. The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions. The left ventricle appears to be normal sized. The aortic valve is heavily calcified. The estimated ejection fraction is approximately 60%. There was 4+ mitral regurgitation noted. The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.
CONCLUSION:
1. Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.
2. Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.
3. 4+ mitral regurgitation.
PLAN: The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.
PROCEDURE PERFORMED: Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.
INDICATION: Syncope with severe aortic stenosis.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state. The right groin was prepped and draped in the usual sterile fashion. After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein. Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg. The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg. The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg. The pulmonary arterial pressures were noted to be 31/14/21 mmHg. Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views. Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter. We were unable to cannulate the right coronary artery. Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views. Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed. Following this, the catheters were removed. Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device. The patient tolerated the procedure well. There were no complications.
DESCRIPTION OF FINDINGS: The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions. The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions. The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches. There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities. The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion. The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions. The left ventricle appears to be normal sized. The aortic valve is heavily calcified. The estimated ejection fraction is approximately 60%. There was 4+ mitral regurgitation noted. The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.
CONCLUSION:
1. Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.
2. Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.
3. 4+ mitral regurgitation.
PLAN: The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - Fiberoptic
Description: Fiberoptic bronchoscopy with endobronchial biopsies. A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.
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HISTORY OF PRESENT ILLNESS: A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss. He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma. There was also a question of liver metastases at that time.
OPERATION PERFORMED: Fiberoptic bronchoscopy with endobronchial biopsies.
The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right. The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant. Approximately 15 biopsies were taken of the tumor.
Attention was then directed at the left upper lobe and lingula. Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review. Approximately eight biopsies were taken of the left upper lobe.
OPERATION PERFORMED: Fiberoptic bronchoscopy with endobronchial biopsies.
The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right. The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant. Approximately 15 biopsies were taken of the tumor.
Attention was then directed at the left upper lobe and lingula. Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review. Approximately eight biopsies were taken of the left upper lobe.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - Pediatric
Description: Flexible Bronchoscopy (pediatric)
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FLEXIBLE BRONCHOSCOPY
The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit. I explained to the parents that the possible risks include: irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax. A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back. The sample will then be sent for testing. The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.
The parents seem to understand, had the opportunity to ask questions and were satisfied with the information. A booklet containing the description of the procedure and other information was provided.
The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit. I explained to the parents that the possible risks include: irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax. A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back. The sample will then be sent for testing. The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.
The parents seem to understand, had the opportunity to ask questions and were satisfied with the information. A booklet containing the description of the procedure and other information was provided.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy & Bronchoalveolar Lavage
Description: Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.
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PREOPERATIVE DIAGNOSIS: Refractory pneumonitis.
POSTOPERATIVE DIAGNOSIS: Refractory pneumonitis.
PROCEDURE PERFORMED: Bronchoscopy with bronchoalveolar lavage.
ANESTHESIA: 5 mg of Versed.
INDICATIONS: A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.
PROCEDURE: The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube. Bronchoscope was advanced. Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out. Relatively few tenacious secretions were noted. These were lavaged out. Specimen collected for culture. No obvious other abnormalities were noted. The patient tolerated the procedure well without complication.
POSTOPERATIVE DIAGNOSIS: Refractory pneumonitis.
PROCEDURE PERFORMED: Bronchoscopy with bronchoalveolar lavage.
ANESTHESIA: 5 mg of Versed.
INDICATIONS: A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.
PROCEDURE: The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube. Bronchoscope was advanced. Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out. Relatively few tenacious secretions were noted. These were lavaged out. Specimen collected for culture. No obvious other abnormalities were noted. The patient tolerated the procedure well without complication.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy & Foreign Body Removal
Description: Plastic piece foreign body in the right main stem bronchus. Rigid bronchoscopy with foreign body removal.
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PREOPERATIVE DIAGNOSIS: Foreign body in airway.
POSTOPERATIVE DIAGNOSIS: Plastic piece foreign body in the right main stem bronchus.
PROCEDURE: Rigid bronchoscopy with foreign body removal.
INDICATIONS FOR PROCEDURE: This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom. The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem. The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed supine, put under general mask anesthesia. Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea. There were some secretions but that looked okay. Got down at the level of the carina to see a foreign body flapping in the right main stem. I then used graspers to grasp to try to pull into the scope itself. I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper. It appeared to be consisting of some type of plastic piece that had broke off some different object. I took the scope and put it back down into the airway again. Again, there was secretion in the trachea that we suctioned out. We looked down into the right bronchus intermedius. There was no other pathology noted, just some irritation in the right main stem area. I looked down the left main stem as well and that looked okay as well. I then withdrew the scope. Trachea looked fine as well as the cords. I put the patient back on mask oxygen to wake the patient up. The patient tolerated the procedure well.
POSTOPERATIVE DIAGNOSIS: Plastic piece foreign body in the right main stem bronchus.
PROCEDURE: Rigid bronchoscopy with foreign body removal.
INDICATIONS FOR PROCEDURE: This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom. The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem. The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed supine, put under general mask anesthesia. Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea. There were some secretions but that looked okay. Got down at the level of the carina to see a foreign body flapping in the right main stem. I then used graspers to grasp to try to pull into the scope itself. I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper. It appeared to be consisting of some type of plastic piece that had broke off some different object. I took the scope and put it back down into the airway again. Again, there was secretion in the trachea that we suctioned out. We looked down into the right bronchus intermedius. There was no other pathology noted, just some irritation in the right main stem area. I looked down the left main stem as well and that looked okay as well. I then withdrew the scope. Trachea looked fine as well as the cords. I put the patient back on mask oxygen to wake the patient up. The patient tolerated the procedure well.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy & Lobectomy
Description: Bronchoscopy with aspiration and left upper lobectomy. Carcinoma of the left upper lobe.
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PREOPERATIVE DIAGNOSIS: Carcinoma of the left upper lobe.
PROCEDURES PERFORMED:
1. Bronchoscopy with aspiration.
2. Left upper lobectomy.
PROCEDURE DETAILS: With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina. The carina was in the midline and sharp. Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions. Aspiration was carried out for backlog ________ examination. We then moved to left side, left upper lobe. There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction. No anatomic lesions were demonstrated. The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter. After proper position, utilizing Betadine solution, they were draped. A posterolateral left thoracotomy incision was performed. Hemostasis was secured with electrocoagulation. The chest wall muscle was then divided over the sixth rib. The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully. At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation. We examined the superior mediastinum. No lymph nodes were demonstrated as well as in the anterior mediastinum. Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe. Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.
Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe. Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue. From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short. Tumor mass was close to the artery at this time. We then directed ourselves once again to the lingual artery which was doubly ligated and cut free. The posterior artery of the superior branch was doubly ligated and cut free also. At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished. We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein. Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal. Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time. A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished. The anterior artery was seen in the clamp also and was separated and ligated and separated. At this time, the entire tumor in the left upper lobe was then removed.
Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place. The clamp was then removed. No bleeding was seen at this time. Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology. We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position. At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture. The chest cavity was then closed. After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength. A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin. The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time. The patient was extubated in the room without difficulty and sent to Recovery in satisfactory.
PROCEDURES PERFORMED:
1. Bronchoscopy with aspiration.
2. Left upper lobectomy.
PROCEDURE DETAILS: With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina. The carina was in the midline and sharp. Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions. Aspiration was carried out for backlog ________ examination. We then moved to left side, left upper lobe. There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction. No anatomic lesions were demonstrated. The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter. After proper position, utilizing Betadine solution, they were draped. A posterolateral left thoracotomy incision was performed. Hemostasis was secured with electrocoagulation. The chest wall muscle was then divided over the sixth rib. The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully. At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation. We examined the superior mediastinum. No lymph nodes were demonstrated as well as in the anterior mediastinum. Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe. Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.
Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe. Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue. From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short. Tumor mass was close to the artery at this time. We then directed ourselves once again to the lingual artery which was doubly ligated and cut free. The posterior artery of the superior branch was doubly ligated and cut free also. At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished. We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein. Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal. Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time. A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished. The anterior artery was seen in the clamp also and was separated and ligated and separated. At this time, the entire tumor in the left upper lobe was then removed.
Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place. The clamp was then removed. No bleeding was seen at this time. Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology. We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position. At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture. The chest cavity was then closed. After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength. A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin. The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time. The patient was extubated in the room without difficulty and sent to Recovery in satisfactory.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy & Thoracotomy
Description: Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. Bilateral bronchopneumonia and empyema of the chest, left.
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PREOPERATIVE DIAGNOSES
1. Bilateral bronchopneumonia.
2. Empyema of the chest, left.
POSTOPERATIVE DIAGNOSES
1. Bilateral bronchopneumonia.
2. Empyema of the chest, left.
PROCEDURES
1. Diagnostic bronchoscopy.
2. Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.
DESCRIPTION OF PROCEDURE: After obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed. Initially, the patient was intubated with a #6 French tube because of the presence of previous laryngectomy. Because of this, I proceeded to use a pediatric bronchoscope, which provided limited visualization, but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated.
Then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope. Therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems. Some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast.
Then, the patient was turned with left side up and prepped for a left thoracotomy. He was properly draped. I had recently re-inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space. Immediately, it was evident that there was a large amount of pus in the left chest. We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus. Then, we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung. We spent several minutes trying to clean up this area. Initially, I had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure. On the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations. We followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex.
The limited thoracotomy was closed with heavy intercostal sutures of Vicryl, then interrupted sutures of #0 Vicryl to the muscle layers, and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus.
The chest tubes were secured with sutures and then connected to Pleur-evac. Then, the patient was transported.
Estimated blood loss was minimal and the patient tolerated the procedure well. He was extubated in the operating room and he was transferred to the ICU to be admitted. A chest x-ray was ordered stat.
1. Bilateral bronchopneumonia.
2. Empyema of the chest, left.
POSTOPERATIVE DIAGNOSES
1. Bilateral bronchopneumonia.
2. Empyema of the chest, left.
PROCEDURES
1. Diagnostic bronchoscopy.
2. Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.
DESCRIPTION OF PROCEDURE: After obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed. Initially, the patient was intubated with a #6 French tube because of the presence of previous laryngectomy. Because of this, I proceeded to use a pediatric bronchoscope, which provided limited visualization, but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated.
Then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope. Therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems. Some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast.
Then, the patient was turned with left side up and prepped for a left thoracotomy. He was properly draped. I had recently re-inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space. Immediately, it was evident that there was a large amount of pus in the left chest. We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus. Then, we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung. We spent several minutes trying to clean up this area. Initially, I had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure. On the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations. We followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex.
The limited thoracotomy was closed with heavy intercostal sutures of Vicryl, then interrupted sutures of #0 Vicryl to the muscle layers, and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus.
The chest tubes were secured with sutures and then connected to Pleur-evac. Then, the patient was transported.
Estimated blood loss was minimal and the patient tolerated the procedure well. He was extubated in the operating room and he was transferred to the ICU to be admitted. A chest x-ray was ordered stat.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy Brushings
Description: Bronchoscopy brushings, washings and biopsies. Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
OPERATIVE PROCEDURE: Bronchoscopy brushings, washings and biopsies.
HISTORY: This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.
INDICATIONS FOR THE PROCEDURE: Bilateral infiltrates, immunocompromised host, and pneumonia.
Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.
DESCRIPTION OF PROCEDURE: Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.
ET tube was visualized approximately 2 cm above the carina. Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings. The patient tolerated the procedure well. Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending. Specimens are sent for immunocompromise panel including PCP stains.
POSTPROCEDURE DIAGNOSIS: Pneumonia, infiltrates.
Keywords: cardiovascular / pulmonary, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised,
HISTORY: This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.
INDICATIONS FOR THE PROCEDURE: Bilateral infiltrates, immunocompromised host, and pneumonia.
Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.
DESCRIPTION OF PROCEDURE: Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.
ET tube was visualized approximately 2 cm above the carina. Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings. The patient tolerated the procedure well. Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending. Specimens are sent for immunocompromise panel including PCP stains.
POSTPROCEDURE DIAGNOSIS: Pneumonia, infiltrates.
Keywords: cardiovascular / pulmonary, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised,
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Broviac Catheter Placement
Description: Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Lumbar osteomyelitis.
2. Need for durable central intravenous access.
POSTOPERATIVE DIAGNOSES:
1. Lumbar osteomyelitis.
2. Need for durable central intravenous access.
ANESTHESIA: General.
PROCEDURE: Placement of left subclavian 4-French Broviac catheter.
INDICATIONS: The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas. The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed. She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement. I met with the patient's mom. With the help of a Spanish interpreter, I explained the technique for Broviac placement. We discussed the surgical risks and alternatives, most of which have been exhausted. All their questions have been answered, and the patient is fit for operation today.
DESCRIPTION OF OPERATION: The patient came to the operating room and had an uneventful induction of general anesthesia. We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter. Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed. A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins. The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines. The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath. There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava. The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred. Heparinized saline solution was used to flush the line. A sterile occlusive dressing was applied, and the line was prepared for immediate use. The patient was transported to the recovery room in good condition. There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.
Keywords: cardiovascular / pulmonary, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,
1. Lumbar osteomyelitis.
2. Need for durable central intravenous access.
POSTOPERATIVE DIAGNOSES:
1. Lumbar osteomyelitis.
2. Need for durable central intravenous access.
ANESTHESIA: General.
PROCEDURE: Placement of left subclavian 4-French Broviac catheter.
INDICATIONS: The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas. The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed. She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement. I met with the patient's mom. With the help of a Spanish interpreter, I explained the technique for Broviac placement. We discussed the surgical risks and alternatives, most of which have been exhausted. All their questions have been answered, and the patient is fit for operation today.
DESCRIPTION OF OPERATION: The patient came to the operating room and had an uneventful induction of general anesthesia. We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter. Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed. A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins. The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines. The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath. There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava. The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred. Heparinized saline solution was used to flush the line. A sterile occlusive dressing was applied, and the line was prepared for immediate use. The patient was transported to the recovery room in good condition. There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.
Keywords: cardiovascular / pulmonary, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,
PHYSICAL EXAM: The patient is a 40-year-old white male.
General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates without gait abnormality or difficulty.
HEENT: Normocephalic/atraumatic head. Pupils are 2.5 mm, equal round and react to light bilaterally. Extra-ocular muscles are intact bilaterally. External auditory canals are clear bilaterally. Tympanic membranes are clear and intact bilaterally.
Neck: No JVD. Neck is supple. There is free range of motion & no tenderness, thyromegaly or lymphadenopathy noted.
Pharynx: Clear, no erythema, exudates or tonsillar enlargement.
Chest: No chest wall tenderness to palpation. Lungs: Clear to auscultation bilaterally. Heart: irregularly-irregular rate and rhythm no murmurs gallops or rubs. Normal PMI
Abdomen: Soft, non-distended. No tenderness noted. No CVAT.
Skin: Warm, diaphoretic, mucous membranes moist, normal turgor, no rash noted.
Extremities: No gross visible deformity, free range of motion. No edema or cyanosis. No calf/ thigh tenderness or swelling.
COURSE IN EMERGENCY DEPARTMENT: The patient's chest pain improved after the sublingual nitroglycerine and completely resolved with the Nitroglycerin Drip at 30 ug/Minute. He tolerated the TPA well. He was transferred to the CCU in a stable condition
PROCEDURES:
10:40 PM Dr. ABC (cardiologist) apprised. He agrees with T PA per 90 minute protocol & IV nitroglycerin drip. He is to come see patient in the emergency department.
10:45 PM risks & benefits of TPA discussed with patient & his family. They agree with administration of TPA and are willing to accept the risks.
10:50 PM TPA started.
11:20 PM Dr. ABC present in emergency department assisting with patient care.
General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates without gait abnormality or difficulty.
HEENT: Normocephalic/atraumatic head. Pupils are 2.5 mm, equal round and react to light bilaterally. Extra-ocular muscles are intact bilaterally. External auditory canals are clear bilaterally. Tympanic membranes are clear and intact bilaterally.
Neck: No JVD. Neck is supple. There is free range of motion & no tenderness, thyromegaly or lymphadenopathy noted.
Pharynx: Clear, no erythema, exudates or tonsillar enlargement.
Chest: No chest wall tenderness to palpation. Lungs: Clear to auscultation bilaterally. Heart: irregularly-irregular rate and rhythm no murmurs gallops or rubs. Normal PMI
Abdomen: Soft, non-distended. No tenderness noted. No CVAT.
Skin: Warm, diaphoretic, mucous membranes moist, normal turgor, no rash noted.
Extremities: No gross visible deformity, free range of motion. No edema or cyanosis. No calf/ thigh tenderness or swelling.
COURSE IN EMERGENCY DEPARTMENT: The patient's chest pain improved after the sublingual nitroglycerine and completely resolved with the Nitroglycerin Drip at 30 ug/Minute. He tolerated the TPA well. He was transferred to the CCU in a stable condition
PROCEDURES:
10:40 PM Dr. ABC (cardiologist) apprised. He agrees with T PA per 90 minute protocol & IV nitroglycerin drip. He is to come see patient in the emergency department.
10:45 PM risks & benefits of TPA discussed with patient & his family. They agree with administration of TPA and are willing to accept the risks.
10:50 PM TPA started.
11:20 PM Dr. ABC present in emergency department assisting with patient care.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Adenosine Nuclear Scan
Description: Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INDICATION: Chest pain.
TYPE OF TEST: Adenosine with nuclear scan as the patient unable to walk on a treadmill.
INTERPRETATION: Resting heart rate of 67, blood pressure of 129/86. EKG, normal sinus rhythm. Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74. EKG remained the same. No symptoms were noted.
SUMMARY:
1. Nondiagnostic adenosine stress test.
2. Nuclear interpretation as below.
NUCLEAR INTERPRETATION: Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 58%. End-diastolic volume of 74, end-systolic volume of 31.
IMPRESSION:
1. Normal nuclear myocardial perfusion scan.
2. Ejection fraction 58% by gated SPECT.
TYPE OF TEST: Adenosine with nuclear scan as the patient unable to walk on a treadmill.
INTERPRETATION: Resting heart rate of 67, blood pressure of 129/86. EKG, normal sinus rhythm. Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74. EKG remained the same. No symptoms were noted.
SUMMARY:
1. Nondiagnostic adenosine stress test.
2. Nuclear interpretation as below.
NUCLEAR INTERPRETATION: Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 58%. End-diastolic volume of 74, end-systolic volume of 31.
IMPRESSION:
1. Normal nuclear myocardial perfusion scan.
2. Ejection fraction 58% by gated SPECT.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angiogram & Angioplasty
Description: Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.
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(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Left superficial femoral artery subtotal stenosis.
2. Arterial insufficiency, left lower extremity.
POSTOPERATIVE DIAGNOSES:
1. Left superficial femoral artery subtotal stenosis.
2. Arterial insufficiency, left lower extremity.
OPERATIONS PERFORMED:
1. Left lower extremity angiogram.
2. Left superficial femoral artery laser atherectomy.
3. Left superficial femoral artery percutaneous transluminal balloon angioplasty.
4. Left external iliac artery angioplasty.
5. Left external iliac artery stent placement.
6. Completion angiogram.
FINDINGS: This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh. He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.
Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary. However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery. The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament. Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area. Ultimately, this wound up being a much more complex case than initially anticipated.
Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result. The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity. We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.
The left superficial femoral artery was dilated with a 6-mm balloon.
The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.
A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh. After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.
The patient had good dorsalis pedis pulses bilaterally upon completion.
The right common femoral artery was used for access in an up-and-over technique.
PROCEDURE: With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.
The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed. We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery. We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire. A selective left lower extremity angiogram was then done with the above-noted findings.
We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery. Because of the findings as noted above, this became more involved than initially hoped for. Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area. Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.
Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.
Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.
Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery. Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.
The patient tolerated the procedure well throughout. He had good palpable dorsalis pedis pulses bilaterally on completion. He was taken to the recovery room in satisfactory condition. Protamine was given to partially reverse the heparin.
1. Left superficial femoral artery subtotal stenosis.
2. Arterial insufficiency, left lower extremity.
POSTOPERATIVE DIAGNOSES:
1. Left superficial femoral artery subtotal stenosis.
2. Arterial insufficiency, left lower extremity.
OPERATIONS PERFORMED:
1. Left lower extremity angiogram.
2. Left superficial femoral artery laser atherectomy.
3. Left superficial femoral artery percutaneous transluminal balloon angioplasty.
4. Left external iliac artery angioplasty.
5. Left external iliac artery stent placement.
6. Completion angiogram.
FINDINGS: This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh. He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.
Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary. However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery. The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament. Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area. Ultimately, this wound up being a much more complex case than initially anticipated.
Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result. The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity. We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.
The left superficial femoral artery was dilated with a 6-mm balloon.
The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.
A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh. After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.
The patient had good dorsalis pedis pulses bilaterally upon completion.
The right common femoral artery was used for access in an up-and-over technique.
PROCEDURE: With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.
The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed. We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery. We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire. A selective left lower extremity angiogram was then done with the above-noted findings.
We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery. Because of the findings as noted above, this became more involved than initially hoped for. Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area. Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.
Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.
Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.
Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery. Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.
The patient tolerated the procedure well throughout. He had good palpable dorsalis pedis pulses bilaterally on completion. He was taken to the recovery room in satisfactory condition. Protamine was given to partially reverse the heparin.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angiogram & StarClose Closure
Description: Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
EXAM: Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.
REASON FOR EXAM: Abnormal stress test and episode of shortness of breath.
PROCEDURE: Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.
FINDINGS:
1. Left main is a large-caliber vessel. It is angiographically free of disease,
2. LAD is a large-caliber vessel. It gives rise to two diagonals and septal perforator. It erupts around the apex. LAD shows an area of 60% to 70% stenosis probably in its mid portion. The lesion is a type A finishing before the takeoff of diagonal 1. The rest of the vessel is angiographically free of disease.
3. Diagonal 1 and diagonal 2 are angiographically free of disease.
4. Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM. It is angiographically free of disease.
5. OM-1 is angiographically free of disease.
6. RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL. RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.
7. LVEDP is measured 40 mmHg.
8. No gradient between LV and aorta is noted.
Due to contrast concern due to renal function, no LV gram was performed.
Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.
IMPRESSION:
1. 60% to 70% mid left anterior descending stenosis.
2. Mild 30% to 40% stenosis of the proximal right coronary artery.
3. Status post StarClose closure of the right common femoral artery.
PLAN: Plan will be to perform elective PCI of the mid LAD.
REASON FOR EXAM: Abnormal stress test and episode of shortness of breath.
PROCEDURE: Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.
FINDINGS:
1. Left main is a large-caliber vessel. It is angiographically free of disease,
2. LAD is a large-caliber vessel. It gives rise to two diagonals and septal perforator. It erupts around the apex. LAD shows an area of 60% to 70% stenosis probably in its mid portion. The lesion is a type A finishing before the takeoff of diagonal 1. The rest of the vessel is angiographically free of disease.
3. Diagonal 1 and diagonal 2 are angiographically free of disease.
4. Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM. It is angiographically free of disease.
5. OM-1 is angiographically free of disease.
6. RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL. RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.
7. LVEDP is measured 40 mmHg.
8. No gradient between LV and aorta is noted.
Due to contrast concern due to renal function, no LV gram was performed.
Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.
IMPRESSION:
1. 60% to 70% mid left anterior descending stenosis.
2. Mild 30% to 40% stenosis of the proximal right coronary artery.
3. Status post StarClose closure of the right common femoral artery.
PLAN: Plan will be to perform elective PCI of the mid LAD.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angiography & Catheterization
Description: Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization. Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Bilateral selective coronary angiography.
3. Left ventriculography.
4. Right heart catheterization.
INDICATION: Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.
PROCEDURE: After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was flushed. Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire. The catheter was then guided into the left ventricle. The guidewire and dilator were then removed. The catheter was then flushed. LVEDP was measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material. LVEDP was then remeasured. Pullback was performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary was unable to be engaged with this catheter. Thus it was removed over a guidewire. Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Left main coronary artery was then engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. The catheter was then removed from the ostium of the right coronary artery and then removed. The sheath was then flushed. Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization. Thus an #18 gauge Argon needle was used to cannulate the right femoral vein. A steel guidewire was inserted through the needle into the vascular lumen. The needle was removed over the guidewire. Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, a Swan-Ganz catheter was advanced to the level of 20 cm. The balloon was inflated. Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position. Hemodynamics were measured along the way. PA saturation, right atrial saturation, femoral artery saturation were all obtained. Once adequate study has been performed, the catheter was then removed. Both sheaths were flushed and found fine. The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.
FINDINGS:
LEFT VENTRICULOGRAM: There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection. There is no LVAO. There is no mitral regurgitation. There is a trileaflet aortic valve noted.
LEFT MAIN CORONARY ARTERY: The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.
LEFT ANTERIOR DESCENDING: The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart. There is a proximal 60% to 70% stenotic lesion. There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.
CIRCUMFLEX ARTERY: The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion. The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease. The third obtuse marginal branch is also small.
RIGHT CORONARY ARTERY: The RCA is a moderate caliber vessel with minor luminal irregularities throughout. There is no evidence of any critical disease. The right coronary artery is the dominant right coronary vessel.
RIGHT HEART FINDINGS: Pulmonary artery pressure equals 61/23 with a mean of 44. Pulmonary artery wedge pressure equals 32. Right ventricle pressure equals 65/24. The right atrial pressure equals to 22. Cardiac output by Fick is 4.9. Cardiac index by Fick is 2.3. Hand calculated cardiac output equals 7.8. Hand calculated cardiac index equals 3.7. On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%. Femoral artery saturation equals 99.1%. Pulse oximetry is 99%. Right atrial saturation is 76.3%. Systemic blood pressure is 166/58. Body surface area equals 2.12. Hemoglobin equals 12.6.
IMPRESSION:
1. Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.
2. Normal left ventricular function with an estimated ejection fraction of 60%.
3. Biventricular overload.
4. Moderate pulmonary hypertension.
5. There is no evidence of shunt.
PLAN:
1. The patient will be admitted for IV diuresis in light of the biventricular overload.
2. The findings of the heart catheterization were discussed in detail with the patient and the patient's family. There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history. We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.
3. The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.
4. The patient will need to undergo aggressive risk factor modification including weight loss and diet control.
5. The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.
1. Left heart catheterization.
2. Bilateral selective coronary angiography.
3. Left ventriculography.
4. Right heart catheterization.
INDICATION: Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.
PROCEDURE: After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was flushed. Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire. The catheter was then guided into the left ventricle. The guidewire and dilator were then removed. The catheter was then flushed. LVEDP was measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material. LVEDP was then remeasured. Pullback was performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary was unable to be engaged with this catheter. Thus it was removed over a guidewire. Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Left main coronary artery was then engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. The catheter was then removed from the ostium of the right coronary artery and then removed. The sheath was then flushed. Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization. Thus an #18 gauge Argon needle was used to cannulate the right femoral vein. A steel guidewire was inserted through the needle into the vascular lumen. The needle was removed over the guidewire. Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, a Swan-Ganz catheter was advanced to the level of 20 cm. The balloon was inflated. Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position. Hemodynamics were measured along the way. PA saturation, right atrial saturation, femoral artery saturation were all obtained. Once adequate study has been performed, the catheter was then removed. Both sheaths were flushed and found fine. The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.
FINDINGS:
LEFT VENTRICULOGRAM: There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection. There is no LVAO. There is no mitral regurgitation. There is a trileaflet aortic valve noted.
LEFT MAIN CORONARY ARTERY: The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.
LEFT ANTERIOR DESCENDING: The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart. There is a proximal 60% to 70% stenotic lesion. There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.
CIRCUMFLEX ARTERY: The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion. The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease. The third obtuse marginal branch is also small.
RIGHT CORONARY ARTERY: The RCA is a moderate caliber vessel with minor luminal irregularities throughout. There is no evidence of any critical disease. The right coronary artery is the dominant right coronary vessel.
RIGHT HEART FINDINGS: Pulmonary artery pressure equals 61/23 with a mean of 44. Pulmonary artery wedge pressure equals 32. Right ventricle pressure equals 65/24. The right atrial pressure equals to 22. Cardiac output by Fick is 4.9. Cardiac index by Fick is 2.3. Hand calculated cardiac output equals 7.8. Hand calculated cardiac index equals 3.7. On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%. Femoral artery saturation equals 99.1%. Pulse oximetry is 99%. Right atrial saturation is 76.3%. Systemic blood pressure is 166/58. Body surface area equals 2.12. Hemoglobin equals 12.6.
IMPRESSION:
1. Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.
2. Normal left ventricular function with an estimated ejection fraction of 60%.
3. Biventricular overload.
4. Moderate pulmonary hypertension.
5. There is no evidence of shunt.
PLAN:
1. The patient will be admitted for IV diuresis in light of the biventricular overload.
2. The findings of the heart catheterization were discussed in detail with the patient and the patient's family. There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history. We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.
3. The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.
4. The patient will need to undergo aggressive risk factor modification including weight loss and diet control.
5. The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angiography & Catheterization - 1
Description: Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INDICATION: Acute coronary syndrome.
CONSENT FORM: The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. He understands. All questions answered and is willing to sign consent.
PROCEDURE PERFORMED: Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.
NARRATIVE: The patient was brought to the cardiac catheterization laboratory in a fasting state. Both groins were draped and sterilized in the usual fashion. Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery. Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery. Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.
FINDINGS
1. Hemodynamics systemic blood pressure 140/70 mmHg. LVEDP at the end of the procedure was 13 mmHg.
2. The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.
The LAD is calcified and diffusely disease in the proximal and mid portion. There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.
3. The right coronary artery is dominant. It is septal to be occluded in the mid portion.
The findings were discussed with the patient and she opted for PCI. Angiomax bolus was started. The ACT was checked. It was higher in 300. I have given the patient 600 mg of oral Plavix.
The right coronary artery was engaged using a #6-French JR4 guide catheter. I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support. I was unable to cross with this lesion using a whisper wire. I was unable to cross with this lesion using Cross-IT 100 wire. I have also used second #6-French Amplatz right I guide catheter. At one time, I have lost flow in the distal vessel. The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.
Dr. X was notified.
Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel. I have performed careful balloon angioplasty of the mid RCA. I have given nitroglycerin under the nursing several times during the procedure.
I then performed arthrectomy using #5-French export catheter.
I performed more balloon predilation using a 3.0 x16 mm Voyager balloon. I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result. Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.
Left ventricular catheterization was performed with #6-French angle pigtail catheter. The left ventricle is rather smaller in size. The mid inferior wall is minimally hypokinetic, ejection fraction is 70%. There is no evidence of aortic wall stenosis or mitral regurgitation.
Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.
CONCLUSIONS
1. Normal left ventricular size and function. Ejection fraction is 65% to 70%. No MR.
2. Successful angioplasty and stenting of the subtotally closed mid RCA. This was hard, organized thrombus, very difficult to penetrate. I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. The RCA is dominant.
3. No moderate disease in the distal left main. Moderate disease in the ostium of the left circumflex artery. Mild disease in the proximal LAD.
PLAN: Recommend smoking cessation. Continue aspirin lifelong and continue Plavix for at least 12 months.
CONSENT FORM: The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. He understands. All questions answered and is willing to sign consent.
PROCEDURE PERFORMED: Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.
NARRATIVE: The patient was brought to the cardiac catheterization laboratory in a fasting state. Both groins were draped and sterilized in the usual fashion. Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery. Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery. Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.
FINDINGS
1. Hemodynamics systemic blood pressure 140/70 mmHg. LVEDP at the end of the procedure was 13 mmHg.
2. The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.
The LAD is calcified and diffusely disease in the proximal and mid portion. There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.
3. The right coronary artery is dominant. It is septal to be occluded in the mid portion.
The findings were discussed with the patient and she opted for PCI. Angiomax bolus was started. The ACT was checked. It was higher in 300. I have given the patient 600 mg of oral Plavix.
The right coronary artery was engaged using a #6-French JR4 guide catheter. I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support. I was unable to cross with this lesion using a whisper wire. I was unable to cross with this lesion using Cross-IT 100 wire. I have also used second #6-French Amplatz right I guide catheter. At one time, I have lost flow in the distal vessel. The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.
Dr. X was notified.
Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel. I have performed careful balloon angioplasty of the mid RCA. I have given nitroglycerin under the nursing several times during the procedure.
I then performed arthrectomy using #5-French export catheter.
I performed more balloon predilation using a 3.0 x16 mm Voyager balloon. I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result. Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.
Left ventricular catheterization was performed with #6-French angle pigtail catheter. The left ventricle is rather smaller in size. The mid inferior wall is minimally hypokinetic, ejection fraction is 70%. There is no evidence of aortic wall stenosis or mitral regurgitation.
Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.
CONCLUSIONS
1. Normal left ventricular size and function. Ejection fraction is 65% to 70%. No MR.
2. Successful angioplasty and stenting of the subtotally closed mid RCA. This was hard, organized thrombus, very difficult to penetrate. I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. The RCA is dominant.
3. No moderate disease in the distal left main. Moderate disease in the ostium of the left circumflex artery. Mild disease in the proximal LAD.
PLAN: Recommend smoking cessation. Continue aspirin lifelong and continue Plavix for at least 12 months.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortic Valve Replacement
Description: Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
DIAGNOSIS: Aortic valve stenosis with coronary artery disease associated with congestive heart failure. The patient has diabetes and is morbidly obese.
PROCEDURES: Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.
ANESTHESIA: General endotracheal
INCISION: Median sternotomy
INDICATIONS: The patient presented with severe congestive heart failure associated with the patient's severe diabetes. The patient was found to have moderately stenotic aortic valve. In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system. It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.
FINDINGS: The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion. It is a tricuspid type of valve. The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.
The radial artery was used for the left anterior descending artery. Flow was excellent. Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches. On the angiogram these vessels appeared to be quite small. Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken. The patient was brought to the operating room
PROCEDURE: The patient was brought to the operating room and placed in supine position. A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs nearly three hundred pounds. There was concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory. The patient was cannulated after the aorta and atrium were exposed and full heparinization.
The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.
The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner. The two proximal anastomoses were then carried out to the root of the aorta.
The patient came off cardiopulmonary bypass after aortic cross-clamp was released. The patient was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples.
PROCEDURES: Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.
ANESTHESIA: General endotracheal
INCISION: Median sternotomy
INDICATIONS: The patient presented with severe congestive heart failure associated with the patient's severe diabetes. The patient was found to have moderately stenotic aortic valve. In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system. It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.
FINDINGS: The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion. It is a tricuspid type of valve. The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.
The radial artery was used for the left anterior descending artery. Flow was excellent. Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches. On the angiogram these vessels appeared to be quite small. Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken. The patient was brought to the operating room
PROCEDURE: The patient was brought to the operating room and placed in supine position. A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs nearly three hundred pounds. There was concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory. The patient was cannulated after the aorta and atrium were exposed and full heparinization.
The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.
The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner. The two proximal anastomoses were then carried out to the root of the aorta.
The patient came off cardiopulmonary bypass after aortic cross-clamp was released. The patient was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortobifemoral Bypass
Description: Aortoiliac occlusive disease. Aortobifemoral bypass. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Aortoiliac occlusive disease.
POSTOPERATIVE DIAGNOSIS: Aortoiliac occlusive disease.
PROCEDURE PERFORMED: Aortobifemoral bypass.
OPERATIVE FINDINGS: The patient was taken to the operating room. The abdominal contents were within normal limits. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.
PROCEDURE: The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution. A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area. Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges. Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery. Mild adhesions were lysed. The omentum was freed. The small and large intestine were run with no evidence of abnormalities. The liver and gallbladder were within normal limits. No abnormalities were noted. At this point, the Bookwalter retractor was placed. NG tube was placed in the stomach and placed on suction. The intestines were gently packed intraabdominally and laterally. The rest of the peritoneum was then opened. The aorta was cleared, both proximally and distally. The left iliac was completely occluded. The right iliac was to be cleansed. At this point, 5000 units of aqueous heparin was administered to allow take effect. The aorta was then clamped below the renal arteries and opened in a longitudinal fashion. A single lumbar was ligated with #3-0 Prolene. The inferior mesenteric artery was occluded intraluminally and required no suture closure. Care was taken to preserve collaterals. The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion. Last stitch was tied. Hemostasis was excellent. The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis. At this point, strong pulses were present within the graft. The limbs were vented and irrigated. Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin. The grafts were then brought through these, care being taken to avoid twisting of the graft. At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed. Hemostasis was excellent. The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors. The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion. Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied. Flow was initially restored proximally then distally with good results. Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally. The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis. The last stitch was tied. Strong pulses were present within the artery and graft itself. At this point, 25 mg of protamine was administered. The wounds were irrigated with antibiotic solution. The groins were repacked. Attention was then returned to the abdomen. The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present. The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft. The intraabdominal contents were then allowed to resume their normal position. There was no evidence of ischemia to the large or small bowel. At this point, the omentum and stomach were repositioned. The abdominal wall was closed in a running single layer fashion using #1 PDS. The skin was closed with skin staples. The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips. The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well. Sponges and instrument counts were correct. Estimated blood loss 900 cc.
POSTOPERATIVE DIAGNOSIS: Aortoiliac occlusive disease.
PROCEDURE PERFORMED: Aortobifemoral bypass.
OPERATIVE FINDINGS: The patient was taken to the operating room. The abdominal contents were within normal limits. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.
PROCEDURE: The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution. A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area. Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges. Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery. Mild adhesions were lysed. The omentum was freed. The small and large intestine were run with no evidence of abnormalities. The liver and gallbladder were within normal limits. No abnormalities were noted. At this point, the Bookwalter retractor was placed. NG tube was placed in the stomach and placed on suction. The intestines were gently packed intraabdominally and laterally. The rest of the peritoneum was then opened. The aorta was cleared, both proximally and distally. The left iliac was completely occluded. The right iliac was to be cleansed. At this point, 5000 units of aqueous heparin was administered to allow take effect. The aorta was then clamped below the renal arteries and opened in a longitudinal fashion. A single lumbar was ligated with #3-0 Prolene. The inferior mesenteric artery was occluded intraluminally and required no suture closure. Care was taken to preserve collaterals. The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion. Last stitch was tied. Hemostasis was excellent. The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis. At this point, strong pulses were present within the graft. The limbs were vented and irrigated. Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin. The grafts were then brought through these, care being taken to avoid twisting of the graft. At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed. Hemostasis was excellent. The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors. The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion. Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied. Flow was initially restored proximally then distally with good results. Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally. The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis. The last stitch was tied. Strong pulses were present within the artery and graft itself. At this point, 25 mg of protamine was administered. The wounds were irrigated with antibiotic solution. The groins were repacked. Attention was then returned to the abdomen. The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present. The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft. The intraabdominal contents were then allowed to resume their normal position. There was no evidence of ischemia to the large or small bowel. At this point, the omentum and stomach were repositioned. The abdominal wall was closed in a running single layer fashion using #1 PDS. The skin was closed with skin staples. The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips. The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well. Sponges and instrument counts were correct. Estimated blood loss 900 cc.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortobifemoral Bypass - 1
Description: Dementia and aortoiliac occlusive disease bilaterally. Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS
1. Aortoiliac occlusive disease bilaterally.
2. Dementia.
POSTOPERATIVE DIAGNOSIS
1. Aortoiliac occlusive disease bilaterally.
2. Dementia.
OPERATION: Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: 300 cc
INTRAVENOUS FLUIDS: 1200 cc of crystalloid
URINE OUTPUT: 250 cc
OPERATION IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Note that previously the patient was found to have some baseline dementia, although slight. The patient was seen and evaluated by the neurology team, who cleared the patient for surgery. The patient was taken to the operating room and general endotracheal anesthesia was administered. The abdomen was prepped and draped in the standard surgical fashion. We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally. Dissection was carried down to the level of the femoral vessels using Bovie electrocautery. The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally. Vessel loops were placed around the aforementioned arteries. After doing so, we turned our attention to beginning our abdominal dissection. We used a #10-blade scalpel to make a midline laparotomy incision. Dissection was carried down to the level of the fascia using Bovie electrocautery. The abdomen was opened and an Omni retractor was positioned. The aorta was dissected out in the abdomen. The left femoral vein was identified. There was a nicely clampable portion of aorta visible. We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis. Full-dose heparin was given. Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels. A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors. We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion. Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis. We then created our tunnels over the iliac vessels. We pulled the distal limbs over our ABF graft into the groin. We then proceeded to perform our right anastomosis first. We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries. We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally. We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion. Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries. We then removed our clamp. We opened the limb more proximally in the abdomen on the right side. We then turned our attention to the left side and similarly placed our vascular clamps. We used a #11-blade scalpel to make an arteriotomy in the vessel. We then lengthened our arteriotomy both proximally and distally again onto the SFA. We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion. Upon completion of our anastomosis, we opened our clamps. There was no noticeable leak from the newly constructed anastomosis. We checked our proximal graft to aortic anastomosis, which was noted to be in good condition. We then gave full-dose protamine. We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion. The abdomen was closed with #1 nylon in a running fashion. The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion. The instrument and sponge count was correct at end of case. Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
1. Aortoiliac occlusive disease bilaterally.
2. Dementia.
POSTOPERATIVE DIAGNOSIS
1. Aortoiliac occlusive disease bilaterally.
2. Dementia.
OPERATION: Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: 300 cc
INTRAVENOUS FLUIDS: 1200 cc of crystalloid
URINE OUTPUT: 250 cc
OPERATION IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Note that previously the patient was found to have some baseline dementia, although slight. The patient was seen and evaluated by the neurology team, who cleared the patient for surgery. The patient was taken to the operating room and general endotracheal anesthesia was administered. The abdomen was prepped and draped in the standard surgical fashion. We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally. Dissection was carried down to the level of the femoral vessels using Bovie electrocautery. The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally. Vessel loops were placed around the aforementioned arteries. After doing so, we turned our attention to beginning our abdominal dissection. We used a #10-blade scalpel to make a midline laparotomy incision. Dissection was carried down to the level of the fascia using Bovie electrocautery. The abdomen was opened and an Omni retractor was positioned. The aorta was dissected out in the abdomen. The left femoral vein was identified. There was a nicely clampable portion of aorta visible. We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis. Full-dose heparin was given. Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels. A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors. We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion. Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis. We then created our tunnels over the iliac vessels. We pulled the distal limbs over our ABF graft into the groin. We then proceeded to perform our right anastomosis first. We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries. We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally. We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion. Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries. We then removed our clamp. We opened the limb more proximally in the abdomen on the right side. We then turned our attention to the left side and similarly placed our vascular clamps. We used a #11-blade scalpel to make an arteriotomy in the vessel. We then lengthened our arteriotomy both proximally and distally again onto the SFA. We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion. Upon completion of our anastomosis, we opened our clamps. There was no noticeable leak from the newly constructed anastomosis. We checked our proximal graft to aortic anastomosis, which was noted to be in good condition. We then gave full-dose protamine. We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion. The abdomen was closed with #1 nylon in a running fashion. The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion. The instrument and sponge count was correct at end of case. Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortogram - Leg claudication.
Description: Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREPROCEDURE DIAGNOSIS: Left leg claudication.
POSTPROCEDURE DIAGNOSIS: Left leg claudication.
OPERATION PERFORMED: Aortogram with bilateral, segmental lower extremity run off.
ANESTHESIA: Conscious sedation.
INDICATION FOR PROCEDURE: The patient presents with lower extremity claudication. She is a 68-year-old woman, who is very fearful of the aforementioned procedures. Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence. She appears to understand and agrees to proceed.
DESCRIPTION OF PROCEDURE: The patient was taken to the Angio Suite, placed in a supine position. After adequate conscious sedation, both groins were prepped with Chloraseptic prep. Cloth towels and paper drapes were placed. Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed. Guidewire was threaded followed by a
4-French sheath. Through the 4-French sheath a 4-French Omni flush catheter was placed. The glidewire was removed and contrast administered to identify the level of the renal artery. Using power injector an aortogram proceeded.
The catheter was then pulled down to the aortic bifurcation. A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach. The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery. The Omni flush catheter was advanced to the left distal external iliac artery. The glidewire rather exchanged for an Amplatz stiff wire. This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath. This was advanced into the proximal superficial femoral artery and an angiogram performed. I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.
The patient was given 5000 units of heparin and this was allowed to circulate. A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels. A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.
Final views after dilatation revealed a dissection. A search for a 5-mm stent was performed, but none of this was available. For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery. Post dilatation was performed with a 4-mm angioplasty balloon. Further views of the left lower extremity showed irregular change in the popliteal artery. No significant stenosis could be identified in the left popliteal artery and noninvasive scan. For this reason, I chose not to treat any further areas in the left leg.
I then performed closure of the right femoral artery with a 6-French Angio-Seal device. Attention was turned to the left femoral artery and local anesthesia administered. Access was obtained with the ultrasound and the femoral artery identified. Guidewire was threaded followed by a 4-French sheath. This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery. The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath. The destination was placed in the proximal superficial femoral artery and angiogram obtained. Initial views had been obtained from the right femoral sheath before removal.
Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery. For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon. A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation. No further significant abnormality was identified. To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery. A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis. Reasonable use were obtained and possibly a 4-mm balloon could have been used. However, due to her propensity for dissection I opted not to. I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length. This was placed into the left posterior tibial artery. A 2-mm balloon was used to dilate the orifice of the posterior tibial artery. I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel. Final images showed improved run-off to the right calf. The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.
FINDINGS: Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma. No evidence of renal artery stenosis is noted bilaterally. There is a single left renal artery. The infrarenal aorta, both common iliac and the external iliac arteries are normal. On the right, a superficial femoral artery is widely patent and normal proximally. At the distal third of the thigh there is diffuse disease with moderate stenosis noted. Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted. The perineal artery is functionally occluded at the midcalf. The dorsal pedal artery filled by collateral at the high ankle level.
On the left, the proximal superficial femoral artery is patent. Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery. This was successfully treated with angioplasty and a stent placement. The popliteal artery is diffusely diseased without focal stenosis. The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.
IMPRESSION
1. Normal bilateral renal arteries with a small accessory right renal artery.
2. Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.
3. The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries. Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.
4. Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement. Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.
POSTPROCEDURE DIAGNOSIS: Left leg claudication.
OPERATION PERFORMED: Aortogram with bilateral, segmental lower extremity run off.
ANESTHESIA: Conscious sedation.
INDICATION FOR PROCEDURE: The patient presents with lower extremity claudication. She is a 68-year-old woman, who is very fearful of the aforementioned procedures. Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence. She appears to understand and agrees to proceed.
DESCRIPTION OF PROCEDURE: The patient was taken to the Angio Suite, placed in a supine position. After adequate conscious sedation, both groins were prepped with Chloraseptic prep. Cloth towels and paper drapes were placed. Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed. Guidewire was threaded followed by a
4-French sheath. Through the 4-French sheath a 4-French Omni flush catheter was placed. The glidewire was removed and contrast administered to identify the level of the renal artery. Using power injector an aortogram proceeded.
The catheter was then pulled down to the aortic bifurcation. A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach. The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery. The Omni flush catheter was advanced to the left distal external iliac artery. The glidewire rather exchanged for an Amplatz stiff wire. This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath. This was advanced into the proximal superficial femoral artery and an angiogram performed. I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.
The patient was given 5000 units of heparin and this was allowed to circulate. A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels. A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.
Final views after dilatation revealed a dissection. A search for a 5-mm stent was performed, but none of this was available. For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery. Post dilatation was performed with a 4-mm angioplasty balloon. Further views of the left lower extremity showed irregular change in the popliteal artery. No significant stenosis could be identified in the left popliteal artery and noninvasive scan. For this reason, I chose not to treat any further areas in the left leg.
I then performed closure of the right femoral artery with a 6-French Angio-Seal device. Attention was turned to the left femoral artery and local anesthesia administered. Access was obtained with the ultrasound and the femoral artery identified. Guidewire was threaded followed by a 4-French sheath. This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery. The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath. The destination was placed in the proximal superficial femoral artery and angiogram obtained. Initial views had been obtained from the right femoral sheath before removal.
Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery. For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon. A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation. No further significant abnormality was identified. To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery. A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis. Reasonable use were obtained and possibly a 4-mm balloon could have been used. However, due to her propensity for dissection I opted not to. I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length. This was placed into the left posterior tibial artery. A 2-mm balloon was used to dilate the orifice of the posterior tibial artery. I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel. Final images showed improved run-off to the right calf. The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.
FINDINGS: Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma. No evidence of renal artery stenosis is noted bilaterally. There is a single left renal artery. The infrarenal aorta, both common iliac and the external iliac arteries are normal. On the right, a superficial femoral artery is widely patent and normal proximally. At the distal third of the thigh there is diffuse disease with moderate stenosis noted. Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted. The perineal artery is functionally occluded at the midcalf. The dorsal pedal artery filled by collateral at the high ankle level.
On the left, the proximal superficial femoral artery is patent. Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery. This was successfully treated with angioplasty and a stent placement. The popliteal artery is diffusely diseased without focal stenosis. The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.
IMPRESSION
1. Normal bilateral renal arteries with a small accessory right renal artery.
2. Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.
3. The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries. Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.
4. Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement. Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Arterial Imaging
Description: Arterial imaging of bilateral lower extremities.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INDICATIONS: Peripheral vascular disease with claudication.
RIGHT:
1. Normal arterial imaging of right lower extremity.
2. Peak systolic velocity is normal.
3. Arterial waveform is triphasic.
4. Ankle brachial index is 0.96.
LEFT:
1. Normal arterial imaging of left lower extremity.
2. Peak systolic velocity is normal.
3. Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.
4. Ankle brachial index is 1.06.
IMPRESSION:
Normal arterial imaging of both lower extremities.
RIGHT:
1. Normal arterial imaging of right lower extremity.
2. Peak systolic velocity is normal.
3. Arterial waveform is triphasic.
4. Ankle brachial index is 0.96.
LEFT:
1. Normal arterial imaging of left lower extremity.
2. Peak systolic velocity is normal.
3. Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.
4. Ankle brachial index is 1.06.
IMPRESSION:
Normal arterial imaging of both lower extremities.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Atrioventricular Septal Defect
Description: The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
HISTORY: The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries. He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital. This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve. A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve. The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung. The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.
PROCEDURE: After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case. The patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures
Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries. This catheter was exchanged over wire. A 5-French marker pigtail catheter was directed into the main pulmonary artery. A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.
Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle. Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents. The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm. The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter. The left femoral venous sheath was exchanged over wire for a 7-French sheath. Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist. The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram. The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.
Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.
Cineangiograms were obtained with angiograph injection in the main pulmonary artery.
After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.
DISCUSSION: Oxygen consumption was assumed to be in normal. Mixed venous saturation that was not normal with no evidence of intracardiac shunt. Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg. Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery. There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery. Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg. Left ventricular systolic pressure was systemic. No outflow constriction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification. The proximal narrowing of the distal main pulmonary artery was appreciated. Neointimal ingrowth within the proximal stents were appreciated. There is good distal growth of the pulmonary arteries. Arborization appeared normal. Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch. Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation. Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%. The main pulmonary pressures remained similar. There was 10 mmHg systolic gradient into the branch of pulmonary arteries. There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg. Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve. A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens. There was no evidence of intimal disruption.
DIAGNOSES:
1. Atrioventricular septal defect.
2. Tetralogy of Fallot with the pulmonary atresia.
3. Bilateral superior vena cava. The left cava draining to the coronary sinus.
4. The right aortic arch.
5. Discontinuous pulmonary arteries.
6. Down syndrome.
PRIOR SURGERIES AND INTERVENTIONS:
1. Right modified Blalock-Taussig shunt.
2. Repair of tetralogy of Fallot with external conduit.
3. The atrioventricular septal defect repair.
4. Unifocalization of branch pulmonary arteries.
5. Bilateral balloon pulmonary angioplasty and stent implantation.
6. Pulmonary valve replacement with 16-mm Contegra valve.
CURRENT DIAGNOSES:
1. Mild-to-moderate proximal branch pulmonary stenosis.
2. Well-functioning Contegra valve and current intervention. A balloon dilation of the right pulmonary artery.
3. Balloon dilation of left pulmonary artery.
MANAGEMENT: The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued. Further cardiologic care be directed by Dr. X.
PROCEDURE: After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case. The patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures
Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries. This catheter was exchanged over wire. A 5-French marker pigtail catheter was directed into the main pulmonary artery. A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.
Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle. Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents. The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm. The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter. The left femoral venous sheath was exchanged over wire for a 7-French sheath. Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist. The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram. The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.
Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.
Cineangiograms were obtained with angiograph injection in the main pulmonary artery.
After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.
DISCUSSION: Oxygen consumption was assumed to be in normal. Mixed venous saturation that was not normal with no evidence of intracardiac shunt. Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg. Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery. There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery. Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg. Left ventricular systolic pressure was systemic. No outflow constriction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification. The proximal narrowing of the distal main pulmonary artery was appreciated. Neointimal ingrowth within the proximal stents were appreciated. There is good distal growth of the pulmonary arteries. Arborization appeared normal. Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch. Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation. Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%. The main pulmonary pressures remained similar. There was 10 mmHg systolic gradient into the branch of pulmonary arteries. There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg. Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve. A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens. There was no evidence of intimal disruption.
DIAGNOSES:
1. Atrioventricular septal defect.
2. Tetralogy of Fallot with the pulmonary atresia.
3. Bilateral superior vena cava. The left cava draining to the coronary sinus.
4. The right aortic arch.
5. Discontinuous pulmonary arteries.
6. Down syndrome.
PRIOR SURGERIES AND INTERVENTIONS:
1. Right modified Blalock-Taussig shunt.
2. Repair of tetralogy of Fallot with external conduit.
3. The atrioventricular septal defect repair.
4. Unifocalization of branch pulmonary arteries.
5. Bilateral balloon pulmonary angioplasty and stent implantation.
6. Pulmonary valve replacement with 16-mm Contegra valve.
CURRENT DIAGNOSES:
1. Mild-to-moderate proximal branch pulmonary stenosis.
2. Well-functioning Contegra valve and current intervention. A balloon dilation of the right pulmonary artery.
3. Balloon dilation of left pulmonary artery.
MANAGEMENT: The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued. Further cardiologic care be directed by Dr. X.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bilateral Carotid Angiography
Description: Carotid artery angiograms.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURE PERFORMED:
1. Selective ascending aortic arch angiogram.
2. Selective left common carotid artery angiogram.
3. Selective right common carotid artery angiogram.
4. Selective left subclavian artery angiogram.
5. Right iliac angio with runoff.
6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.
INDICATIONS FOR PROCEDURE: TIA, aortic stenosis, postoperative procedure. Moderate carotid artery stenosis.
ESTIMATED BLOOD LOSS: 400 ml.
SPECIMENS REMOVED: Not applicable.
TECHNIQUE OF PROCEDURE: After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.
ANGIOGRAPHIC FINDINGS:
1. Type 2 aortic arch.
2. Left subclavian artery was patent.
3 Left vertebral artery was patent.
4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.
5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.
6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.
PLAN: Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.
1. Selective ascending aortic arch angiogram.
2. Selective left common carotid artery angiogram.
3. Selective right common carotid artery angiogram.
4. Selective left subclavian artery angiogram.
5. Right iliac angio with runoff.
6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.
INDICATIONS FOR PROCEDURE: TIA, aortic stenosis, postoperative procedure. Moderate carotid artery stenosis.
ESTIMATED BLOOD LOSS: 400 ml.
SPECIMENS REMOVED: Not applicable.
TECHNIQUE OF PROCEDURE: After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.
ANGIOGRAPHIC FINDINGS:
1. Type 2 aortic arch.
2. Left subclavian artery was patent.
3 Left vertebral artery was patent.
4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.
5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.
6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.
PLAN: Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bilateral Carotid Cerebral Angiogram
Description: Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Carotid artery occlusive disease.
2. Peripheral vascular disease.
POSTOPERATIVE DIAGNOSES:
1. Carotid artery occlusive disease.
2. Peripheral vascular disease.
OPERATIONS PERFORMED:
1. Bilateral carotid cerebral angiogram.
2. Right femoral-popliteal angiogram.
FINDINGS: The right carotid cerebral system was selectively catheterized and visualized. The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted. Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.
The left carotid cerebral system was selectively catheterized and visualized. The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present. The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.
Visualization of the right lower extremity showed no significant disease.
PROCEDURE: With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.
The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance. A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.
Following completion of the above, the catheter and introducer sheath were removed. Heparin had been initially given, which was reversed with protamine. Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.
The patient tolerated the procedure well throughout.
1. Carotid artery occlusive disease.
2. Peripheral vascular disease.
POSTOPERATIVE DIAGNOSES:
1. Carotid artery occlusive disease.
2. Peripheral vascular disease.
OPERATIONS PERFORMED:
1. Bilateral carotid cerebral angiogram.
2. Right femoral-popliteal angiogram.
FINDINGS: The right carotid cerebral system was selectively catheterized and visualized. The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted. Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.
The left carotid cerebral system was selectively catheterized and visualized. The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present. The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.
Visualization of the right lower extremity showed no significant disease.
PROCEDURE: With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.
The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance. A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.
Following completion of the above, the catheter and introducer sheath were removed. Heparin had been initially given, which was reversed with protamine. Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.
The patient tolerated the procedure well throughout.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Biventricular Cardioverter Defibrillator Implantation
Description: Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES
1. Dilated cardiomyopathy.
2. Ejection fraction less than 10%.
3. Ventricular tachycardia.
4. Bradycardia with likely high degree of pacing.
PROCEDURES PLANNED AND PERFORMED
1. Implantation of biventricular automatic implantable cardioverter defibrillator.
2. Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.
3. Coronary sinus venogram for left ventricular lead placement.
4. Defibrillation threshold testing x2.
FLUOROSCOPY TIME: 18.5 minutes.
MEDICATIONS AT THE TIME OF STUDY
1. Vancomycin 1 g (the patient was allergic to penicillin).
2. Versed 10 mg.
3. Fentanyl 100 mcg.
4. Benadryl 50 mg.
CLINICAL HISTORY: The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia. He has underlying sinus bradycardia. Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.
RISKS AND BENEFITS: Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.
DESCRIPTION OF PROCEDURE: The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks. Guidewires were advanced down into the left axillary vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein. The dilator was removed and another wire was advanced down into the sheath. The sheath was then backed up over the top of the two wires. One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein. The dilator and wire were removed. A defibrillation lead was then advanced down into the atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical septal location. The active fix screw was deployed. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation. The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein. The wire and dilator were removed. An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed. The lead was parked until a later time. Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein. The dilator and wire were removed. A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus. The coronary sinus was cannulated. Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus. A coronary sinus venogram was then performed. It was noted that the most suitable location for lead placement was the middle cardiac vein. This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily. There was no diaphragmatic stimulation. The outer sheath was peeled away. The 9 French sheath was then peeled away. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet. The lead body was turned several times and the lead was affixed to the tissue. Adequate pacing and sensing function were established. A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.
The patient was sedated further and shock on T was performed on two separate occasions. The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.
DEVICE DATA
1. Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.
2. Right atrial lead, manufacturer Guidant, model #4470, serial #12345.
3. Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.
4. Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.
MEASURED INTRAOPERATIVE DATA
1. Right atrial lead impedance 705 ohms. P-waves measured at 1.7 millivolts. Pacing threshold 0.5 volt at 0.4 milliseconds.
2. Right ventricular lead impedance 685 ohms. R-waves measured 10.5 millivolts. Pacing threshold 0.6 volt at 0.4 milliseconds.
3. Left ventricular lead impedance 1098 ohms. R-waves measured 5.2 millivolts. Pacing threshold 1.4 volts at 0.4 milliseconds.
DEFIBRILLATION THRESHOLD TESTING
1. Shock on T. Charge time 2.9 seconds. Energy delivered 17 joules, successful with lead impedance of 39 ohms.
2. Shock on T. Charge time 2.8 seconds. Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.
DEVICE SETTINGS
1. A pacing DDD 60 to 120.
2. VT-1 zone 165 beats per minute. VT-2 zone 185 beats per minute. VF zone 205 beats per minute.
CONCLUSIONS
1. Successful implantation of a biventricular automatic implantable cardiovascular defibrillator
2. Defibrillation threshold of less than or equal to 17.5 joules.
2. No acute complications.
PLAN
1. The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.
2. Chest x-ray to rule out pneumothorax and verified lead position.
3. Device interrogation in the morning.
4. Completion of the course of antibiotics.
5. Home dismissal instructions provided in written format.
6. Wound check in 7 to 10 days.
7. Enrollment in device clinic.
1. Dilated cardiomyopathy.
2. Ejection fraction less than 10%.
3. Ventricular tachycardia.
4. Bradycardia with likely high degree of pacing.
PROCEDURES PLANNED AND PERFORMED
1. Implantation of biventricular automatic implantable cardioverter defibrillator.
2. Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.
3. Coronary sinus venogram for left ventricular lead placement.
4. Defibrillation threshold testing x2.
FLUOROSCOPY TIME: 18.5 minutes.
MEDICATIONS AT THE TIME OF STUDY
1. Vancomycin 1 g (the patient was allergic to penicillin).
2. Versed 10 mg.
3. Fentanyl 100 mcg.
4. Benadryl 50 mg.
CLINICAL HISTORY: The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia. He has underlying sinus bradycardia. Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.
RISKS AND BENEFITS: Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.
DESCRIPTION OF PROCEDURE: The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks. Guidewires were advanced down into the left axillary vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein. The dilator was removed and another wire was advanced down into the sheath. The sheath was then backed up over the top of the two wires. One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein. The dilator and wire were removed. A defibrillation lead was then advanced down into the atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical septal location. The active fix screw was deployed. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation. The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein. The wire and dilator were removed. An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed. The lead was parked until a later time. Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein. The dilator and wire were removed. A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus. The coronary sinus was cannulated. Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus. A coronary sinus venogram was then performed. It was noted that the most suitable location for lead placement was the middle cardiac vein. This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily. There was no diaphragmatic stimulation. The outer sheath was peeled away. The 9 French sheath was then peeled away. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet. The lead body was turned several times and the lead was affixed to the tissue. Adequate pacing and sensing function were established. A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.
The patient was sedated further and shock on T was performed on two separate occasions. The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.
DEVICE DATA
1. Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.
2. Right atrial lead, manufacturer Guidant, model #4470, serial #12345.
3. Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.
4. Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.
MEASURED INTRAOPERATIVE DATA
1. Right atrial lead impedance 705 ohms. P-waves measured at 1.7 millivolts. Pacing threshold 0.5 volt at 0.4 milliseconds.
2. Right ventricular lead impedance 685 ohms. R-waves measured 10.5 millivolts. Pacing threshold 0.6 volt at 0.4 milliseconds.
3. Left ventricular lead impedance 1098 ohms. R-waves measured 5.2 millivolts. Pacing threshold 1.4 volts at 0.4 milliseconds.
DEFIBRILLATION THRESHOLD TESTING
1. Shock on T. Charge time 2.9 seconds. Energy delivered 17 joules, successful with lead impedance of 39 ohms.
2. Shock on T. Charge time 2.8 seconds. Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.
DEVICE SETTINGS
1. A pacing DDD 60 to 120.
2. VT-1 zone 165 beats per minute. VT-2 zone 185 beats per minute. VF zone 205 beats per minute.
CONCLUSIONS
1. Successful implantation of a biventricular automatic implantable cardiovascular defibrillator
2. Defibrillation threshold of less than or equal to 17.5 joules.
2. No acute complications.
PLAN
1. The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.
2. Chest x-ray to rule out pneumothorax and verified lead position.
3. Device interrogation in the morning.
4. Completion of the course of antibiotics.
5. Home dismissal instructions provided in written format.
6. Wound check in 7 to 10 days.
7. Enrollment in device clinic.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 97.7 and pulse is 181, but the patient is fussy. Respiratory rate ranged between 36 and 44. The patient is saturating 100% on one-half liter and 89% on room air.
GENERAL APPEARANCE: Nontoxic child, but with increased work of breathing. No respiratory distress.
HEENT: Head is normocephalic and atraumatic. Anterior fontanelle flat. Pupils are equal, round, and reactive to light bilaterally. Tympanic membranes are clear bilaterally. Nares are congested. Mucous membranes are moist without erythema.
NECK: Supple. No lymphadenopathy.
CHEST: Exhibits symmetric expansion and retractions.
LUNGS: The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.
CARDIOVASCULAR: Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.
ABDOMEN: Soft, nondistended, and nondistended. Good bowel sounds noted in all 4 quadrants.
GU: Normal female. No discharge or erythema.
BACK: Normal with a normal curvature.
EXTREMITIES: A 2+ pulses in the bilateral upper lower extremities. No evidence of clubbing, cyanosis, or edema. Capillary refill less than 3 seconds.
VITAL SIGNS: Temperature is 97.7 and pulse is 181, but the patient is fussy. Respiratory rate ranged between 36 and 44. The patient is saturating 100% on one-half liter and 89% on room air.
GENERAL APPEARANCE: Nontoxic child, but with increased work of breathing. No respiratory distress.
HEENT: Head is normocephalic and atraumatic. Anterior fontanelle flat. Pupils are equal, round, and reactive to light bilaterally. Tympanic membranes are clear bilaterally. Nares are congested. Mucous membranes are moist without erythema.
NECK: Supple. No lymphadenopathy.
CHEST: Exhibits symmetric expansion and retractions.
LUNGS: The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.
CARDIOVASCULAR: Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.
ABDOMEN: Soft, nondistended, and nondistended. Good bowel sounds noted in all 4 quadrants.
GU: Normal female. No discharge or erythema.
BACK: Normal with a normal curvature.
EXTREMITIES: A 2+ pulses in the bilateral upper lower extremities. No evidence of clubbing, cyanosis, or edema. Capillary refill less than 3 seconds.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchiolitis - Discharge Summary
Description: Bronchiolitis, respiratory syncytial virus positive; improved and stable. Innocent heart murmur, stable.
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DIAGNOSES:
1. Bronchiolitis, respiratory syncytial virus positive; improved and stable.
2. Innocent heart murmur, stable.
HOSPITAL COURSE: The patient was admitted for an acute onset of congestion. She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis. She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness. She was treated per pathway orders. However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission. There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained. We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe. However, the rest of the lungs were normal and the heart was also normal. There were no complications during her hospitalization and she continued to be stable and eating better. On day 2 of the admission, it was decided she was okay to go home. Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this. During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care. The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.
DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS: She is afebrile. Vital signs were stable within normal limits on room air.
GENERAL: She is sleeping and in no acute distress.
HEENT: Her anterior fontanelle was soft and flat. She does have some upper airway congestion.
CARDIOVASCULAR: Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.
EXTREMITIES: Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.
LUNGS: Her lungs did show some slight coarseness, but good air movement with equal breath sounds. She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases. She did not have any respiratory distress while she was asleep.
ABDOMEN: Normal bowel sounds. Soft and nondistended.
GENITOURINARY: She is Tanner I female.
DISCHARGE WEIGHT: Her weight at discharge 3.346 kg, which is up 6 grams from admission.
DISCHARGE INSTRUCTIONS:
ACTIVITY: No one should smoke near The patient. She should also avoid all other exposures to smoke such as from fireplaces and barbecues. She is to avoid contact with other infants since she is sick and they are to limit travel. There should be frequent hand washings.
DIET: Regular diet. Continue breast-feeding as much as possible and encourage oral intake.
MEDICATIONS: She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.
ADDITIONAL INSTRUCTIONS: Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.
1. Bronchiolitis, respiratory syncytial virus positive; improved and stable.
2. Innocent heart murmur, stable.
HOSPITAL COURSE: The patient was admitted for an acute onset of congestion. She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis. She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness. She was treated per pathway orders. However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission. There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained. We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe. However, the rest of the lungs were normal and the heart was also normal. There were no complications during her hospitalization and she continued to be stable and eating better. On day 2 of the admission, it was decided she was okay to go home. Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this. During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care. The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.
DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS: She is afebrile. Vital signs were stable within normal limits on room air.
GENERAL: She is sleeping and in no acute distress.
HEENT: Her anterior fontanelle was soft and flat. She does have some upper airway congestion.
CARDIOVASCULAR: Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.
EXTREMITIES: Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.
LUNGS: Her lungs did show some slight coarseness, but good air movement with equal breath sounds. She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases. She did not have any respiratory distress while she was asleep.
ABDOMEN: Normal bowel sounds. Soft and nondistended.
GENITOURINARY: She is Tanner I female.
DISCHARGE WEIGHT: Her weight at discharge 3.346 kg, which is up 6 grams from admission.
DISCHARGE INSTRUCTIONS:
ACTIVITY: No one should smoke near The patient. She should also avoid all other exposures to smoke such as from fireplaces and barbecues. She is to avoid contact with other infants since she is sick and they are to limit travel. There should be frequent hand washings.
DIET: Regular diet. Continue breast-feeding as much as possible and encourage oral intake.
MEDICATIONS: She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.
ADDITIONAL INSTRUCTIONS: Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoalveolar lavage.
Description: Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.
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PREOPERATIVE DIAGNOSIS: Fever.
POSTOPERATIVE DIAGNOSIS: Fever.
PROCEDURES: Bronchoalveolar lavage.
INDICATIONS FOR PROCEDURE: The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008. Greater than 24 hours postoperative, the patient began to run a fever in excess of 102. Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.
DESCRIPTION OF PROCEDURE: The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure. The correct patient and procedure was identified by time out by all members of the team. The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction. A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap. A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology. The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia. A postoperative chest x-ray was obtained.
POSTOPERATIVE DIAGNOSIS: Fever.
PROCEDURES: Bronchoalveolar lavage.
INDICATIONS FOR PROCEDURE: The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008. Greater than 24 hours postoperative, the patient began to run a fever in excess of 102. Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.
DESCRIPTION OF PROCEDURE: The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure. The correct patient and procedure was identified by time out by all members of the team. The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction. A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap. A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology. The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia. A postoperative chest x-ray was obtained.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 1
Description: Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.
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INDICATIONS FOR PROCEDURE: A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tuesday morning. She was treated with Plavix, Lovenox, etc., and transferred for coronary angiography and possible PCI. The plan was discussed with the patient and all questions answered.
PROCEDURE NOTE: Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.
Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.
ANGIOGRAPHIC FINDINGS:
I. Left coronary artery: The left main coronary artery is
normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.
II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior
descending and posterior lateral branches. TIMI 3 flow is present.
III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).
DISCUSSION: Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.
PLAN: Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.
PROCEDURE NOTE: Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.
Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.
ANGIOGRAPHIC FINDINGS:
I. Left coronary artery: The left main coronary artery is
normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.
II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior
descending and posterior lateral branches. TIMI 3 flow is present.
III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).
DISCUSSION: Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.
PLAN: Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 10
Description: Left Heart Catheterization. Chest pain, coronary artery disease, prior bypass surgery. Left coronary artery disease native. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. Native right coronary artery is patent, mild disease.
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EXAM: Left Heart Catheterization
REASON FOR EXAM: Chest pain, coronary artery disease, prior bypass surgery.
INTERPRETATION: The procedure and complications were explained to the patient in detail and formal consent was obtained. The patient was brought to the cath lab. The right groin was draped in the usual sterile manner. Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery. A JL4 catheter was used to cannulate the left coronary arteries. A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts. The same catheter was used to cannulate the vein graft and also LIMA. I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful. A 6-French pigtail catheter was used to perform left ventriculography and pullback was done. No gradient was noted. Arterial sheath was removed. Hemostasis was obtained with manual compression. The patient tolerated the procedure very well without any complications.
FINDINGS:
1. Native coronary arteries. The left main is patent. The left anterior descending artery is not clearly visualized. The circumflex artery appears to be patent. The proximal segment gives rise to small caliber obtuse marginal vessel.
2. Right coronary artery is patent with mild distal and mid segment. No evidence of focal stenosis or dominant system.
3. Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site. There appears to be possible _______ graft to the diagonal 1 vessel. The distal LAD wraps around the apex. No stenosis following the anastomotic site noted.
4. Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.
5. No other bypass grafts are noted by left ventriculography and also aortic root shot.
6. Left ventriculography with an ejection fraction of 60%.
IMPRESSION:
1. Left coronary artery disease native.
2. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. _______ graft to the diagonal 1 vessel.
3. Native right coronary artery is patent, mild disease.
RECOMMENDATIONS: Medical treatment.
REASON FOR EXAM: Chest pain, coronary artery disease, prior bypass surgery.
INTERPRETATION: The procedure and complications were explained to the patient in detail and formal consent was obtained. The patient was brought to the cath lab. The right groin was draped in the usual sterile manner. Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery. A JL4 catheter was used to cannulate the left coronary arteries. A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts. The same catheter was used to cannulate the vein graft and also LIMA. I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful. A 6-French pigtail catheter was used to perform left ventriculography and pullback was done. No gradient was noted. Arterial sheath was removed. Hemostasis was obtained with manual compression. The patient tolerated the procedure very well without any complications.
FINDINGS:
1. Native coronary arteries. The left main is patent. The left anterior descending artery is not clearly visualized. The circumflex artery appears to be patent. The proximal segment gives rise to small caliber obtuse marginal vessel.
2. Right coronary artery is patent with mild distal and mid segment. No evidence of focal stenosis or dominant system.
3. Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site. There appears to be possible _______ graft to the diagonal 1 vessel. The distal LAD wraps around the apex. No stenosis following the anastomotic site noted.
4. Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.
5. No other bypass grafts are noted by left ventriculography and also aortic root shot.
6. Left ventriculography with an ejection fraction of 60%.
IMPRESSION:
1. Left coronary artery disease native.
2. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. _______ graft to the diagonal 1 vessel.
3. Native right coronary artery is patent, mild disease.
RECOMMENDATIONS: Medical treatment.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 11
Description: Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization.
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A 60-year-old gentleman with markedly abnormal stress test in my office today who is admitted with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization. I discussed the procedure in detail with the patient and his wife as well as perform a risk/benefit/alternative analysis with benefits being more definitive exclusion of significant obstructive coronary artery disease and evaluation of such to help guide further treatment, alternatives being alternative stress imaging or empiric medical therapy which I was not recommending nor was the patient interested in and risks including but not limited to and the patient and his wife were aware that this was not an all inclusive list of over-sedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of excessive fluoroscopic exposure causing skin necrosis, risk of dye reaction as well as due to the inherent invasive nature of cardiac catheterization at least 1 in 1,000 risk of stroke, heart attack, heart failure, death, kidney failure, peripheral vascular disease, femoral arteriotomy access site complications including bleeding, need for surgical intervention of the femoral arteriotomy access site, aneurysmal formation, pseudoaneurysmal formation, and/or need for blood transfusions. The patient expressed understanding of this risk/benefit/alternative analysis and stated in a clear competent and coherent fashion that he wished to go forward with the cardiac catheterization which I felt was appropriate.
The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.
PROCEDURE NOTE: The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed. Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff. He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect. Bilateral groins had been prepped and draped in the usual fashion. Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle. All catheters were passed using a J-tipped guide-wire. Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter. Left system coronary angiography performed using a 6-French JL4 catheter. Right system coronary angiography performed using a 6-French CDRC catheter. Following the procedure, all catheters were removed. Manual pressure was held with the Neptune pad and the patient was discharged back to his room. I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses. There were no apparent complications. A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.
FINDINGS:
HEMODYNAMICS: LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.
LV function is normal, EF 60%, no wall motion abnormalities.
CORONARY ANATOMY:
1. Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.
2. The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.
3. The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.
4. The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity. There is a moderate distal PDA lesion of 60% seen.
IMPRESSION:
1. Mild to moderate left main stenosis.
2. Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.
We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin. We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.
The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.
PROCEDURE NOTE: The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed. Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff. He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect. Bilateral groins had been prepped and draped in the usual fashion. Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle. All catheters were passed using a J-tipped guide-wire. Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter. Left system coronary angiography performed using a 6-French JL4 catheter. Right system coronary angiography performed using a 6-French CDRC catheter. Following the procedure, all catheters were removed. Manual pressure was held with the Neptune pad and the patient was discharged back to his room. I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses. There were no apparent complications. A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.
FINDINGS:
HEMODYNAMICS: LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.
LV function is normal, EF 60%, no wall motion abnormalities.
CORONARY ANATOMY:
1. Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.
2. The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.
3. The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.
4. The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity. There is a moderate distal PDA lesion of 60% seen.
IMPRESSION:
1. Mild to moderate left main stenosis.
2. Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.
We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin. We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 12
Description: Cardiac catheterization. Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.
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PREOPERATIVE DIAGNOSIS: Coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.
DESCRIPTION OF PROCEDURE:
LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:
Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done. Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed. Coronary arteriography was performed with 6-French performed coronary catheters. We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries. After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery. A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.
ANALYSIS OF PRESSURE DATA: Left ventricular end-diastolic pressure was 5 mmHg. On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve. The aortic pressures were normal. Contours of intracardiac pressure were normal.
ANALYSIS OF ANGIOGRAMS: Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta. A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position. The mitral valve is competent and demonstrates normal mobility. The left ventricular cavity is normal in size with excellent contractility. Aneurysmal dilatation and/or dyskinesia absent. The aortic valve is tricuspid and normal mobility. The ascending aorta appeared normal.
Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries. An abdominal aortic injection was performed. Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation. There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis. The abdominal aortogram reveals wide patency of that area with mild intimal irregularity. There is a normal left renal artery, normal right renal artery. The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal. The common left iliac and common right iliac arteries are essentially normal in this area.
CORONARY ANATOMY: One notes ostial coronary calcification of the right coronary artery. Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters. Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually. The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%. There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery. In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third. Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel. The distal portion of the vessel is free of disease. The conus branch is seen arising right at the beginning part of the right coronary artery. We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%. At the ostium of the right coronary artery, calcification again is identified. Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.
The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis. It forms the left anterior descending artery, the ramus branch, and the circumflex artery.
The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment. There appears to be some mild stenosis of 10% in the proximal segment. It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease. The remaining portion of the left anterior descending artery is free of disease. Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed. I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.
The ramus branch is normal and free of disease.
The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.
The patient has a predominantly right coronary system. There is no _______ circulation connecting the right and left coronary systems.
The patient tolerated the procedure well. The catheter was removed. Hemostasis was achieved. The patient was transferred to the recovery room in a stable condition.
IMPRESSION:
1. Excellent left ventricular contractility with normal left ventricular cavity size.
2. Calcification of the mid abdominal aorta with wide patency of all vessels. The left and right renal arteries are normal. The external iliac arteries are normal.
3. Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.
4. Ostial stenosis of the right coronary artery that appears to be about 50% or greater. The proximal right coronary artery has 50% stenosis as well.
5. Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.
RECOMMENDATIONS: The patient has heavy calcification of the coronary arteries and continued risk factor management is needed. The ostial lesion of the right coronary artery may be severe. It is at least 50%, but it could be worse. Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery. We will reevaluate her stress nuclear study as well. Continue aggressive medical therapy.
POSTOPERATIVE DIAGNOSIS: Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.
DESCRIPTION OF PROCEDURE:
LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:
Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done. Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed. Coronary arteriography was performed with 6-French performed coronary catheters. We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries. After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery. A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.
ANALYSIS OF PRESSURE DATA: Left ventricular end-diastolic pressure was 5 mmHg. On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve. The aortic pressures were normal. Contours of intracardiac pressure were normal.
ANALYSIS OF ANGIOGRAMS: Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta. A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position. The mitral valve is competent and demonstrates normal mobility. The left ventricular cavity is normal in size with excellent contractility. Aneurysmal dilatation and/or dyskinesia absent. The aortic valve is tricuspid and normal mobility. The ascending aorta appeared normal.
Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries. An abdominal aortic injection was performed. Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation. There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis. The abdominal aortogram reveals wide patency of that area with mild intimal irregularity. There is a normal left renal artery, normal right renal artery. The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal. The common left iliac and common right iliac arteries are essentially normal in this area.
CORONARY ANATOMY: One notes ostial coronary calcification of the right coronary artery. Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters. Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually. The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%. There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery. In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third. Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel. The distal portion of the vessel is free of disease. The conus branch is seen arising right at the beginning part of the right coronary artery. We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%. At the ostium of the right coronary artery, calcification again is identified. Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.
The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis. It forms the left anterior descending artery, the ramus branch, and the circumflex artery.
The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment. There appears to be some mild stenosis of 10% in the proximal segment. It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease. The remaining portion of the left anterior descending artery is free of disease. Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed. I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.
The ramus branch is normal and free of disease.
The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.
The patient has a predominantly right coronary system. There is no _______ circulation connecting the right and left coronary systems.
The patient tolerated the procedure well. The catheter was removed. Hemostasis was achieved. The patient was transferred to the recovery room in a stable condition.
IMPRESSION:
1. Excellent left ventricular contractility with normal left ventricular cavity size.
2. Calcification of the mid abdominal aorta with wide patency of all vessels. The left and right renal arteries are normal. The external iliac arteries are normal.
3. Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.
4. Ostial stenosis of the right coronary artery that appears to be about 50% or greater. The proximal right coronary artery has 50% stenosis as well.
5. Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.
RECOMMENDATIONS: The patient has heavy calcification of the coronary arteries and continued risk factor management is needed. The ostial lesion of the right coronary artery may be severe. It is at least 50%, but it could be worse. Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery. We will reevaluate her stress nuclear study as well. Continue aggressive medical therapy.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 2
Description: The patient with atypical type right arm discomfort and neck discomfort.
(Medical Transcription Sample Report)
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INDICATIONS FOR PROCEDURE: The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.
APPROACH: Right common femoral artery.
ANESTHESIA: IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 10 ml.
ESTIMATED CONTRAST: Less than 250 ml.
PROCEDURE PERFORMED: Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.
DESCRIPTION OF PROCEDURE: The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.
AORTIC ARCH ANGIOGRAM: Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.
SELECTIVE SUBCLAVIAN ANGIOGRAPHY: Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.
ANGIOGRAPHIC DETAILS: The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.
IMPRESSION:
1. Moderate grade stenosis in the right subclavian artery.
2. Patent proximal edge of the right carotid.
APPROACH: Right common femoral artery.
ANESTHESIA: IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 10 ml.
ESTIMATED CONTRAST: Less than 250 ml.
PROCEDURE PERFORMED: Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.
DESCRIPTION OF PROCEDURE: The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.
AORTIC ARCH ANGIOGRAM: Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.
SELECTIVE SUBCLAVIAN ANGIOGRAPHY: Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.
ANGIOGRAPHIC DETAILS: The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.
IMPRESSION:
1. Moderate grade stenosis in the right subclavian artery.
2. Patent proximal edge of the right carotid.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 3
Description: White male with onset of chest pain, with history of on and off chest discomfort over the past several days.
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INDICATIONS FOR PROCEDURE: This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual shortness of breath, no orthopnea. Cardiac monitor shows resolution of ST elevation lead III.
DESCRIPTION OF PROCEDURE: Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.
HEMODYNAMIC DATA: Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.
ANGIOGRAPHIC FINDINGS:
I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.
II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.
III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.
DISCUSSION: Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.
PLAN: Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.
DESCRIPTION OF PROCEDURE: Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.
HEMODYNAMIC DATA: Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.
ANGIOGRAPHIC FINDINGS:
I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.
II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.
III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.
DISCUSSION: Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.
PLAN: Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 4
Description: Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.
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PROCEDURES PERFORMED:
1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.
2. Left ventricular angiography was not performed.
3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.
4. Right femoral artery angiography.
5. Perclose to seal the right femoral arteriotomy.
INDICATIONS FOR PROCEDURE: Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.
HEMODYNAMIC DATA: The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.
CORONARY ANGIOGRAM: The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.
CONCLUSION: Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.
The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.
ANGIOPLASTY CONCLUSION: Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.
RECOMMENDATIONS: Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.
TOTAL MEDICATIONS DURING PROCEDURE: Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.
CONTRAST ADMINISTERED: 200 mL.
FLUOROSCOPY TIME: 12.4 minutes.
1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.
2. Left ventricular angiography was not performed.
3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.
4. Right femoral artery angiography.
5. Perclose to seal the right femoral arteriotomy.
INDICATIONS FOR PROCEDURE: Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.
HEMODYNAMIC DATA: The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.
CORONARY ANGIOGRAM: The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.
CONCLUSION: Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.
The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.
ANGIOPLASTY CONCLUSION: Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.
RECOMMENDATIONS: Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.
TOTAL MEDICATIONS DURING PROCEDURE: Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.
CONTRAST ADMINISTERED: 200 mL.
FLUOROSCOPY TIME: 12.4 minutes.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 5
Description: Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.
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PROCEDURE PERFORMED:
1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.
2. Right femoral selective angiogram.
3. Closure device the seal the femoral arteriotomy using an Angio-Seal.
INDICATIONS FOR PROCEDURE: The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.
HEMODYNAMIC DATA: Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.
CORONARY ANGIOGRAM: The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.
CONCLUSION: 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.
PLAN: The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.
After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.
1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.
2. Right femoral selective angiogram.
3. Closure device the seal the femoral arteriotomy using an Angio-Seal.
INDICATIONS FOR PROCEDURE: The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.
HEMODYNAMIC DATA: Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.
CORONARY ANGIOGRAM: The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.
CONCLUSION: 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.
PLAN: The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.
After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 6
Description: Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.
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PRECATHETERIZATION DIAGNOSIS (ES): Hypoplastic left heart, status post Norwood procedure and Glenn shunt.
POSTCATHETERIZATION DIAGNOSIS (ES):
1. Hypoplastic left heart.
A. Status post Norwood.
B. Status post Glenn.
2. Left pulmonary artery hypoplasia.
3. Diminished right ventricular systolic function.
4. Trivial neo-aortic stenosis.
5. Trivial coarctation.
6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.
PROCEDURE (S): Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.
I. PROCEDURES: XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.
Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.
A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.
The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.
The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.
The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.
A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.
The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.
Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.
II. PRESSURES:
A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.
B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.
C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.
INTERPRETATION: Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.
III. OXIMETRY: Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.
INTERPRETATION: Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.
IV. SPECIAL PROCEDURE (S): None done.
V. CALCULATIONS:
Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.
VI. ANGIOGRAPHY: The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.
The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.
The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.
The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.s
POSTCATHETERIZATION DIAGNOSIS (ES):
1. Hypoplastic left heart.
A. Status post Norwood.
B. Status post Glenn.
2. Left pulmonary artery hypoplasia.
3. Diminished right ventricular systolic function.
4. Trivial neo-aortic stenosis.
5. Trivial coarctation.
6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.
PROCEDURE (S): Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.
I. PROCEDURES: XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.
Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.
A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.
The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.
The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.
The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.
A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.
The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.
Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.
II. PRESSURES:
A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.
B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.
C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.
INTERPRETATION: Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.
III. OXIMETRY: Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.
INTERPRETATION: Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.
IV. SPECIAL PROCEDURE (S): None done.
V. CALCULATIONS:
Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.
VI. ANGIOGRAPHY: The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.
The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.
The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.
The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.s
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 7
Description: Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INDICATIONS FOR PROCEDURE: The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.
APPROACH: Right common femoral artery.
ANESTHESIA: IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 10 mL.
ESTIMATED CONTRAST: Less than 150 mL.
PROCEDURES PERFORMED: Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.
OPERATIVE TECHNIQUE: The patient was brought to the cardiac catheterization lab in the usual fasting state. She was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. One percent Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was then placed in the right common femoral artery by the modified Seldinger technique.
SELECTIVE CORONARY ARTERIOGRAPHY: Next, right and left Judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views.
LEFT VENTRICULOGRAM: Next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. Next, an LV-gram was then performed with a hand injection of 50 mL of contrast. Next, pull-back pressure was measured across the aortic valve.
AORTA ARCH ANGIOGRAM: Next, aortic arch angiogram was then performed with injection of 50 mL of contrast at a rate of 20 mL/second to maximum pressure of 750 PSI performed in the 40-degree LAO view.
Next, right iliofemoral angiogram was performed in the 20-degree RAO view. Next Angio-Seal was applied successfully.
The patient left the cath lab without problems or issues.
DIAGNOSES: Left ventricular end-diastolic pressure was 18 mmHg. There was no gradient across the aortic valve. The central aortic pressure was 160 mmHg.
LEFT VENTRICULOGRAM: The left ventriculogram demonstrated normal LV systolic function with estimated ejection fraction greater than 50%.
AORTIC ARCH ANGIOGRAM: The aortic arch angiogram demonstrated normal aortic arch. No aortic regurgitation was seen.
SELECTIVE CORONARY ARTERIOGRAPHY: The right coronary artery is large and dominant.
The left main is patent.
The left anterior descending is patent.
The left circumflex is patent.
IMPRESSION: This study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. In addition, the aortic root is normal.
APPROACH: Right common femoral artery.
ANESTHESIA: IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 10 mL.
ESTIMATED CONTRAST: Less than 150 mL.
PROCEDURES PERFORMED: Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.
OPERATIVE TECHNIQUE: The patient was brought to the cardiac catheterization lab in the usual fasting state. She was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. One percent Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was then placed in the right common femoral artery by the modified Seldinger technique.
SELECTIVE CORONARY ARTERIOGRAPHY: Next, right and left Judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views.
LEFT VENTRICULOGRAM: Next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. Next, an LV-gram was then performed with a hand injection of 50 mL of contrast. Next, pull-back pressure was measured across the aortic valve.
AORTA ARCH ANGIOGRAM: Next, aortic arch angiogram was then performed with injection of 50 mL of contrast at a rate of 20 mL/second to maximum pressure of 750 PSI performed in the 40-degree LAO view.
Next, right iliofemoral angiogram was performed in the 20-degree RAO view. Next Angio-Seal was applied successfully.
The patient left the cath lab without problems or issues.
DIAGNOSES: Left ventricular end-diastolic pressure was 18 mmHg. There was no gradient across the aortic valve. The central aortic pressure was 160 mmHg.
LEFT VENTRICULOGRAM: The left ventriculogram demonstrated normal LV systolic function with estimated ejection fraction greater than 50%.
AORTIC ARCH ANGIOGRAM: The aortic arch angiogram demonstrated normal aortic arch. No aortic regurgitation was seen.
SELECTIVE CORONARY ARTERIOGRAPHY: The right coronary artery is large and dominant.
The left main is patent.
The left anterior descending is patent.
The left circumflex is patent.
IMPRESSION: This study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. In addition, the aortic root is normal.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 8
Description: Left heart cardiac catheterization.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURE PERFORMED:
1. Right femoral artery access.
2. Selective right and left coronary angiogram.
3. Left heart catheterization.
4. Left ventriculogram.
INDICATIONS FOR PROCEDURE: A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath. The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%. This was a sharp decline from a previous LVEF of 50% to 55%. We therefore, decided to proceed with coronary angiography.
TECHNIQUE: After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state. The right groin was prepped and draped in the usual sterile manner. 2% Lidocaine was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery. 6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram. A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.
HEMODYNAMIC DATA: LVEDP of 11. There was no gradient across the aortic valve upon pullback.
ANGIOGRAPHIC FINDINGS:
1. The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.
2. The left main coronary artery is free of any disease.
3. The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches. The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.
4. The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches. One of its secondary branches which is a small caliber has an ostial 70% stenosis.
5. The left anterior descending artery has a patent stent in the proximal LAD. The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss. There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery. The diagonal branches are free of any disease.
6. The right coronary artery is a dominant vessel and has mild luminal irregularities. Its midsegment has a focal area of 30% narrowing as well. The rest of the right coronary artery is free of any disease.
7. The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.
RECOMMENDATION: Continue with optimum medical therapy. Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram. The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.
1. Right femoral artery access.
2. Selective right and left coronary angiogram.
3. Left heart catheterization.
4. Left ventriculogram.
INDICATIONS FOR PROCEDURE: A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath. The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%. This was a sharp decline from a previous LVEF of 50% to 55%. We therefore, decided to proceed with coronary angiography.
TECHNIQUE: After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state. The right groin was prepped and draped in the usual sterile manner. 2% Lidocaine was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery. 6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram. A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.
HEMODYNAMIC DATA: LVEDP of 11. There was no gradient across the aortic valve upon pullback.
ANGIOGRAPHIC FINDINGS:
1. The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.
2. The left main coronary artery is free of any disease.
3. The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches. The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.
4. The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches. One of its secondary branches which is a small caliber has an ostial 70% stenosis.
5. The left anterior descending artery has a patent stent in the proximal LAD. The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss. There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery. The diagonal branches are free of any disease.
6. The right coronary artery is a dominant vessel and has mild luminal irregularities. Its midsegment has a focal area of 30% narrowing as well. The rest of the right coronary artery is free of any disease.
7. The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.
RECOMMENDATION: Continue with optimum medical therapy. Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram. The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 9
Description: Cardiac catheterization and coronary intervention report.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
EXAM: Cardiac catheterization and coronary intervention report.
PROCEDURES:
1. Left heart catheterization, coronary angiography, left ventriculography.
2. PTCA/Endeavor stent, proximal LAD.
INDICATIONS: Acute anterior ST-elevation MI.
ACCESS: Right femoral artery 6-French.
MEDICATIONS:
1. IV Valium.
2. IV Benadryl.
3. Subcutaneous lidocaine.
4. IV heparin.
5. IV ReoPro.
6. Intracoronary nitroglycerin.
ESTIMATED BLOOD LOSS: 10 mL.
CONTRAST: 185 mL.
COMPLICATIONS: None.
PROCEDURE: The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG. She was prepped and draped in the usual sterile fashion. The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained. The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed. The needle was exchanged for 6 French sheath. The wire was removed. The sheath was washed with sterile saline. Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed. A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD. The patient had an ACT check, received additional IV heparin and IV ReoPro. The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures. The balloon was deflated and angiography demonstrated establishment of flow. Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres. The balloon was deflated, reinflated at 12 atmospheres, deflated and removed. Final angiography demonstrated excellent clinical result. Additional angiography was performed with a wire out. Following this, the wire and the catheter was removed. Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views. This catheter was removed. The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve. At the end of procedure, wires and catheter were removed. Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site. There was no hematoma. Peripheral pulses _______ procedure. The patient tolerated the procedure well. Symptoms of chest pain resolved at the end of the procedure with no complications.
RESULTS:
1. Coronary angiography.
A. Left main free of obstruction.
B. LAD, subtotal proximal stenosis.
C. Circumflex large vessel with three large obtuse marginal branches. No high-grade obstruction, evidence of minimal plaquing.
D. Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.
2. Left ventriculogram. Left ventricular ejection fraction estimated at 45% to 50%. There was an akinetic apical wall.
3. Hemodynamics. Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.
IMPRESSION:
1. Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.
2. Two-vessel coronary disease.
3. Mild-to-moderate impaired LV systolic function.
4. Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.
PLAN: Overnight observation in ICU. Start aspirin, Plavix, beta-blocker and ACE inhibitor. Check serial cardiac enzymes. Further recommendations to follow. Check fasting lipid panel, in addition add a statin. Further recommendations to follow.
PROCEDURES:
1. Left heart catheterization, coronary angiography, left ventriculography.
2. PTCA/Endeavor stent, proximal LAD.
INDICATIONS: Acute anterior ST-elevation MI.
ACCESS: Right femoral artery 6-French.
MEDICATIONS:
1. IV Valium.
2. IV Benadryl.
3. Subcutaneous lidocaine.
4. IV heparin.
5. IV ReoPro.
6. Intracoronary nitroglycerin.
ESTIMATED BLOOD LOSS: 10 mL.
CONTRAST: 185 mL.
COMPLICATIONS: None.
PROCEDURE: The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG. She was prepped and draped in the usual sterile fashion. The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained. The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed. The needle was exchanged for 6 French sheath. The wire was removed. The sheath was washed with sterile saline. Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed. A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD. The patient had an ACT check, received additional IV heparin and IV ReoPro. The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures. The balloon was deflated and angiography demonstrated establishment of flow. Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres. The balloon was deflated, reinflated at 12 atmospheres, deflated and removed. Final angiography demonstrated excellent clinical result. Additional angiography was performed with a wire out. Following this, the wire and the catheter was removed. Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views. This catheter was removed. The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve. At the end of procedure, wires and catheter were removed. Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site. There was no hematoma. Peripheral pulses _______ procedure. The patient tolerated the procedure well. Symptoms of chest pain resolved at the end of the procedure with no complications.
RESULTS:
1. Coronary angiography.
A. Left main free of obstruction.
B. LAD, subtotal proximal stenosis.
C. Circumflex large vessel with three large obtuse marginal branches. No high-grade obstruction, evidence of minimal plaquing.
D. Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.
2. Left ventriculogram. Left ventricular ejection fraction estimated at 45% to 50%. There was an akinetic apical wall.
3. Hemodynamics. Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.
IMPRESSION:
1. Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.
2. Two-vessel coronary disease.
3. Mild-to-moderate impaired LV systolic function.
4. Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.
PLAN: Overnight observation in ICU. Start aspirin, Plavix, beta-blocker and ACE inhibitor. Check serial cardiac enzymes. Further recommendations to follow. Check fasting lipid panel, in addition add a statin. Further recommendations to follow.
PHYSICAL EXAM: Blood pressure 156/93, pulse is 100, respiratory rate 18. On general exam, he is a pleasant overweight gentleman, in no acute distress. HEENT: Shows cranium is normocephalic and atraumatic. He has moist mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin warm and perfused. Affect appropriate. He is quite oriented and pleasant. No significant kyphoscoliosis on recumbent back exam. Lungs are clear to auscultation anteriorly. No wheezes. No egophony. Cardiac Exam: S1, S2. Regular rate, controlled. No significant murmurs, rubs or gallops. PMI is nondisplaced. Abdomen is soft, nondistended, appears benign. Extremities without significant edema. Pulses grossly intact.
REVIEW OF SYSTEMS
CONSTITUTIONAL: Positive for generalized fatigue and malaise.
HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.
CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.
RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing.
ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.
GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence.
MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.
SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms.
NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria.
PSYCHIATRIC: Negative for depression, anxiety, or mood swings.
All other systems reviewed are negative.
PHYSICAL EXAMINATION
VITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6.
CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.
HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat.
NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact.
CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs.
EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish.
RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded.
ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated.
GENITOURINARY: Deferred.
MUSCULOSKELETAL: Adequate range of motion along with extremities.
SKIN: Warm and dry. No lesions or ulcerations are noted.
NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits.
PSYCHIATRIC: Normal affect.
CONSTITUTIONAL: Positive for generalized fatigue and malaise.
HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.
CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.
RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing.
ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.
GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence.
MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.
SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms.
NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria.
PSYCHIATRIC: Negative for depression, anxiety, or mood swings.
All other systems reviewed are negative.
PHYSICAL EXAMINATION
VITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6.
CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.
HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat.
NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact.
CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs.
EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish.
RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded.
ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated.
GENITOURINARY: Deferred.
MUSCULOSKELETAL: Adequate range of motion along with extremities.
SKIN: Warm and dry. No lesions or ulcerations are noted.
NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits.
PSYCHIATRIC: Normal affect.
REVIEW OF SYSTEMS: Remarkable for heavy snoring, daytime sleepiness, and easy fatigability.
PHYSICAL EXAMINATION:
GENERAL: Well-built, well-nourished black female in no acute distress.
VITAL SIGNS: Blood pressure is 120/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 226 pounds, height 68 inches. BMI is 34.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.
CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard.
CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is no murmur, gallop, or pericardial friction rub heard.
ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.
EXTREMITIES: No pedal edema or calf muscle tenderness. Proximal and distal arterial pulsations are well felt.
PHYSICAL EXAMINATION:
GENERAL: Well-built, well-nourished black female in no acute distress.
VITAL SIGNS: Blood pressure is 120/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 226 pounds, height 68 inches. BMI is 34.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.
CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard.
CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is no murmur, gallop, or pericardial friction rub heard.
ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.
EXTREMITIES: No pedal edema or calf muscle tenderness. Proximal and distal arterial pulsations are well felt.
REVIEW OF SYSTEMS: Otherwise negative.
PHYSICAL EXAMINATION:
GENERAL: Well-built, well-nourished white female in no acute distress.
VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.
CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard.
CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard.
ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.
EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides.
NEURO: Normal.
PHYSICAL EXAMINATION:
GENERAL: Well-built, well-nourished white female in no acute distress.
VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.
CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard.
CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard.
ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.
EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides.
NEURO: Normal.
REVIEW OF SYSTEMS:
OPHTHALMOLOGIC: Uses glasses.
ENT: Complains of occasional sinusitis.
CARDIOVASCULAR: Hypertension and atrial fibrillation.
RESPIRATORY: Normal.
GI: Colon bleeding. The patient believes he had ulcers.
GENITOURINARY: Normal.
MUSCULOSKELETAL: Complains of arthritis and gout.
INTEGUMENTARY: Edema of ankles and joints.
NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.
ENDOCRINE: Diabetes, NIDDM.
HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.
LABORATORY: Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.
PHYSICAL EXAMINATION:
GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.
VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.
NECK: Without JVD, bruit, or thyromegaly. The neck is supple.
CHEST: Symmetric. There is no heave or retraction.
HEART: The heart sounds are irregular and no significant murmurs could be auscultated.
LUNGS: Clear to auscultation.
ABDOMEN: Exam was deferred.
LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.
OPHTHALMOLOGIC: Uses glasses.
ENT: Complains of occasional sinusitis.
CARDIOVASCULAR: Hypertension and atrial fibrillation.
RESPIRATORY: Normal.
GI: Colon bleeding. The patient believes he had ulcers.
GENITOURINARY: Normal.
MUSCULOSKELETAL: Complains of arthritis and gout.
INTEGUMENTARY: Edema of ankles and joints.
NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.
ENDOCRINE: Diabetes, NIDDM.
HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.
LABORATORY: Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.
PHYSICAL EXAMINATION:
GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.
VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.
NECK: Without JVD, bruit, or thyromegaly. The neck is supple.
CHEST: Symmetric. There is no heave or retraction.
HEART: The heart sounds are irregular and no significant murmurs could be auscultated.
LUNGS: Clear to auscultation.
ABDOMEN: Exam was deferred.
LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.
EXAMINATION: This is a 42-year old male awake, alert, and oriented x3 in no acute distress.
Wt: 238 BP: 144/82 HR: 69
HEENT: Normocephalic and atraumatic.
NECK: Supple, no jugular venous distension.
LUNGS: Good breath sounds bilaterally.
HEART: Regular rate and rhythm, S1 and S2, no murmurs, rubs, or gallops.
ABDOMEN: Soft, no organomegalies, bowel sounds positive.
EXTREMITIES: No clubbing, edema, or cyanosis.
Wt: 238 BP: 144/82 HR: 69
HEENT: Normocephalic and atraumatic.
NECK: Supple, no jugular venous distension.
LUNGS: Good breath sounds bilaterally.
HEART: Regular rate and rhythm, S1 and S2, no murmurs, rubs, or gallops.
ABDOMEN: Soft, no organomegalies, bowel sounds positive.
EXTREMITIES: No clubbing, edema, or cyanosis.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit. Moderate obesity is present.
CARDIAC: Carotid upstroke is slightly diminished, but no clear bruit heard.
LUNGS: Slightly decreased air entry at both bases. No rales or rhonchi heard.
CARDIOVASCULAR: PMI in the left fifth intercostal space in the midclavicular line. Regular heart rhythm. S1 and S2 normal. S4 is present. No S3 heard. Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.
ABDOMEN: Soft, obese, no tenderness, no masses felt. Bowel sounds are present.
EXTREMITIES: Bilateral trace edema. The extremities are heavy. There is no pitting at this stage. No clubbing or cyanosis. Distal pulses are fair.
CENTRAL NERVOUS SYSTEM: Without any obvious focal deficits.
LABORATORY DATA: Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block. This is overall unchanged compared to previous electrocardiogram, which also has the same present. Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia. Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000. Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7. AST and ALT are normal. Albumin is 4.1. Lipase and amylase are normal. INR is 0.92. Urinalysis is relatively unremarkable except for trace protein. Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures. No infiltrates seen. Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia. Volvulus or adhesions have been considered. Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.
REVIEW OF SYSTEMS:
GENERAL: The patient is able to walk one block or less prior to the onset of significant leg pain. She ever denies any cardiac symptoms with this degree of exertion. She denies any dyspnea on exertion or chest pain with activities of daily living. She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea. She does have chronic lower extremity edema. Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis. She denies any palpitations or tachycardia. She has remote history of presyncope, no true syncope.
HEMATOLOGIC: Negative for bleeding diathesis or coagulopathy.
ONCOLOGIC: Remarkable for past medical history.
PULMONARY: Remarkable for childhood pneumonia times several. No recurrent pneumonias, bronchitis, reactive airway disease as an adult.
GASTROINTESTINAL: Remarkable for past medical history.
GENITOURINARY: Remarkable for past medical history.
MUSCULOSKELETAL: Remarkable for past medical history.
CENTRAL NERVOUS SYSTEM: Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.
PSYCHIATRIC: Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman. No recurrence.
PHYSICAL EXAMINATION:
GENERAL: This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.
VITAL SIGNS: She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6. Pulse ranges from 123 to 86 beats per minute. Blood pressure ranges from 124/65 to 152/67 mmHg. Oxygen saturation on 2 L nasal cannula was 94%.
HEENT: Exam is benign. Normocephalic and atraumatic. Extraocular motions are intact. Sclerae anicteric. Conjunctivae noninjected. She does have bilateral arcus senilis. Oral mucosa is pink and moist.
NECK: Jugular venous pulsations are normal. Carotid upstrokes are palpable bilaterally. There is no audible bruit. There is no lymphadenopathy or thyromegaly at the base of the neck. There is a well-healed scar at the base of the neck. Cardiothoracic contour is normal.
LUNGS: Limited to anterior auscultation only, which was clear.
CARDIAC: Regular rhythm and rate. S1 and S2 with no significant murmur, rub, or gallop appreciated. The point of maximal impulse is normal. There is no right ventricular heave.
ABDOMEN: Soft with active bowel sounds. No organomegaly. No audible bruit. Nontender.
EXTREMITIES: Femoral pulses were deferred. Lower extremities revealed trace to 1+edema at the level of ankles bilaterally.
DIAGNOSTIC DATA: EKG: Electrocardiogram on 11/20/2006 at 1539 showed sinus rhythm with left axis deviation, borderline first-degree atrioventricular (AV) block, sinus arrhythmia. Nonspecific ST-segment flattening seen predominantly in aVL, but to a lesser extent in lead I. Early R-wave progression also noted. No evidence for resting ischemia or prior infarction. Repeat electrocardiogram on 11/21/2006 at 0037 essentially unchanged with regard to ST segments except there is perhaps slightly more flattening in lead I. P-wave morphology is slightly different than that noted on prior tracing consistent with ectopic atrial rhythm. Repeat electrocardiogram on 11/21/2006 at 1713 shows persistence of ST segment flattening in lead I, aVL. Persistence of early R-wave progression and left axis deviation. Rhythm does appear to be sinus on current tracing.
LABORATORY DATA: White blood cell count 4.7 on admission, hematocrit currently 33.2 with platelet count of 243 on admission. INR 1.0 with PTT of 20. Sodium 144 with potassium 3.6, chloride 107, CO2 25, BUN 10 with creatinine of 1.1. Albumin depressed at 3.3. AST and ALT normal at 19 and 24 respectively, lipase normal at 45. Troponins are negative x4 over the course of 14 hours. Urinalysis is suggestive of urinary tract infection (UTI) with no blood, positive nitrates, positive leuk esterase, 5 to 10 white blood cells, and many bacteria with no epithelial cells.
GENERAL: The patient is able to walk one block or less prior to the onset of significant leg pain. She ever denies any cardiac symptoms with this degree of exertion. She denies any dyspnea on exertion or chest pain with activities of daily living. She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea. She does have chronic lower extremity edema. Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis. She denies any palpitations or tachycardia. She has remote history of presyncope, no true syncope.
HEMATOLOGIC: Negative for bleeding diathesis or coagulopathy.
ONCOLOGIC: Remarkable for past medical history.
PULMONARY: Remarkable for childhood pneumonia times several. No recurrent pneumonias, bronchitis, reactive airway disease as an adult.
GASTROINTESTINAL: Remarkable for past medical history.
GENITOURINARY: Remarkable for past medical history.
MUSCULOSKELETAL: Remarkable for past medical history.
CENTRAL NERVOUS SYSTEM: Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.
PSYCHIATRIC: Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman. No recurrence.
PHYSICAL EXAMINATION:
GENERAL: This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.
VITAL SIGNS: She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6. Pulse ranges from 123 to 86 beats per minute. Blood pressure ranges from 124/65 to 152/67 mmHg. Oxygen saturation on 2 L nasal cannula was 94%.
HEENT: Exam is benign. Normocephalic and atraumatic. Extraocular motions are intact. Sclerae anicteric. Conjunctivae noninjected. She does have bilateral arcus senilis. Oral mucosa is pink and moist.
NECK: Jugular venous pulsations are normal. Carotid upstrokes are palpable bilaterally. There is no audible bruit. There is no lymphadenopathy or thyromegaly at the base of the neck. There is a well-healed scar at the base of the neck. Cardiothoracic contour is normal.
LUNGS: Limited to anterior auscultation only, which was clear.
CARDIAC: Regular rhythm and rate. S1 and S2 with no significant murmur, rub, or gallop appreciated. The point of maximal impulse is normal. There is no right ventricular heave.
ABDOMEN: Soft with active bowel sounds. No organomegaly. No audible bruit. Nontender.
EXTREMITIES: Femoral pulses were deferred. Lower extremities revealed trace to 1+edema at the level of ankles bilaterally.
DIAGNOSTIC DATA: EKG: Electrocardiogram on 11/20/2006 at 1539 showed sinus rhythm with left axis deviation, borderline first-degree atrioventricular (AV) block, sinus arrhythmia. Nonspecific ST-segment flattening seen predominantly in aVL, but to a lesser extent in lead I. Early R-wave progression also noted. No evidence for resting ischemia or prior infarction. Repeat electrocardiogram on 11/21/2006 at 0037 essentially unchanged with regard to ST segments except there is perhaps slightly more flattening in lead I. P-wave morphology is slightly different than that noted on prior tracing consistent with ectopic atrial rhythm. Repeat electrocardiogram on 11/21/2006 at 1713 shows persistence of ST segment flattening in lead I, aVL. Persistence of early R-wave progression and left axis deviation. Rhythm does appear to be sinus on current tracing.
LABORATORY DATA: White blood cell count 4.7 on admission, hematocrit currently 33.2 with platelet count of 243 on admission. INR 1.0 with PTT of 20. Sodium 144 with potassium 3.6, chloride 107, CO2 25, BUN 10 with creatinine of 1.1. Albumin depressed at 3.3. AST and ALT normal at 19 and 24 respectively, lipase normal at 45. Troponins are negative x4 over the course of 14 hours. Urinalysis is suggestive of urinary tract infection (UTI) with no blood, positive nitrates, positive leuk esterase, 5 to 10 white blood cells, and many bacteria with no epithelial cells.
REVIEW OF SYSTEMS:
General: Unremarkable.
Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.
Gastrointestinal: Unremarkable.
Genitourinary: See above.
Musculoskeletal: Unremarkable.
Neurologic: Unremarkable.
General: Unremarkable.
Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.
Gastrointestinal: Unremarkable.
Genitourinary: See above.
Musculoskeletal: Unremarkable.
Neurologic: Unremarkable.
PHYSICAL EXAMINATION:
General: A well-appearing, obese black male.
Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.
HEENT: Grossly normal.
Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.
Chest: Midline sternotomy scar.
Lungs: Clear.
Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.
Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.
Extremities: Normal. No edema. Pulses bilaterally intact, carotid, radial, femoral, and dorsalis pedis.
Neurologic: Mental status, no gross cranial nerve, motor, or sensory deficits.
ELECTROCARDIOGRAM: Normal sinus rhythm. Right bundle-branch block. Findings compatible with old anteroseptal and lateral wall myocardial infarction.
_______ nonspecific ST-T abnormality.
General: A well-appearing, obese black male.
Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.
HEENT: Grossly normal.
Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.
Chest: Midline sternotomy scar.
Lungs: Clear.
Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.
Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.
Extremities: Normal. No edema. Pulses bilaterally intact, carotid, radial, femoral, and dorsalis pedis.
Neurologic: Mental status, no gross cranial nerve, motor, or sensory deficits.
ELECTROCARDIOGRAM: Normal sinus rhythm. Right bundle-branch block. Findings compatible with old anteroseptal and lateral wall myocardial infarction.
_______ nonspecific ST-T abnormality.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Radionuclide Stress Test
Description: Patient with chest pains, CAD, and cardiomyopathy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INDICATION FOR STUDY: Chest pains, CAD, and cardiomyopathy.
MEDICATIONS: Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.
BASELINE EKG: Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.
PERSANTINE RESULTS: Heart rate increased from 70 to 72. Blood pressure decreased from 160/84 to 130/78. The patient felt slightly dizziness, but there was no chest pain or EKG changes.
NUCLEAR PROTOCOL: Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test. 53 mg of Persantine were used, reversed with 125 mg of aminophylline.
NUCLEAR RESULTS:
1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images are normal. The post Persantine images show mildly decreased uptake in the septum. The sum score is 0.
2. The Gated SPECT shows enlarged heart with a preserved EF of 52%.
IMPRESSION:
1. Mild septal ischemia. Likely due to the left bundle-branch block.
2. Mild cardiomyopathy, EF of 52%.
3. Mild hypertension at 160/84.
4. Left bundle-branch block.
MEDICATIONS: Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.
BASELINE EKG: Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.
PERSANTINE RESULTS: Heart rate increased from 70 to 72. Blood pressure decreased from 160/84 to 130/78. The patient felt slightly dizziness, but there was no chest pain or EKG changes.
NUCLEAR PROTOCOL: Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test. 53 mg of Persantine were used, reversed with 125 mg of aminophylline.
NUCLEAR RESULTS:
1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images are normal. The post Persantine images show mildly decreased uptake in the septum. The sum score is 0.
2. The Gated SPECT shows enlarged heart with a preserved EF of 52%.
IMPRESSION:
1. Mild septal ischemia. Likely due to the left bundle-branch block.
2. Mild cardiomyopathy, EF of 52%.
3. Mild hypertension at 160/84.
4. Left bundle-branch block.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardio/Pulmo Discharge Summary
Description: A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.
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ADMISSION DIAGNOSIS:
1. Respiratory arrest.
2 . End-stage chronic obstructive pulmonary disease.
3. Coronary artery disease.
4. History of hypertension.
DISCHARGE DIAGNOSIS:
1. Status post-respiratory arrest.
2. Chronic obstructive pulmonary disease.
3. Congestive heart failure.
4. History of coronary artery disease.
5. History of hypertension.
SUMMARY: The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.
ADMISSION PHYSICAL EXAMINATION:
GENERAL: Showed a well-developed, slightly obese man who was in extremis.
NECK: Supple, with no jugular venous distension.
HEART: Showed tachycardia without murmurs or gallops.
PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.
EXTREMITIES: Free of edema.
HOSPITAL COURSE: The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a
significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.
DIAGNOSTIC DATA: The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.
DISPOSITION: The patient was discharged home.
DISCHARGE INSTRUCTIONS: His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.
1. Respiratory arrest.
2 . End-stage chronic obstructive pulmonary disease.
3. Coronary artery disease.
4. History of hypertension.
DISCHARGE DIAGNOSIS:
1. Status post-respiratory arrest.
2. Chronic obstructive pulmonary disease.
3. Congestive heart failure.
4. History of coronary artery disease.
5. History of hypertension.
SUMMARY: The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.
ADMISSION PHYSICAL EXAMINATION:
GENERAL: Showed a well-developed, slightly obese man who was in extremis.
NECK: Supple, with no jugular venous distension.
HEART: Showed tachycardia without murmurs or gallops.
PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.
EXTREMITIES: Free of edema.
HOSPITAL COURSE: The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a
significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.
DIAGNOSTIC DATA: The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.
DISPOSITION: The patient was discharged home.
DISCHARGE INSTRUCTIONS: His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiolite Treadmill Stress Test
Description: Cardiolite treadmill exercise stress test. The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.
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CARDIOLITE TREADMILL EXERCISE STRESS TEST
CLINICAL DATA: This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.
PROCEDURE: The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS. There was a normal blood pressure response. The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.
Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite. At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.
Gating poststress tomographic imaging was performed 30 minutes after the stress.
FINDINGS:
1. The overall quality of the study is fair.
2. The left ventricular cavity appears to be normal on the rest and stress studies.
3. SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.
4. The left ventricular ejection fraction was normal and estimated to be 78%.
IMPRESSION: Myocardial perfusion imaging is normal. Result of this test suggests low probability for significant coronary artery disease.
CLINICAL DATA: This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.
PROCEDURE: The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS. There was a normal blood pressure response. The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.
Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite. At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.
Gating poststress tomographic imaging was performed 30 minutes after the stress.
FINDINGS:
1. The overall quality of the study is fair.
2. The left ventricular cavity appears to be normal on the rest and stress studies.
3. SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.
4. The left ventricular ejection fraction was normal and estimated to be 78%.
IMPRESSION: Myocardial perfusion imaging is normal. Result of this test suggests low probability for significant coronary artery disease.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. JVP is flat. Carotid upstroke is good.
LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides.
CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex.
ABDOMEN: Soft. There is no hepatosplenomegaly.
EXTREMITIES: Patient has 1+ pedal edema.
VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. JVP is flat. Carotid upstroke is good.
LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides.
CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex.
ABDOMEN: Soft. There is no hepatosplenomegaly.
EXTREMITIES: Patient has 1+ pedal edema.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 135/70. Respirations 18 per minute. Heart rate 70 beats per minute. Weight 258 pounds.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. JVP is flat. Carotid upstroke is good.
LUNGS: Clear.
CARDIOVASCULAR: There is no murmur or gallop heard over the precordium.
ABDOMEN: Soft. There is no hepatosplenomegaly.
EXTREMITIES: The patient has no pedal edema.
VITAL SIGNS: Blood pressure is 135/70. Respirations 18 per minute. Heart rate 70 beats per minute. Weight 258 pounds.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. JVP is flat. Carotid upstroke is good.
LUNGS: Clear.
CARDIOVASCULAR: There is no murmur or gallop heard over the precordium.
ABDOMEN: Soft. There is no hepatosplenomegaly.
EXTREMITIES: The patient has no pedal edema.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.
HEAD AND NECK: Face is symmetrical. Cranial nerves are intact.
CHEST: There is prolonged expiration.
CARDIOVASCULAR: First and second heart sounds are heard. No murmur was appreciated.
ABDOMEN: Soft and nontender. Bowel sounds are positive.
EXTREMITIES: He has 2+ pedal swelling.
NEUROLOGIC: The patient is asleep, but easily arousable.
LABORATORY DATA: PTT is 49. INR is pending. BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8. AST is down to 45 and ALT to 99.
DIAGNOSTIC STUDIES: Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia. Ejection fraction is 25%.
VITAL SIGNS: Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.
HEAD AND NECK: Face is symmetrical. Cranial nerves are intact.
CHEST: There is prolonged expiration.
CARDIOVASCULAR: First and second heart sounds are heard. No murmur was appreciated.
ABDOMEN: Soft and nontender. Bowel sounds are positive.
EXTREMITIES: He has 2+ pedal swelling.
NEUROLOGIC: The patient is asleep, but easily arousable.
LABORATORY DATA: PTT is 49. INR is pending. BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8. AST is down to 45 and ALT to 99.
DIAGNOSTIC STUDIES: Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia. Ejection fraction is 25%.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever or chills.
EYES: No visual disturbances.
ENT: No difficulty swallowing.
CARDIOVASCULAR: Basically, no angina or chest pressure. No palpitations.
RESPIRATORY: No wheezes.
GI: No abdominal pain, although she had diarrhea.
GU: No specific symptoms.
MUSCULOSKELETAL: Have sores on the back.
NEUROLOGIC: Have dementia.
All other systems are otherwise unremarkable as far as the patient can give me information.
CONSTITUTIONAL: No fever or chills.
EYES: No visual disturbances.
ENT: No difficulty swallowing.
CARDIOVASCULAR: Basically, no angina or chest pressure. No palpitations.
RESPIRATORY: No wheezes.
GI: No abdominal pain, although she had diarrhea.
GU: No specific symptoms.
MUSCULOSKELETAL: Have sores on the back.
NEUROLOGIC: Have dementia.
All other systems are otherwise unremarkable as far as the patient can give me information.
PHYSICAL EXAMINATION:
GENERAL: Elderly in no apparent distress.
VITAL SIGNS: Heart rate of 71, blood pressure 116/48. Upon presentation, her blood pressure was in the 80s.
HEENT: Normocephalic and atraumatic. No thyromegaly or lymphadenopathy.
NECK: Supple.
CARDIOVASCULAR: Carotid upstroke normal. Jugular venous pressure is about 7 cm of H2O. The heart is irregularly irregular with a normal S1 and S2. There is a 2/6 holosystolic murmur.
LUNGS: Clear to auscultation. No rales.
ABDOMEN: Benign.
MUSCULOSKELETAL: No edema.
LABORATORY TESTS: Hemoglobin of 8.7, hematocrit 25.7. BUN 111; creatinine of 5.0, prior creatinine of 1.88 on 11/30/2009. Troponin of 0.09 with very elevated myoglobin of 575. The blood dipstick in the urine was moderate.
GENERAL: Elderly in no apparent distress.
VITAL SIGNS: Heart rate of 71, blood pressure 116/48. Upon presentation, her blood pressure was in the 80s.
HEENT: Normocephalic and atraumatic. No thyromegaly or lymphadenopathy.
NECK: Supple.
CARDIOVASCULAR: Carotid upstroke normal. Jugular venous pressure is about 7 cm of H2O. The heart is irregularly irregular with a normal S1 and S2. There is a 2/6 holosystolic murmur.
LUNGS: Clear to auscultation. No rales.
ABDOMEN: Benign.
MUSCULOSKELETAL: No edema.
LABORATORY TESTS: Hemoglobin of 8.7, hematocrit 25.7. BUN 111; creatinine of 5.0, prior creatinine of 1.88 on 11/30/2009. Troponin of 0.09 with very elevated myoglobin of 575. The blood dipstick in the urine was moderate.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardioversion
Description: Cardioversion. An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation
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HISTORY: The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress. Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation. I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure. After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday. The patient declined. I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.
PROCEDURE NOTE: The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff. The patient participated actively in this. She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect. She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm. This was confirmed on 12 lead EKG.
IMPRESSION/PLAN: Successful resumption of normal sinus rhythm from recurrent atrial fibrillation. The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress. She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted. She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.
This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.
PROCEDURE NOTE: The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff. The patient participated actively in this. She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect. She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm. This was confirmed on 12 lead EKG.
IMPRESSION/PLAN: Successful resumption of normal sinus rhythm from recurrent atrial fibrillation. The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress. She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted. She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.
This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardioversion - Direct Current
Description: Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.
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PROCEDURE: Direct current cardioversion.
REASON FOR PROCEDURE: Atrial fibrillation.
PROCEDURE IN DETAIL: The procedure was explained to the patient with risks and benefits including risk of stroke. The patient understands as well as her husband. The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium. There was spontaneous echocardiogram contrast noticed. The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed. The pads applied in the anterior and posterior approach. With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm. The patient had some occasional PACs noticed with occasional sinus tachycardia. The patient had no immediate post-procedure complications. The rhythm was maintained and 12-lead EKG was requested.
IMPRESSION: Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.
REASON FOR PROCEDURE: Atrial fibrillation.
PROCEDURE IN DETAIL: The procedure was explained to the patient with risks and benefits including risk of stroke. The patient understands as well as her husband. The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium. There was spontaneous echocardiogram contrast noticed. The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed. The pads applied in the anterior and posterior approach. With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm. The patient had some occasional PACs noticed with occasional sinus tachycardia. The patient had no immediate post-procedure complications. The rhythm was maintained and 12-lead EKG was requested.
IMPRESSION: Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardioversion - Direct Current - 1
Description: Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation.
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PROCEDURE: Direct-current cardioversion.
BRIEF HISTORY: This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. He had a wide area of circumferential ablation done on November 9th for atrial fibrillation. He did develop recurrent atrial fibrillation the day before yesterday and this is persistent. Therefore, he came in for cardioversion today. He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.
The patient was in the SDI unit, attached to noninvasive monitoring devices. After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s. He tolerated it well. He will be observed for couple hours and discharged home later today. He will continue on his current medications. He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.
CONCLUSIONS / FINAL DIAGNOSES: Successful DC cardioversion of atrial fibrillation.
BRIEF HISTORY: This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. He had a wide area of circumferential ablation done on November 9th for atrial fibrillation. He did develop recurrent atrial fibrillation the day before yesterday and this is persistent. Therefore, he came in for cardioversion today. He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.
The patient was in the SDI unit, attached to noninvasive monitoring devices. After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s. He tolerated it well. He will be observed for couple hours and discharged home later today. He will continue on his current medications. He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.
CONCLUSIONS / FINAL DIAGNOSES: Successful DC cardioversion of atrial fibrillation.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardioversion - Unsuccessful
Description: Cardioversion. Unsuccessful direct current cardioversion with permanent atrial fibrillation.
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REASON FOR EXAM: Atrial flutter/cardioversion.
PROCEDURE IN DETAIL: The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed. The pads were applied in the anterior-posterior approach. The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful. Second attempt at 200 J with anterior-posterior approach. With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.
The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.
IMPRESSION: Unsuccessful direct current cardioversion with permanent atrial fibrillation.
PROCEDURE IN DETAIL: The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed. The pads were applied in the anterior-posterior approach. The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful. Second attempt at 200 J with anterior-posterior approach. With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.
The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.
IMPRESSION: Unsuccessful direct current cardioversion with permanent atrial fibrillation.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid & Cerebral Arteriograms
Description: Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.
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EXAM: Carotid and cerebral arteriograms.
INDICATION: Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.
IMPRESSION:
1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.
2. Mild stenosis of the right internal carotid artery measured at 20%.
3. Patent bilateral vertebral arteries.
4. No significant disease was identified of the anterior cerebral vessels.
DISCUSSION: Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.
The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.
Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.
The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home.
INDICATION: Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.
IMPRESSION:
1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.
2. Mild stenosis of the right internal carotid artery measured at 20%.
3. Patent bilateral vertebral arteries.
4. No significant disease was identified of the anterior cerebral vessels.
DISCUSSION: Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.
The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.
Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.
The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid Doppler Report
Description: Carotid Ultrasonic & Color Flow Imaging
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Grade I: Intimal thickening or some atherosclerotic plaques are seen appearing to cause less than 40% obstruction.
Grade II: Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.
Grade III: Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.
Grade IV: The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.
RIGHT CAROTID SYSTEM: The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease. The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.
LEFT CAROTID SYSTEM: The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.
IMPRESSION: Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.
Grade II: Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.
Grade III: Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.
Grade IV: The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.
RIGHT CAROTID SYSTEM: The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease. The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.
LEFT CAROTID SYSTEM: The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.
IMPRESSION: Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid Endarterectomy
Description: Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.
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(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Right carotid stenosis.
2. Prior cerebrovascular accident.
POSTOPERATIVE DIAGNOSES:
1. Right carotid stenosis.
2. Prior cerebrovascular accident.
PROCEDURE PERFORMED: Right carotid endarterectomy with patch angioplasty.
ESTIMATED BLOOD LOSS: 250 cc.
OPERATIVE FINDINGS: The common and internal carotid arteries were opened. A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid. This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.
PROCEDURE: The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution. Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The platysmal muscle was divided. The carotid sheath was identified and opened. The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided. The common internal and external carotids were then freed from the surrounding tissue. At this point, 10,000 units of aqueous heparin were administered and allowed to take effect. The external and common carotids were then clamped. The patient's neurological status was evaluated and found to be unchanged from preoperative levels.
Once sufficient time had lapsed, we proceeded with the procedure. The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid. The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external. The plaque tapered nicely on the internal and no tacking sutures were necessary. Heparinized saline was injected and no evidence of flapping or other debris was noted. The remaining carotid was examined under magnification, which showed no debris of flaps present. At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion. Prior to the time of last stitch, the internal carotid was back-bled through this. The last stitch was tied. Hemostasis was excellent. The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system. At this point, a total of 50 mg of Protamine was administered and allowed to take effect. Hemostasis was excellent. The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl. The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well. Sponge, needles, and instrument count were correct. Estimated blood loss was 250 cc.
1. Right carotid stenosis.
2. Prior cerebrovascular accident.
POSTOPERATIVE DIAGNOSES:
1. Right carotid stenosis.
2. Prior cerebrovascular accident.
PROCEDURE PERFORMED: Right carotid endarterectomy with patch angioplasty.
ESTIMATED BLOOD LOSS: 250 cc.
OPERATIVE FINDINGS: The common and internal carotid arteries were opened. A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid. This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.
PROCEDURE: The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution. Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The platysmal muscle was divided. The carotid sheath was identified and opened. The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided. The common internal and external carotids were then freed from the surrounding tissue. At this point, 10,000 units of aqueous heparin were administered and allowed to take effect. The external and common carotids were then clamped. The patient's neurological status was evaluated and found to be unchanged from preoperative levels.
Once sufficient time had lapsed, we proceeded with the procedure. The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid. The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external. The plaque tapered nicely on the internal and no tacking sutures were necessary. Heparinized saline was injected and no evidence of flapping or other debris was noted. The remaining carotid was examined under magnification, which showed no debris of flaps present. At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion. Prior to the time of last stitch, the internal carotid was back-bled through this. The last stitch was tied. Hemostasis was excellent. The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system. At this point, a total of 50 mg of Protamine was administered and allowed to take effect. Hemostasis was excellent. The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl. The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well. Sponge, needles, and instrument count were correct. Estimated blood loss was 250 cc.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid Endarterectomy - 1
Description: Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.
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(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right common, internal and external carotid artery stenosis.
POSTOPERATIVE DIAGNOSIS: Right common, internal and external carotid artery stenosis.
OPERATIONS
1. Right common carotid endarterectomy.
2. Right internal carotid endarterectomy.
3. Right external carotid endarterectomy.
4. Hemashield patch angioplasty of the right common, internal and external carotid arteries.
ANESTHESIA: General endotracheal anesthesia.
URINE OUTPUT: Not recorded
OPERATION IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next the right neck was prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle. Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors. The common, internal and external carotid arteries were identified. The facial vein was ligated with #3-0 silk. The hypoglossal nerve was identified and preserved as it coursed across the carotid artery. After dissecting out an adequate length of common, internal and external carotid artery, heparin was given. Next, an umbilical tape was passed around the common carotid artery. A #0 silk suture was passed around the internal and external carotid arteries. The hypoglossal nerve was identified and preserved. An appropriate sized Argyle shunt was chosen. A Hemashield patch was cut to the appropriate size. Next, vascular clamps were placed on the external carotid artery. DeBakey pickups were used to control the internal carotid artery and common carotid artery. A #11-blade scalpel was used to make an incision on the common carotid artery. The arteriotomy was lengthened onto the internal carotid artery. Next, the Argyle shunt was placed. It was secured in place. Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries. An inversion technique was used on the external carotid artery. The artery was irrigated and free debris was removed. Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion. Prior to completion of our anastomosis, we removed our shunt. We completed the anastomosis. Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery. There was no evidence of bleeding. Full-dose protamine was given. The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion. A sterile dressing was applied.
POSTOPERATIVE DIAGNOSIS: Right common, internal and external carotid artery stenosis.
OPERATIONS
1. Right common carotid endarterectomy.
2. Right internal carotid endarterectomy.
3. Right external carotid endarterectomy.
4. Hemashield patch angioplasty of the right common, internal and external carotid arteries.
ANESTHESIA: General endotracheal anesthesia.
URINE OUTPUT: Not recorded
OPERATION IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next the right neck was prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle. Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors. The common, internal and external carotid arteries were identified. The facial vein was ligated with #3-0 silk. The hypoglossal nerve was identified and preserved as it coursed across the carotid artery. After dissecting out an adequate length of common, internal and external carotid artery, heparin was given. Next, an umbilical tape was passed around the common carotid artery. A #0 silk suture was passed around the internal and external carotid arteries. The hypoglossal nerve was identified and preserved. An appropriate sized Argyle shunt was chosen. A Hemashield patch was cut to the appropriate size. Next, vascular clamps were placed on the external carotid artery. DeBakey pickups were used to control the internal carotid artery and common carotid artery. A #11-blade scalpel was used to make an incision on the common carotid artery. The arteriotomy was lengthened onto the internal carotid artery. Next, the Argyle shunt was placed. It was secured in place. Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries. An inversion technique was used on the external carotid artery. The artery was irrigated and free debris was removed. Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion. Prior to completion of our anastomosis, we removed our shunt. We completed the anastomosis. Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery. There was no evidence of bleeding. Full-dose protamine was given. The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion. A sterile dressing was applied.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid Endarterectomy & Angioplasty.
Description: Left carotid endarterectomy with endovascular patch angioplasty. Critical left carotid stenosis. The external carotid artery was occluded at its origin. When the endarterectomy was performed, the external carotid artery back-bled nicely. The internal carotid artery had good backflow bleeding noted.
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PREOPERATIVE DIAGNOSIS: Critical left carotid stenosis.
POSTOPERATIVE DIAGNOSIS: Critical left carotid stenosis.
PROCEDURE PERFORMED: Left carotid endarterectomy with endovascular patch angioplasty.
ANESTHESIA: Cervical block.
GROSS FINDINGS: The patient is a 57-year-old black female with chronic renal failure. She does have known critical carotid artery stenosis. She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization. She was admitted to the hospital yesterday with chest pain. She has been considered for coronary artery bypass grafting. I have been asked to address the carotid stenosis, left being more severe, this was addressed first. Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery. The internal carotid artery is quite torturous. The external carotid artery was occluded at its origin. When the endarterectomy was performed, the external carotid artery back-bled nicely. The internal carotid artery had good backflow bleeding noted.
OPERATIVE PROCEDURE: The patient was taken to the OR suite and placed in the supine position. Then neck, shoulder, and chest wall were prepped and draped in appropriate manner. Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.
Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape. During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them. Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved. There was some inflammation above the carotid bulb, but this was not problematic.
The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time. The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips. The common carotid artery was controlled with profunda clamp. The patient remained neurologically intact. A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery. This was extended across the lobe on to the internal carotid artery. An endarterectomy was then performed. The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline. As mentioned before, the internal carotid artery is quite torturous. This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.
The wound was copiously irrigated, rather an endovascular patch was then brought on to the field. This was cut to shape and length. This was sutured in place with continuous running #6-0 Prolene suture. The suture line began at both sites. The suture was tied in the center along the anterior and posterior walls. Prior to completing the closure, the common carotid artery was flushed. The internal carotid artery permitted to back bleed. The clamp was placed after completing the closure. The clamp was placed at the origin of the internal carotid artery. Flow was first directed into the external carotid artery then into the internal carotid artery. The patient remained neurologically intact. Topical ________ Gelfoam was utilized. Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin. The wound was copiously irrigated with antibiotic solution. Sponge, needle, and all counts were correct. All surgical sites were inspected. Good hemostasis noted. The incision was closed in layers with absorbable suture. Stainless steel staples approximated skin. Sterile dressings were applied. The patient tolerated the procedure well, grossly neurologically intact.
POSTOPERATIVE DIAGNOSIS: Critical left carotid stenosis.
PROCEDURE PERFORMED: Left carotid endarterectomy with endovascular patch angioplasty.
ANESTHESIA: Cervical block.
GROSS FINDINGS: The patient is a 57-year-old black female with chronic renal failure. She does have known critical carotid artery stenosis. She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization. She was admitted to the hospital yesterday with chest pain. She has been considered for coronary artery bypass grafting. I have been asked to address the carotid stenosis, left being more severe, this was addressed first. Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery. The internal carotid artery is quite torturous. The external carotid artery was occluded at its origin. When the endarterectomy was performed, the external carotid artery back-bled nicely. The internal carotid artery had good backflow bleeding noted.
OPERATIVE PROCEDURE: The patient was taken to the OR suite and placed in the supine position. Then neck, shoulder, and chest wall were prepped and draped in appropriate manner. Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.
Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape. During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them. Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved. There was some inflammation above the carotid bulb, but this was not problematic.
The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time. The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips. The common carotid artery was controlled with profunda clamp. The patient remained neurologically intact. A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery. This was extended across the lobe on to the internal carotid artery. An endarterectomy was then performed. The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline. As mentioned before, the internal carotid artery is quite torturous. This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.
The wound was copiously irrigated, rather an endovascular patch was then brought on to the field. This was cut to shape and length. This was sutured in place with continuous running #6-0 Prolene suture. The suture line began at both sites. The suture was tied in the center along the anterior and posterior walls. Prior to completing the closure, the common carotid artery was flushed. The internal carotid artery permitted to back bleed. The clamp was placed after completing the closure. The clamp was placed at the origin of the internal carotid artery. Flow was first directed into the external carotid artery then into the internal carotid artery. The patient remained neurologically intact. Topical ________ Gelfoam was utilized. Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin. The wound was copiously irrigated with antibiotic solution. Sponge, needle, and all counts were correct. All surgical sites were inspected. Good hemostasis noted. The incision was closed in layers with absorbable suture. Stainless steel staples approximated skin. Sterile dressings were applied. The patient tolerated the procedure well, grossly neurologically intact.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Central Line Insertion
Description: Central line insertion. Empyema thoracis and need for intravenous antibiotics.
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PREOPERATIVE DIAGNOSES
1. Empyema thoracis.
2. Need for intravenous antibiotics.
POSTOPERATIVE DIAGNOSES
1. Empyema thoracis.
2. Need for intravenous antibiotics.
PROCEDURE: Central line insertion.
DESCRIPTION OF PROCEDURE: With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty. The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline. The catheter was fixed to the skin with sutures. The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.
1. Empyema thoracis.
2. Need for intravenous antibiotics.
POSTOPERATIVE DIAGNOSES
1. Empyema thoracis.
2. Need for intravenous antibiotics.
PROCEDURE: Central line insertion.
DESCRIPTION OF PROCEDURE: With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty. The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline. The catheter was fixed to the skin with sutures. The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Central Line Placement
Description: Right subclavian triple lumen central line placement
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PREOPERATIVE DIAGNOSIS:
1. Severe chronic obstructive coronary disease.
2. Respiratory failure.
POSTOPERATIVE DIAGNOSIS:
1. Severe chronic obstructive coronary disease.
2. Respiratory failure.
OPERATION: Right subclavian triple lumen central line placement.
ANESTHESIA: Local Xylocaine.
INDICATIONS FOR OPERATION: This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.
INFORMED CONSENT: The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.
PROCEDURE: With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.
FINDINGS/SPECIMENS REMOVED: None
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Nil.
1. Severe chronic obstructive coronary disease.
2. Respiratory failure.
POSTOPERATIVE DIAGNOSIS:
1. Severe chronic obstructive coronary disease.
2. Respiratory failure.
OPERATION: Right subclavian triple lumen central line placement.
ANESTHESIA: Local Xylocaine.
INDICATIONS FOR OPERATION: This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.
INFORMED CONSENT: The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.
PROCEDURE: With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.
FINDINGS/SPECIMENS REMOVED: None
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Nil.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Central Venous & Arterial Line
Description: Insertion of central venous line and arterial line and transesophageal echocardiography probe.
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INDICATIONS FOR PROCEDURES: Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.
The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including use of gowns, mask, and gloves, etc. The skin was cleansed with alcohol and then prepped with ChloraPrep solution.
PROCEDURE #1: Insertion of central venous line.
DESCRIPTION OF PROCEDURE #1: Attention was directed to the right groin. A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened. Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery. There was good venous blood return on the first try. Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm. It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact. There was good blood return from both lumens, which were flushed with heparinized saline. The catheter was sutured to the skin at three points with #4-0 silk for stabilization.
PROCEDURE #2: Insertion of arterial line.
DESCRIPTION OF PROCEDURE #2: Attention was directed to the left wrist, which was placed on wrist rest. The Allen test was normal. A Cook 2.5-French 5 cm long arterial catheter kit was opened. A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return. Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact. There was pulsatile blood return and the catheter was flushed with heparinized saline solution. It was sutured to the skin with #4-0 silk at three points for stabilization.
Both catheters functioned well throughout the procedure. The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure. There were no complications.
PROCEDURE #3: Insertion of transesophageal echocardiography probe.
DESCRIPTION OF PROCEDURE #3: The probe was inserted under direct vision because initially there was some resistance to insertion. Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance. There was good visualization of the heart. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. The probe was removed at the end. There was no trauma and there was no blood tingeing.
The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including use of gowns, mask, and gloves, etc. The skin was cleansed with alcohol and then prepped with ChloraPrep solution.
PROCEDURE #1: Insertion of central venous line.
DESCRIPTION OF PROCEDURE #1: Attention was directed to the right groin. A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened. Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery. There was good venous blood return on the first try. Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm. It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact. There was good blood return from both lumens, which were flushed with heparinized saline. The catheter was sutured to the skin at three points with #4-0 silk for stabilization.
PROCEDURE #2: Insertion of arterial line.
DESCRIPTION OF PROCEDURE #2: Attention was directed to the left wrist, which was placed on wrist rest. The Allen test was normal. A Cook 2.5-French 5 cm long arterial catheter kit was opened. A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return. Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact. There was pulsatile blood return and the catheter was flushed with heparinized saline solution. It was sutured to the skin with #4-0 silk at three points for stabilization.
Both catheters functioned well throughout the procedure. The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure. There were no complications.
PROCEDURE #3: Insertion of transesophageal echocardiography probe.
DESCRIPTION OF PROCEDURE #3: The probe was inserted under direct vision because initially there was some resistance to insertion. Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance. There was good visualization of the heart. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. The probe was removed at the end. There was no trauma and there was no blood tingeing.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Closure
Description: Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.
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PROCEDURE: Delayed primary chest closure.
INDICATIONS: The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management. He is now taken back to the operative room for delayed primary chest closure.
PREOP DX: Open chest status post modified stage 1 Norwood operation.
POSTOP DX: Open chest status post modified stage 1 Norwood operation.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
FINDINGS: No evidence of intramediastinal purulence or hematoma. He tolerated the procedure well.
DETAILS OF PROCEDURE: The patient was brought to the operating room and placed on the operating table in the supine position. Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion. The previously placed AlloDerm membrane was removed. Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned. Both cavities were also irrigated and suctioned. The drains were flushed and repositioned. Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line. The sternum was then smeared with a vancomycin paste. The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side. The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches. The skin was closed with interrupted nylon sutures and a sterile dressing was placed. The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed. The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.
I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.
INDICATIONS: The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management. He is now taken back to the operative room for delayed primary chest closure.
PREOP DX: Open chest status post modified stage 1 Norwood operation.
POSTOP DX: Open chest status post modified stage 1 Norwood operation.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
FINDINGS: No evidence of intramediastinal purulence or hematoma. He tolerated the procedure well.
DETAILS OF PROCEDURE: The patient was brought to the operating room and placed on the operating table in the supine position. Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion. The previously placed AlloDerm membrane was removed. Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned. Both cavities were also irrigated and suctioned. The drains were flushed and repositioned. Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line. The sternum was then smeared with a vancomycin paste. The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side. The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches. The skin was closed with interrupted nylon sutures and a sterile dressing was placed. The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed. The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.
I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.
REVIEW OF SYSTEMS: Generally healthy. The patient is a good historian.
ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.
ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.
ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.
ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.
ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.
ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.
ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.
ROS Extremities: The patient denies any extremities complaints.
ROS Cardiovascular: As per HPI.
EXAMINATION:
Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.
Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.
Range of motion is normal. There is no cyanosis, clubbing or edema.
General: Healthy appearing, well developed,. The patient is in no acute distress.
Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.
Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.
Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.
Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.
Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.
ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.
ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.
ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.
ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.
ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.
ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.
ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.
ROS Extremities: The patient denies any extremities complaints.
ROS Cardiovascular: As per HPI.
EXAMINATION:
Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.
Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.
Range of motion is normal. There is no cyanosis, clubbing or edema.
General: Healthy appearing, well developed,. The patient is in no acute distress.
Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.
Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.
Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.
Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.
Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest PA & Lateral
Description: Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.
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EXAM: Chest PA & Lateral.
REASON FOR EXAM: Shortness of breath, evaluate for pneumothorax versus left-sided effusion.
INTERPRETATION: There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation. The heart and pulmonary vascularity are within normal limits. Left-sided port is seen with Groshong tip at the SVC/RA junction. No evidence for acute fracture, malalignment, or dislocation.
IMPRESSION:
1. Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.
2. Rest of visualized exam nonacute/stable.
3. Left central line appropriately situated and stable.
4. Preliminary report was issued at time of dictation. Dr. X was called for results.
REASON FOR EXAM: Shortness of breath, evaluate for pneumothorax versus left-sided effusion.
INTERPRETATION: There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation. The heart and pulmonary vascularity are within normal limits. Left-sided port is seen with Groshong tip at the SVC/RA junction. No evidence for acute fracture, malalignment, or dislocation.
IMPRESSION:
1. Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.
2. Rest of visualized exam nonacute/stable.
3. Left central line appropriately situated and stable.
4. Preliminary report was issued at time of dictation. Dr. X was called for results.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Pulmonary Angio
Description: Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.
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EXAM: CTA chest pulmonary angio.
REASON FOR EXAM: Evaluate for pulmonary embolism.
TECHNIQUE: Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.
FINDINGS: There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. There is no evidence of a central embolism.
As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. However, there is considerable change in the appearance of the lung fields. There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. There are also extensive right lung consolidations, all new or increased significantly from the prior examination. Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. There is no pneumothorax in the interval.
On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. There is aortic root and arch and descending thoracic aortic calcification. There are scattered regions of soft plaque intermixed with this. The heart is not enlarged. The left axilla is intact in regards to adenopathy. The inferior thyroid appears unremarkable.
Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. Spleen, adrenal glands, and upper kidneys appear unremarkable. Visualized portions of the pancreas are unremarkable.
There is extensive rib destruction in the region of the chest wall mass. There are changes suggesting prior trauma to the right clavicle.
IMPRESSION:
1. Again demonstrated is a large right chest wall mass.
2. No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.
3. New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.
4. See above regarding other findings.s
REASON FOR EXAM: Evaluate for pulmonary embolism.
TECHNIQUE: Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.
FINDINGS: There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. There is no evidence of a central embolism.
As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. However, there is considerable change in the appearance of the lung fields. There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. There are also extensive right lung consolidations, all new or increased significantly from the prior examination. Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. There is no pneumothorax in the interval.
On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. There is aortic root and arch and descending thoracic aortic calcification. There are scattered regions of soft plaque intermixed with this. The heart is not enlarged. The left axilla is intact in regards to adenopathy. The inferior thyroid appears unremarkable.
Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. Spleen, adrenal glands, and upper kidneys appear unremarkable. Visualized portions of the pancreas are unremarkable.
There is extensive rib destruction in the region of the chest wall mass. There are changes suggesting prior trauma to the right clavicle.
IMPRESSION:
1. Again demonstrated is a large right chest wall mass.
2. No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.
3. New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.
4. See above regarding other findings.s
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Insertion
Description: Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion.
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PREOPERATIVE DIAGNOSIS: Right hemothorax.
POSTOPERATIVE DIAGNOSIS: Right hemothorax.
PROCEDURE PERFORMED: Insertion of a #32 French chest tube on the right hemithorax.
ANESTHESIA: 1% Lidocaine and sedation.
INDICATIONS FOR PROCEDURE: This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion today. Postoperatively from that, she started having a blood tinged pink frothy sputum. Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum. The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.
DESCRIPTION OF PROCEDURE: The area was prepped and draped in the sterile fashion. The area was anesthetized with 1% Lidocaine solution. The patient was given sedation. A #10 blade scalpel was used to make an incision approximately 1.5 cm long. Then a curved scissor was used to dissect down to the level of the rib. A blunt peon was then used to again enter into the right hemithorax. Immediately a blood tinged effusion was released. The chest tube was placed and directed in a posterior and superior direction. The chest tube was hooked up to the Pleur-evac device which was ________ tip suction. The chest tube was tied in with a #0 silk suture in a U-stitch fashion. It was sutured in place with sterile dressing and silk tape. The patient tolerated this procedure well. We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.
POSTOPERATIVE DIAGNOSIS: Right hemothorax.
PROCEDURE PERFORMED: Insertion of a #32 French chest tube on the right hemithorax.
ANESTHESIA: 1% Lidocaine and sedation.
INDICATIONS FOR PROCEDURE: This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion today. Postoperatively from that, she started having a blood tinged pink frothy sputum. Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum. The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.
DESCRIPTION OF PROCEDURE: The area was prepped and draped in the sterile fashion. The area was anesthetized with 1% Lidocaine solution. The patient was given sedation. A #10 blade scalpel was used to make an incision approximately 1.5 cm long. Then a curved scissor was used to dissect down to the level of the rib. A blunt peon was then used to again enter into the right hemithorax. Immediately a blood tinged effusion was released. The chest tube was placed and directed in a posterior and superior direction. The chest tube was hooked up to the Pleur-evac device which was ________ tip suction. The chest tube was tied in with a #0 silk suture in a U-stitch fashion. It was sutured in place with sterile dressing and silk tape. The patient tolerated this procedure well. We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Insertion in ER
Description: Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.
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PREOPERATIVE DIAGNOSES:
1. Right spontaneous pneumothorax secondary to barometric trauma.
2. Respiratory failure.
3. Pneumonia with sepsis.
POSTOPERATIVE DIAGNOSES:
1. Right spontaneous pneumothorax secondary to barometric trauma.
2. Respiratory failure.
3. Pneumonia with sepsis.
INFORMED CONSENT: Not obtained. This patient is obtunded, intubated, and septic. This is an emergent procedure with 2-physician emergency consent signed and on the chart.
PROCEDURE: The patient's right chest was prepped and draped in sterile fashion. The site of insertion was anesthetized with 1% Xylocaine, and an incision was made. Blunt dissection was carried out 2 intercostal spaces above the initial incision site. The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly. The chest tube was placed.
A postoperative chest x-ray is pending at this time.
The patient tolerated the procedure well and was taken to the recovery room in stable condition.
ESTIMATED BLOOD LOSS: 10 mL
COMPLICATIONS: None.
SPONGE COUNT: Correct x2.
1. Right spontaneous pneumothorax secondary to barometric trauma.
2. Respiratory failure.
3. Pneumonia with sepsis.
POSTOPERATIVE DIAGNOSES:
1. Right spontaneous pneumothorax secondary to barometric trauma.
2. Respiratory failure.
3. Pneumonia with sepsis.
INFORMED CONSENT: Not obtained. This patient is obtunded, intubated, and septic. This is an emergent procedure with 2-physician emergency consent signed and on the chart.
PROCEDURE: The patient's right chest was prepped and draped in sterile fashion. The site of insertion was anesthetized with 1% Xylocaine, and an incision was made. Blunt dissection was carried out 2 intercostal spaces above the initial incision site. The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly. The chest tube was placed.
A postoperative chest x-ray is pending at this time.
The patient tolerated the procedure well and was taken to the recovery room in stable condition.
ESTIMATED BLOOD LOSS: 10 mL
COMPLICATIONS: None.
SPONGE COUNT: Correct x2.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Placement
Description: Left pleural effusion, parapneumonic, loculated. Left chest tube placement.
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PREOPERATIVE DIAGNOSIS: Left pleural effusion, parapneumonic, loculated.
POSTOPERATIVE DIAGNOSIS: Left pleural effusion, parapneumonic, loculated.
OPERATION: Left chest tube placement.
IV SEDATION: 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.
PROCEDURE: With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion. A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple. The incision was made and deepened through the different layers to reach the intercostal space. The pleura was entered on top of the underlying rib and finger digital palpation was performed. Multiple loculations were encountered. Break up of loculations was performed posteriorly and a chest tube was directed posteriorly. Only a small amount of fluid was noted to come out initially. This was sent for various studies. Soft adhesions were encountered. The plan was to obtain a chest x-ray and start Activase installation.
POSTOPERATIVE DIAGNOSIS: Left pleural effusion, parapneumonic, loculated.
OPERATION: Left chest tube placement.
IV SEDATION: 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.
PROCEDURE: With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion. A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple. The incision was made and deepened through the different layers to reach the intercostal space. The pleura was entered on top of the underlying rib and finger digital palpation was performed. Multiple loculations were encountered. Break up of loculations was performed posteriorly and a chest tube was directed posteriorly. Only a small amount of fluid was noted to come out initially. This was sent for various studies. Soft adhesions were encountered. The plan was to obtain a chest x-ray and start Activase installation.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Removal
Description: Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound.
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PREOPERATIVE DIAGNOSIS: Bilateral pleural effusion.
POSTOPERATIVE DIAGNOSIS: Bilateral pleural effusion.
PROCEDURE PERFORMED: Removal of bilateral #32-French chest tubes with closure of wound.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage. A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures. The patient was agreeable to proceed.
OPERATIVE PROCEDURE: The patient was prepped and draped at the bedside over both chest tube sites. The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures. The skin was then cleansed and Vaseline occlusive dressing was applied over the sites. The same procedure was performed on the other side. The chest tubes were removed on full inspiration. Vital signs remained stable throughout the procedure. The patient will remain in the intensive care unit for continued monitoring.
POSTOPERATIVE DIAGNOSIS: Bilateral pleural effusion.
PROCEDURE PERFORMED: Removal of bilateral #32-French chest tubes with closure of wound.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage. A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures. The patient was agreeable to proceed.
OPERATIVE PROCEDURE: The patient was prepped and draped at the bedside over both chest tube sites. The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures. The skin was then cleansed and Vaseline occlusive dressing was applied over the sites. The same procedure was performed on the other side. The chest tubes were removed on full inspiration. Vital signs remained stable throughout the procedure. The patient will remain in the intensive care unit for continued monitoring.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Wall Tumor Resection
Description: Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.
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PREOPERATIVE DIAGNOSIS: Left chest wall tumor, spindle cell histology.
POSTOPERATIVE DIAGNOSIS: Left chest wall tumor, spindle cell histology with pathology pending.
PROCEDURE: Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.
ANESTHESIA: General endotracheal.
SPECIMEN: Left chest wall with tumor and left lower lobe lung wedge resection to pathology.
INDICATIONS FOR PROCEDURE: The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased. Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening. A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma. The patient had a metastatic workup, which was negative including a brain MRI and bone scan. The bone scan showed only signal positivity in the left 9th rib near the tumor. The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia. He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.
PROCEDURE IN DETAIL: The patient was brought to the operating room and placed in the supine position. The patient was intubated with a double-lumen endotracheal tube. Intravenous antibiotics were given. A Foley catheter was placed. The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion. An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass. The skin and subcutaneous tissues were dissected sharply with the electrocautery. Good hemostasis was obtained. The tumor was easily palpable and clearly involving the 8th to 9th rib. A thoracotomy was initially made above the mass in approximately the 7th intercostal space. Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection. The thoracotomy was extended anteriorly and posteriorly. It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected. The ribs of the chest wall were first cut at their anterior aspect. The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery. Hemostasis was obtained with both electrocautery and clips. The chest wall segment to be resected was retracted laterally and posteriorly. It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement. Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor. The spleen and the stomach were identified and were protected. Inferiorly, the resection of the chest wall was continued in the 10th interspace. The dissection was then carried posteriorly to the level of the spine. The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung. A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection. Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies. The ribs were disarticulated, closed to or at their articulations with the spine. Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery. There was no disease grossly involving or encasing the aorta.
The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section. The specimen was oriented for the pathologist who came to the room. Hemostasis was obtained. The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures. This produced a satisfactory diaphragmatic repair without undue tension. A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly. This was secured with a #1 silk suture. The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect. A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually. The resulting mesh closure was snug and deemed adequate. The serratus muscle was reapproximated with figure-of-8 0 Vicryl. The latissimus was reapproximated with a two #1 Vicryl placed in running fashion. Of note, two #10 JP drains were placed over the mesh repair of the chest wall. The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl. The wounds were dressed. The patient was brought from the operating room directly to the North ICU, intubated in stable condition. All counts were correct.
POSTOPERATIVE DIAGNOSIS: Left chest wall tumor, spindle cell histology with pathology pending.
PROCEDURE: Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.
ANESTHESIA: General endotracheal.
SPECIMEN: Left chest wall with tumor and left lower lobe lung wedge resection to pathology.
INDICATIONS FOR PROCEDURE: The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased. Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening. A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma. The patient had a metastatic workup, which was negative including a brain MRI and bone scan. The bone scan showed only signal positivity in the left 9th rib near the tumor. The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia. He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.
PROCEDURE IN DETAIL: The patient was brought to the operating room and placed in the supine position. The patient was intubated with a double-lumen endotracheal tube. Intravenous antibiotics were given. A Foley catheter was placed. The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion. An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass. The skin and subcutaneous tissues were dissected sharply with the electrocautery. Good hemostasis was obtained. The tumor was easily palpable and clearly involving the 8th to 9th rib. A thoracotomy was initially made above the mass in approximately the 7th intercostal space. Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection. The thoracotomy was extended anteriorly and posteriorly. It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected. The ribs of the chest wall were first cut at their anterior aspect. The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery. Hemostasis was obtained with both electrocautery and clips. The chest wall segment to be resected was retracted laterally and posteriorly. It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement. Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor. The spleen and the stomach were identified and were protected. Inferiorly, the resection of the chest wall was continued in the 10th interspace. The dissection was then carried posteriorly to the level of the spine. The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung. A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection. Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies. The ribs were disarticulated, closed to or at their articulations with the spine. Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery. There was no disease grossly involving or encasing the aorta.
The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section. The specimen was oriented for the pathologist who came to the room. Hemostasis was obtained. The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures. This produced a satisfactory diaphragmatic repair without undue tension. A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly. This was secured with a #1 silk suture. The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect. A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually. The resulting mesh closure was snug and deemed adequate. The serratus muscle was reapproximated with figure-of-8 0 Vicryl. The latissimus was reapproximated with a two #1 Vicryl placed in running fashion. Of note, two #10 JP drains were placed over the mesh repair of the chest wall. The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl. The wounds were dressed. The patient was brought from the operating room directly to the North ICU, intubated in stable condition. All counts were correct.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cineangiography
Description: Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURES UNDERTAKEN
1. Left coronary system cineangiography.
2. Right coronary system cineangiography.
3. Cineangiography of SVG to OM.
4. Cineangiography of LIMA to LAD.
5. Left ventriculogram.
6. Aortogram.
7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.
NARRATIVE: After all risks and benefits were explained to the patient, informed consent was obtained. The patient was brought to the cardiac catheterization suite. The right groin was prepped in the usual sterile fashion. Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta. Next, Judkins left catheter was used to engage the left coronary system. Cineangiography was recorded in multiple views. Next, Judkins right catheter was used to engage the right coronary system. Cineangiography was recorded in multiple views. Next, the Judkins right catheter was used to engage the SVG to OM. Cineangiography was recorded. Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views. Next, an angled pigtail catheter was advanced into the left ventricular cavity. LV pressures were measured. LV gram was done and a pullback gradient across the aortic valve was done and recorded. Next, an aortogram was done and recorded. At this point, I decided to proceed with percutaneous intervention of the left circumflex. Therefore, AVA 3.5 guide was used to engage the left coronary artery. Angiomax bolus and drip was started. Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres. Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent. Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion. We next attempted a cutting balloon. Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire. Again, we were unable to cross the lesion with the stent. We then try to cross with a noncompliant balloon, which we were unsuccessful. We also try to cutting balloon again, we were unsuccessful. Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted. Final images showed no evidence of dissection, perforation, or further complication. The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results. The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.
DIAGNOSTIC FINDINGS
1. The LV. LVEDP was 4. LVES is approximately 50%-55% with inferobasal hypokinesis. No significant MR. No gradient across the aortic valve.
2. Aortogram. The ascending aorta shows no significant dilatation or evidence of dissection. The valve shows no significant aortic insufficiencies. The abdominal aorta and distal aorta shows significant tortuosities.
3. The left main. The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.
4. Left circumflex. The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch. The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis. The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.
5. LAD. The LAD is a totally 100% occluded vessel. The LIMA to LAD is patent with only a small-to-moderate caliber LAD. There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%. The diagonal shows proximal 80% stenosis.
6. The right coronary artery: The right coronary artery is 100% occluded. There are retrograde collaterals from left to right to the distal PDA and PLV branches. The SVG to OM is 100% occluded at its take off. The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.
7. LIMA to LAD is widely patent.
ASSESSMENT AND PLAN: Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon. Final images showed some improvement, however, continued residual stenosis. At this point, the patient will be transferred back to telemetry floor and monitored. We can attempt future intervention or continue aggressive medical management. The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch. Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.
1. Left coronary system cineangiography.
2. Right coronary system cineangiography.
3. Cineangiography of SVG to OM.
4. Cineangiography of LIMA to LAD.
5. Left ventriculogram.
6. Aortogram.
7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.
NARRATIVE: After all risks and benefits were explained to the patient, informed consent was obtained. The patient was brought to the cardiac catheterization suite. The right groin was prepped in the usual sterile fashion. Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta. Next, Judkins left catheter was used to engage the left coronary system. Cineangiography was recorded in multiple views. Next, Judkins right catheter was used to engage the right coronary system. Cineangiography was recorded in multiple views. Next, the Judkins right catheter was used to engage the SVG to OM. Cineangiography was recorded. Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views. Next, an angled pigtail catheter was advanced into the left ventricular cavity. LV pressures were measured. LV gram was done and a pullback gradient across the aortic valve was done and recorded. Next, an aortogram was done and recorded. At this point, I decided to proceed with percutaneous intervention of the left circumflex. Therefore, AVA 3.5 guide was used to engage the left coronary artery. Angiomax bolus and drip was started. Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres. Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent. Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion. We next attempted a cutting balloon. Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire. Again, we were unable to cross the lesion with the stent. We then try to cross with a noncompliant balloon, which we were unsuccessful. We also try to cutting balloon again, we were unsuccessful. Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted. Final images showed no evidence of dissection, perforation, or further complication. The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results. The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.
DIAGNOSTIC FINDINGS
1. The LV. LVEDP was 4. LVES is approximately 50%-55% with inferobasal hypokinesis. No significant MR. No gradient across the aortic valve.
2. Aortogram. The ascending aorta shows no significant dilatation or evidence of dissection. The valve shows no significant aortic insufficiencies. The abdominal aorta and distal aorta shows significant tortuosities.
3. The left main. The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.
4. Left circumflex. The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch. The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis. The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.
5. LAD. The LAD is a totally 100% occluded vessel. The LIMA to LAD is patent with only a small-to-moderate caliber LAD. There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%. The diagonal shows proximal 80% stenosis.
6. The right coronary artery: The right coronary artery is 100% occluded. There are retrograde collaterals from left to right to the distal PDA and PLV branches. The SVG to OM is 100% occluded at its take off. The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.
7. LIMA to LAD is widely patent.
ASSESSMENT AND PLAN: Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon. Final images showed some improvement, however, continued residual stenosis. At this point, the patient will be transferred back to telemetry floor and monitored. We can attempt future intervention or continue aggressive medical management. The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch. Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cineangiography - 1
Description: Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CATHETERIZATION: ST-elevation myocardial infarction.
PROCEDURES UNDERTAKEN
1. Left coronary system cineangiography.
2. Right coronary system cineangiography.
3. Left ventriculogram.
4. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.
PROCEDURE: After all risks and benefits were explained to the patient, informed consent was obtained. The patient was brought to the cardiac cath suite. Right groin was prepped in usual sterile fashion. Right common femoral artery was cannulated with the modified Seldinger technique. A 6-French sheath was introduced. Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views. Next, an EBU 3.5 guide was used to engage the left coronary system. Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis. Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion. Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion. Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres. There was noted to be a plaque shift proximally at the edge of the stent. Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres. Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds. Final images showed excellent results with initial 99% stenosis reduced to 0%. The patient continues to have residual stenosis in the mid to distal in the OM branch. At this point, wire was removed. Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.
Next, an angled pigtail catheter was advanced into the left ventricular cavity. LV pressure was measured. LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded. Finally, all guides were removed. Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis. The patient tolerated the procedure very well without complications.
DIAGNOSTIC FINDINGS
1. Left main: Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.
2. The LAD: LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.
3. Left circumflex: Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.
4. Right coronary artery: Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease. Otherwise, no significant stenosis noted.
5. LV: The LVEF 50%. Inferolateral wall hypokinesis. No significant mitral regurgitation. No gradient across the aortic valve on pullback.
ASSESSMENT AND PLAN: ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent. Excellent results, 0% residual stenosis. The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels. Therefore, we will aggressively treat this patient medically with close followup as an outpatient.
PROCEDURES UNDERTAKEN
1. Left coronary system cineangiography.
2. Right coronary system cineangiography.
3. Left ventriculogram.
4. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.
PROCEDURE: After all risks and benefits were explained to the patient, informed consent was obtained. The patient was brought to the cardiac cath suite. Right groin was prepped in usual sterile fashion. Right common femoral artery was cannulated with the modified Seldinger technique. A 6-French sheath was introduced. Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views. Next, an EBU 3.5 guide was used to engage the left coronary system. Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis. Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion. Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion. Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres. There was noted to be a plaque shift proximally at the edge of the stent. Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres. Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds. Final images showed excellent results with initial 99% stenosis reduced to 0%. The patient continues to have residual stenosis in the mid to distal in the OM branch. At this point, wire was removed. Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.
Next, an angled pigtail catheter was advanced into the left ventricular cavity. LV pressure was measured. LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded. Finally, all guides were removed. Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis. The patient tolerated the procedure very well without complications.
DIAGNOSTIC FINDINGS
1. Left main: Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.
2. The LAD: LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.
3. Left circumflex: Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.
4. Right coronary artery: Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease. Otherwise, no significant stenosis noted.
5. LV: The LVEF 50%. Inferolateral wall hypokinesis. No significant mitral regurgitation. No gradient across the aortic valve on pullback.
ASSESSMENT AND PLAN: ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent. Excellent results, 0% residual stenosis. The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels. Therefore, we will aggressively treat this patient medically with close followup as an outpatient.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coarctation of Aorta
Description: Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.
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(Medical Transcription Sample Report)
HISTORY: The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicuspid aortic valve was also seen without insufficiency or stenosis. The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.
PROCEDURE: After sedation and general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.
Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place. There was good blood return from both the ports.
Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries. The atrial septum was not probe patent.
Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle. A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery. The transverse arch measured 5 mm. Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level. The diaphragm measured 5.6 mm. The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery. This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist. Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient. Repeat angiogram showed mild improvement in degree of aortic narrowing. The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist. The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.
Flows were calculated by the Fick technique using an assumed oxygen consumption.
Cineangiograms were obtained with injection in the descending aorta.
After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the pediatric intensive care unit in satisfactory condition. There were no complications.
DISCUSSION: Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to mild systemic arterial desaturation and anemia. There is no evidence of significant intracardiac shunt. Further the heart was desaturated due to VQ mismatch.
Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta. The calculated flows were mildly increased. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels. There is discrete juxtaductal coarctation of the aorta. Flow within the intercostal arteries was retrograde. Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg. There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta. The calculated systemic flow fell to normal values. Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus. There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries. The narrowest diameter of the aorta measured 4.9 x 4.2 mm.
DIAGNOSES:
1. Juxtaductal coarctation of the aorta.
2. Dilated cardiomyopathy.
3. Bicuspid aortic valve.
4. Patent foramen ovale.
INTERVENTION: Balloon dilation of coarctation of the aorta.
MANAGEMENT: The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference. The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery. The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months. The further cardiologic care will be directed by Dr. X.
PROCEDURE: After sedation and general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.
Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place. There was good blood return from both the ports.
Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries. The atrial septum was not probe patent.
Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle. A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery. The transverse arch measured 5 mm. Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level. The diaphragm measured 5.6 mm. The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery. This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist. Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient. Repeat angiogram showed mild improvement in degree of aortic narrowing. The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist. The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.
Flows were calculated by the Fick technique using an assumed oxygen consumption.
Cineangiograms were obtained with injection in the descending aorta.
After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the pediatric intensive care unit in satisfactory condition. There were no complications.
DISCUSSION: Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to mild systemic arterial desaturation and anemia. There is no evidence of significant intracardiac shunt. Further the heart was desaturated due to VQ mismatch.
Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta. The calculated flows were mildly increased. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels. There is discrete juxtaductal coarctation of the aorta. Flow within the intercostal arteries was retrograde. Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg. There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta. The calculated systemic flow fell to normal values. Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus. There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries. The narrowest diameter of the aorta measured 4.9 x 4.2 mm.
DIAGNOSES:
1. Juxtaductal coarctation of the aorta.
2. Dilated cardiomyopathy.
3. Bicuspid aortic valve.
4. Patent foramen ovale.
INTERVENTION: Balloon dilation of coarctation of the aorta.
MANAGEMENT: The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference. The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery. The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months. The further cardiologic care will be directed by Dr. X.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Complex Cyanotic Congenital Heart Disease
Description: A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
HISTORY: The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis. He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation. These procedures were performed at Medical College Hospital. Family states that they moved to the United States. Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery. He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg. The QP:QS ratio of 0.6:1. A large decompressing venous collateral was also appreciated. The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.
DESCRIPTION OF PROCEDURE: After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.
Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.
Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta. A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.
Percutaneous access into the right jugular vein was attempted, but unsuccessful. Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein. Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire. This catheter then also advanced into the bridging innominate vein. The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava. A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery. There was no vascular continuity to the stump of the right Glenn. The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava. The Bernstein catheter was then reintroduced using a Terumo guidewire. Probing of the superior vena cava facilitated access into the right lower pulmonary artery. The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis. The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length. The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist. This facilitated advancement of a flexor sheath into the proximal portion of the stenosis. A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe. A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist. Angiogram demonstrated a good stent apposition to the caval wall. Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist. Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery. The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery. Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery. Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery. Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist. Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery. The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist. Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter. Repeat angiograms were then performed. Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein. A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter. An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein. Once stable device was confirmed, the device was released from the delivery catheter. The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein. A pigtail catheter was then introduced into the left superior vena cava for final angiogram.
Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.
Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.
After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.
DISCUSSION: Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%. The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen. Remaining saturations reflected complete admixture. There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow. Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending, descending pressures were similar and normal. Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg. The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1. The pulmonary vascular resistance was elevated at 4.4 Woods units. Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg. Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation. There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg. There was an increase in arterial pressure. The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared. Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava. There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient. There was absence of contrast filling of the right middle and right upper pulmonary artery. Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow. Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.
INITIAL DIAGNOSES:
1. Asplenia syndrome.
2. Dextrocardia bilateral superior vena cava.
3. Atrioventricular septal defect.
4. Total anomalous pulmonary venous return to the right-sided atrium.
5. Double outlet right ventricle with malposed great vessels.
6. Severe pulmonary stenosis.
7. Separate hepatic venous drainage into the atria.
PRIOR SURGERIES AND INTERVENTIONS:
1. Right modified Blalock-Taussig shunt.
2. Bilateral bidirectional Glenn shunt.
3. Patch augmentation of the main pulmonary to left pulmonary artery.
CURRENT DIAGNOSES:
1. Obstructed right caval pulmonary anastomosis.
2. Obstructed right proximal pulmonary artery.
3. Venovenous collateral vessel.
CURRENT INTERVENTION:
1. Balloon dilation of the right superior vena cava and stent implantation.
2. Balloon dilation of the proximal right pulmonary artery, stent implantation.
3. Embolization of venovenous collateral vessel.
MANAGEMENT: The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference. A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion. The patient will be maintained on anticoagulant medications of aspirin and Plavix. Further cardiology care will be directed by Dr. X.
DESCRIPTION OF PROCEDURE: After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.
Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.
Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta. A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.
Percutaneous access into the right jugular vein was attempted, but unsuccessful. Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein. Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire. This catheter then also advanced into the bridging innominate vein. The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava. A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery. There was no vascular continuity to the stump of the right Glenn. The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava. The Bernstein catheter was then reintroduced using a Terumo guidewire. Probing of the superior vena cava facilitated access into the right lower pulmonary artery. The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis. The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length. The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist. This facilitated advancement of a flexor sheath into the proximal portion of the stenosis. A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe. A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist. Angiogram demonstrated a good stent apposition to the caval wall. Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist. Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery. The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery. Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery. Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery. Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist. Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery. The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist. Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter. Repeat angiograms were then performed. Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein. A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter. An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein. Once stable device was confirmed, the device was released from the delivery catheter. The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein. A pigtail catheter was then introduced into the left superior vena cava for final angiogram.
Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.
Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.
After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.
DISCUSSION: Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%. The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen. Remaining saturations reflected complete admixture. There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow. Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending, descending pressures were similar and normal. Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg. The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1. The pulmonary vascular resistance was elevated at 4.4 Woods units. Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg. Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation. There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg. There was an increase in arterial pressure. The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared. Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava. There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient. There was absence of contrast filling of the right middle and right upper pulmonary artery. Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow. Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.
INITIAL DIAGNOSES:
1. Asplenia syndrome.
2. Dextrocardia bilateral superior vena cava.
3. Atrioventricular septal defect.
4. Total anomalous pulmonary venous return to the right-sided atrium.
5. Double outlet right ventricle with malposed great vessels.
6. Severe pulmonary stenosis.
7. Separate hepatic venous drainage into the atria.
PRIOR SURGERIES AND INTERVENTIONS:
1. Right modified Blalock-Taussig shunt.
2. Bilateral bidirectional Glenn shunt.
3. Patch augmentation of the main pulmonary to left pulmonary artery.
CURRENT DIAGNOSES:
1. Obstructed right caval pulmonary anastomosis.
2. Obstructed right proximal pulmonary artery.
3. Venovenous collateral vessel.
CURRENT INTERVENTION:
1. Balloon dilation of the right superior vena cava and stent implantation.
2. Balloon dilation of the proximal right pulmonary artery, stent implantation.
3. Embolization of venovenous collateral vessel.
MANAGEMENT: The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference. A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion. The patient will be maintained on anticoagulant medications of aspirin and Plavix. Further cardiology care will be directed by Dr. X.
REVIEW OF SYSTEMS
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: No history of cataract, history of blurry vision and hearing impairment.
CARDIOVASCULAR: Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.
RESPIRATORY: Shortness of breath, questionable pneumonia. No valley fever.
GASTROINTESTINAL: No nausea, no vomiting, hematemesis or melena.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: Arthritis, muscle weakness.
CNS: No TIA. No CVA. No seizure disorder.
SKIN: Nonsignificant.
PSYCHOLOGIC: Anxiety and depression.
ALLERGIES: Nonsignificant except as mentioned above for medications.
PHYSICAL EXAMINATION
VITAL SIGNS: Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.
HEENT AND NECK: Neck is supple. Atraumatic and normocephalic. Neck veins are flat. No thyromegaly.
LUNGS: Air entry bilaterally fair. Decreased breath sounds especially in the right basilar areas. Few crackles.
HEART: Normal S1 and S2, irregular.
ABDOMEN: Soft and nontender.
EXTREMITIES: No edema. Pulse is palpable. No clubbing or cyanosis.
CNS: Grossly intact.
MUSCULOSKELETAL: Arthritic changes.
PSYCHOLOGICAL: None significant.
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: No history of cataract, history of blurry vision and hearing impairment.
CARDIOVASCULAR: Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.
RESPIRATORY: Shortness of breath, questionable pneumonia. No valley fever.
GASTROINTESTINAL: No nausea, no vomiting, hematemesis or melena.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: Arthritis, muscle weakness.
CNS: No TIA. No CVA. No seizure disorder.
SKIN: Nonsignificant.
PSYCHOLOGIC: Anxiety and depression.
ALLERGIES: Nonsignificant except as mentioned above for medications.
PHYSICAL EXAMINATION
VITAL SIGNS: Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.
HEENT AND NECK: Neck is supple. Atraumatic and normocephalic. Neck veins are flat. No thyromegaly.
LUNGS: Air entry bilaterally fair. Decreased breath sounds especially in the right basilar areas. Few crackles.
HEART: Normal S1 and S2, irregular.
ABDOMEN: Soft and nontender.
EXTREMITIES: No edema. Pulse is palpable. No clubbing or cyanosis.
CNS: Grossly intact.
MUSCULOSKELETAL: Arthritic changes.
PSYCHOLOGICAL: None significant.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air. Temperature 99, respiratory rate 16.
GENERAL: The patient is sitting in the chair at bedside. Appears comfortable. Left facial droop. Left side hemiplegia.
HEAD AND NECK: No JVP seen. Right side carotid bruit heard.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: PMI not displaced, regular rhythm. Normal S1 and S2. Positive S4. There is a 2/6 systolic murmur best heard at the left lower sternal border.
ABDOMEN: Soft.
EXTREMITIES: Not edematous.
VITAL SIGNS: Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air. Temperature 99, respiratory rate 16.
GENERAL: The patient is sitting in the chair at bedside. Appears comfortable. Left facial droop. Left side hemiplegia.
HEAD AND NECK: No JVP seen. Right side carotid bruit heard.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: PMI not displaced, regular rhythm. Normal S1 and S2. Positive S4. There is a 2/6 systolic murmur best heard at the left lower sternal border.
ABDOMEN: Soft.
EXTREMITIES: Not edematous.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Weakness, fatigue, tiredness.
HEENT: No history of cataracts, blurry vision or glaucoma.
CARDIOVASCULAR: Arrhythmia, congestive heart failure, no coronary artery disease.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.
GASTROINTESTINAL: Nausea, no vomiting, hematemesis, or melena.
UROLOGICAL: Some frequency, urgency, no hematuria.
MUSCULOSKELETAL: Arthritis, muscle weakness.
SKIN: Chronic skin changes.
CNS: History of TIA. No CVA, no seizure disorder.
ENDOCRINE: Nonsignificant.
HEMATOLOGICAL: Nonsignificant.
PSYCHOLOGICAL: No anxiety or depression.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.
HEENT: Atraumatic and normocephalic.
NECK: Neck veins flat. No significant carotid bruits.
LUNGS: Air entry bilaterally fair, decreased in basal areas. No rales or wheezes.
HEART: PMI displaced. S1 and S2 regular.
ABDOMEN: Soft and nontender. Bowel sounds present.
EXTREMITIES: Chronic skin changes. Pulses are palpable. No clubbing or cyanosis.
CNS: Grossly intact.
CONSTITUTIONAL: Weakness, fatigue, tiredness.
HEENT: No history of cataracts, blurry vision or glaucoma.
CARDIOVASCULAR: Arrhythmia, congestive heart failure, no coronary artery disease.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.
GASTROINTESTINAL: Nausea, no vomiting, hematemesis, or melena.
UROLOGICAL: Some frequency, urgency, no hematuria.
MUSCULOSKELETAL: Arthritis, muscle weakness.
SKIN: Chronic skin changes.
CNS: History of TIA. No CVA, no seizure disorder.
ENDOCRINE: Nonsignificant.
HEMATOLOGICAL: Nonsignificant.
PSYCHOLOGICAL: No anxiety or depression.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.
HEENT: Atraumatic and normocephalic.
NECK: Neck veins flat. No significant carotid bruits.
LUNGS: Air entry bilaterally fair, decreased in basal areas. No rales or wheezes.
HEART: PMI displaced. S1 and S2 regular.
ABDOMEN: Soft and nontender. Bowel sounds present.
EXTREMITIES: Chronic skin changes. Pulses are palpable. No clubbing or cyanosis.
CNS: Grossly intact.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: History of blurry vision and hearing impaired. No glaucoma.
CARDIOVASCULAR: Shortness of breath, congestive heart failure, and arrhythmia. Prior history of chest pain.
RESPIRATORY: Bronchitis and pneumonia. No valley fever.
GASTROINTESTINAL: No nausea, vomiting, hematemesis, melena, or abdominal pain.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: No arthritis or muscle weakness.
SKIN: Non-significant.
NEUROLOGICAL: No TIA. No CVA or seizure disorder.
ENDOCRINE: Non-significant.
HEMATOLOGICAL: Non-significant.
PSYCHOLOGICAL: Anxiety. No depression.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.
HEENT: Atraumatic and normocephalic.
NECK: Supple. Neck veins flat.
LUNGS: Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.
HEART: PMI displaced. S1 and S2, regular. Systolic murmur.
ABDOMEN: Soft and nontender.
EXTREMITIES: Trace edema of the ankle. Pulses are feebly palpable. Clubbing plus. No cyanosis.
CNS: Grossly intact.
MUSCULOSKELETAL: Arthritic changes.
PSYCHOLOGICAL: Normal affect.
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: History of blurry vision and hearing impaired. No glaucoma.
CARDIOVASCULAR: Shortness of breath, congestive heart failure, and arrhythmia. Prior history of chest pain.
RESPIRATORY: Bronchitis and pneumonia. No valley fever.
GASTROINTESTINAL: No nausea, vomiting, hematemesis, melena, or abdominal pain.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: No arthritis or muscle weakness.
SKIN: Non-significant.
NEUROLOGICAL: No TIA. No CVA or seizure disorder.
ENDOCRINE: Non-significant.
HEMATOLOGICAL: Non-significant.
PSYCHOLOGICAL: Anxiety. No depression.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.
HEENT: Atraumatic and normocephalic.
NECK: Supple. Neck veins flat.
LUNGS: Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.
HEART: PMI displaced. S1 and S2, regular. Systolic murmur.
ABDOMEN: Soft and nontender.
EXTREMITIES: Trace edema of the ankle. Pulses are feebly palpable. Clubbing plus. No cyanosis.
CNS: Grossly intact.
MUSCULOSKELETAL: Arthritic changes.
PSYCHOLOGICAL: Normal affect.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors.
HEENT: No history of cataract or glaucoma.
CARDIOVASCULAR: As above.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.
GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena.
UROLOGICAL: Frequency, urgency.
MUSCULOSKELETAL: No muscle weakness.
SKIN: None significant.
NEUROLOGICAL: No TIA or CVA. No seizure disorder.
PSYCHOLOGICAL: No anxiety or depression.
ENDOCRINE: As above.
HEMATOLOGICAL: None significant.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.
HEENT: Atraumatic, normocephalic.
NECK: Veins flat. No significant carotid bruits.
LUNGS: Air entry bilaterally fair.
HEART: PMI displaced. S1 and S2 regular.
ABDOMEN: Soft, nontender. Bowel sounds present.
EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis.
CNS: Benign.
CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors.
HEENT: No history of cataract or glaucoma.
CARDIOVASCULAR: As above.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.
GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena.
UROLOGICAL: Frequency, urgency.
MUSCULOSKELETAL: No muscle weakness.
SKIN: None significant.
NEUROLOGICAL: No TIA or CVA. No seizure disorder.
PSYCHOLOGICAL: No anxiety or depression.
ENDOCRINE: As above.
HEMATOLOGICAL: None significant.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.
HEENT: Atraumatic, normocephalic.
NECK: Veins flat. No significant carotid bruits.
LUNGS: Air entry bilaterally fair.
HEART: PMI displaced. S1 and S2 regular.
ABDOMEN: Soft, nontender. Bowel sounds present.
EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis.
CNS: Benign.
PHYSICAL EXAMINATION: Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: COPD & Bronchitis - Discharge Summary
Description: Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
DIAGNOSIS AT ADMISSION: Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.
DIAGNOSES AT DISCHARGE
1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.
2. Congestive heart failure.
3. Atherosclerotic cardiovascular disease.
4. Mild senile-type dementia.
5. Hypothyroidism.
6. Chronic oxygen dependent.
7. Do not resuscitate/do not intubate.
HOSPITAL COURSE: The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed.
Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload.
The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable.
She is discharged home to follow up with me in a week and a half.
Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.
PROGNOSIS: Guarded.
DIAGNOSES AT DISCHARGE
1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.
2. Congestive heart failure.
3. Atherosclerotic cardiovascular disease.
4. Mild senile-type dementia.
5. Hypothyroidism.
6. Chronic oxygen dependent.
7. Do not resuscitate/do not intubate.
HOSPITAL COURSE: The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed.
Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload.
The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable.
She is discharged home to follow up with me in a week and a half.
Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.
PROGNOSIS: Guarded.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary Angiography
Description: Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR EXAM: Dynamic ST-T changes with angina.
PROCEDURE:
1. Selective coronary angiography.
2. Left heart catheterization with hemodynamics.
3. LV gram with power injection.
4. Right femoral artery angiogram.
5. Closure of the right femoral artery using 6-French AngioSeal.
Procedure explained to the patient, with risks and benefits. The patient agreed and signed the consent form.
The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation. The patient was draped and dressed in the usual sterile fashion. The right groin area infiltrated with lidocaine solution. Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick. Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.
Over the J-wire, a JL4 catheter was passed over the aortic arch. The wire was removed. Catheter was engaged into the left main. Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained. Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed. Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained. The cath disengaged and exchanged over J-wire into a pigtail catheter. Pigtail catheter across the aortic valve. Hemodynamics obtained. LV gram with power injection of 36 mL of contrast was obtained.
The LV gram assessed followed by pullback hemodynamics.
The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma. The patient tolerated the procedure well with no immediate postprocedure complication.
HEMODYNAMICS: The aortic pressure was 117/61 with a mean pressure of 83. The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg. The pullback across the aortic valve reveals zero gradient.
ANATOMY: The left main showed minimal calcification as well as the proximal LAD. No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.
The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD. The LAD gave off two early diagonal branches. The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.
Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA. The left circumflex was large and patent, 6.0 mm in diameter. All three obtuse marginal branches appeared to be with no significant stenosis.
The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis. The PDA was wide, patent, with no focal stenosis.
The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.
LV gram showed that the LV EF is preserved with EF of 60%. No mitral regurgitation identified.
IMPRESSION:
1. Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.
2. Nondominant right, which is free of atheromatous plaque.
3. Minimal plaque in the diagonal branch II, and the obtuse
marginal branch III, with no focal stenosis.
4. Normal left ventricular function.
5. Evaluation for noncardiac chest pain would be recommended.
PROCEDURE:
1. Selective coronary angiography.
2. Left heart catheterization with hemodynamics.
3. LV gram with power injection.
4. Right femoral artery angiogram.
5. Closure of the right femoral artery using 6-French AngioSeal.
Procedure explained to the patient, with risks and benefits. The patient agreed and signed the consent form.
The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation. The patient was draped and dressed in the usual sterile fashion. The right groin area infiltrated with lidocaine solution. Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick. Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.
Over the J-wire, a JL4 catheter was passed over the aortic arch. The wire was removed. Catheter was engaged into the left main. Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained. Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed. Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained. The cath disengaged and exchanged over J-wire into a pigtail catheter. Pigtail catheter across the aortic valve. Hemodynamics obtained. LV gram with power injection of 36 mL of contrast was obtained.
The LV gram assessed followed by pullback hemodynamics.
The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma. The patient tolerated the procedure well with no immediate postprocedure complication.
HEMODYNAMICS: The aortic pressure was 117/61 with a mean pressure of 83. The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg. The pullback across the aortic valve reveals zero gradient.
ANATOMY: The left main showed minimal calcification as well as the proximal LAD. No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.
The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD. The LAD gave off two early diagonal branches. The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.
Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA. The left circumflex was large and patent, 6.0 mm in diameter. All three obtuse marginal branches appeared to be with no significant stenosis.
The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis. The PDA was wide, patent, with no focal stenosis.
The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.
LV gram showed that the LV EF is preserved with EF of 60%. No mitral regurgitation identified.
IMPRESSION:
1. Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.
2. Nondominant right, which is free of atheromatous plaque.
3. Minimal plaque in the diagonal branch II, and the obtuse
marginal branch III, with no focal stenosis.
4. Normal left ventricular function.
5. Evaluation for noncardiac chest pain would be recommended.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary Angiography & Abdominal Aortography
Description: Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
NAME OF PROCEDURE
1. Selective coronary angiography.
2. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.
3. Abdominal aortography.
INDICATIONS: The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. Thallium scan has been negative. He is undergoing angiography to determine if his symptoms are due to coronary artery disease.
NARRATIVE: The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine. Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg. Received additional Versed and fentanyl during the procedure. Please refer to the nurses' notes for dosages and timing.
The right femoral artery was entered and a 4-French sheath was placed. Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta. Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch. The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed. This revealed a very high-grade lesion at the proximal right coronary artery. This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.
The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed. A 6-French sheath and a right Judkins guide was placed. The patient was started on bivalarudin. A BMW wire was easily placed across the lesion and into the distal right coronary artery. A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres. The intermediate result was improved with TIMI-3 flow to the terminus of the vessel. Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres. This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection. This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres. Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing. The guiding catheter was withdrawn over wire and a pigtail was placed. This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection. The catheter was removed. The bivalarudin was stopped at the termination of procedure. A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.
It should also be noted that an 8-French sheath was placed in the right femoral vein. This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.
Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.
HEMODYNAMICS: Rhythm was sinus throughout the procedure. Aortic pressure was 170/81 mmHg.
The right coronary artery is a dominant vessel. This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch. It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals. In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity. After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow. There was approximately 10% residual stenosis at the worst part of the previous stenosis.
The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex. The ramus intermedius is free of disease. The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment. This measures 25% to 30% at its worst point. The circumflex is a large caliber vessel. There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex. Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.
The aortogram demonstrates eccentric aneurysm formation. This may represent a small retrograde dissection as well. There was some dye hang up in the wall.
IMPRESSION
1. Successful stenting of subtotal stenosis of the proximal coronary artery.
2. Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.
3. Left to right collateral filling noted prior to coronary intervention.
4. Small area of eccentric aneurysm formation in the abdominal aorta.
1. Selective coronary angiography.
2. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.
3. Abdominal aortography.
INDICATIONS: The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. Thallium scan has been negative. He is undergoing angiography to determine if his symptoms are due to coronary artery disease.
NARRATIVE: The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine. Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg. Received additional Versed and fentanyl during the procedure. Please refer to the nurses' notes for dosages and timing.
The right femoral artery was entered and a 4-French sheath was placed. Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta. Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch. The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed. This revealed a very high-grade lesion at the proximal right coronary artery. This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.
The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed. A 6-French sheath and a right Judkins guide was placed. The patient was started on bivalarudin. A BMW wire was easily placed across the lesion and into the distal right coronary artery. A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres. The intermediate result was improved with TIMI-3 flow to the terminus of the vessel. Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres. This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection. This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres. Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing. The guiding catheter was withdrawn over wire and a pigtail was placed. This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection. The catheter was removed. The bivalarudin was stopped at the termination of procedure. A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.
It should also be noted that an 8-French sheath was placed in the right femoral vein. This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.
Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.
HEMODYNAMICS: Rhythm was sinus throughout the procedure. Aortic pressure was 170/81 mmHg.
The right coronary artery is a dominant vessel. This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch. It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals. In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity. After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow. There was approximately 10% residual stenosis at the worst part of the previous stenosis.
The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex. The ramus intermedius is free of disease. The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment. This measures 25% to 30% at its worst point. The circumflex is a large caliber vessel. There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex. Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.
The aortogram demonstrates eccentric aneurysm formation. This may represent a small retrograde dissection as well. There was some dye hang up in the wall.
IMPRESSION
1. Successful stenting of subtotal stenosis of the proximal coronary artery.
2. Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.
3. Left to right collateral filling noted prior to coronary intervention.
4. Small area of eccentric aneurysm formation in the abdominal aorta.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 1
Description: CCTA with cardiac function and calcium scoring.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
HISTORY: Coronary artery disease.
TECHNIQUE AND FINDINGS: Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agent. 0.4 milligrams of nitroglycerin was given.
Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age. There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.
Cardiac wall motion was within normal limits. Left ventricular ejection fraction calculated to be 82%. End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.
There is normal coronary artery origins. There is codominance between the right coronary artery and the circumflex artery. There is mild to moderate stenosis of the proximal LAD with mixed plaque. Mild stenosis mid LAD with mixed plaque. No stenosis. Distal LAD with the distal vessel becoming diminutive in size. Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque. Once again the distal vessel becomes diminutive in size. Circumflex shows mild stenosis due to focal calcified plaque proximally. No stenosis is seen involving the mid or distal circumflex. The distal circumflex also becomes diminutive in size. The left main shows small amount of focal calcified plaque without stenosis. Myocardium, pericardium and wall motion was unremarkable as seen.
IMPRESSION:
1. Atherosclerotic coronary artery disease with values as above. There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.
2. Consider cardiology consult and further evaluation if clinically indicated.
3. Full report was sent to the PACS. Report will be mailed to Dr. ABC.
TECHNIQUE AND FINDINGS: Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agent. 0.4 milligrams of nitroglycerin was given.
Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age. There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.
Cardiac wall motion was within normal limits. Left ventricular ejection fraction calculated to be 82%. End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.
There is normal coronary artery origins. There is codominance between the right coronary artery and the circumflex artery. There is mild to moderate stenosis of the proximal LAD with mixed plaque. Mild stenosis mid LAD with mixed plaque. No stenosis. Distal LAD with the distal vessel becoming diminutive in size. Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque. Once again the distal vessel becomes diminutive in size. Circumflex shows mild stenosis due to focal calcified plaque proximally. No stenosis is seen involving the mid or distal circumflex. The distal circumflex also becomes diminutive in size. The left main shows small amount of focal calcified plaque without stenosis. Myocardium, pericardium and wall motion was unremarkable as seen.
IMPRESSION:
1. Atherosclerotic coronary artery disease with values as above. There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.
2. Consider cardiology consult and further evaluation if clinically indicated.
3. Full report was sent to the PACS. Report will be mailed to Dr. ABC.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 2
Description: CCTA with Cardiac Function/Calcium Scoring
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
Your patient, (ABC), a 59-year-old female with no known coronary artery disease was referred to us for a CT coronary angiogram. The patient's cardiac risk factors include chest discomfort, family history of coronary artery disease, and hypercholesterolemia. She is on no cardiac medications at the time of testing. The patient's resting ECG demonstrated no ischemic changes.
CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY
PROCEDURE: Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time. Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV. Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.
Retrospective ECG gating was performed. The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan. The average heart rate was 62 beats/min.
The patient had no adverse reaction to the contrast. Multiphase retrospective reconstructions were performed. Small field of view cardiac and coronary images were analyzed on a 3D work station. Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.
CORONARY CTA:
1. The technical quality of the scan is adequate.
2. The coronary ostia are in their normal position. The coronary anatomy is right dominant.
3. LEFT MAIN: The left main coronary artery is patent without angiographic stenosis.
4. LEFT ANTERIOR DESCENDING ARTERY: The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity. Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.
5. The ramus intermedius is a small vessel with minor irregularities.
6. LEFT CIRCUMFLEX: The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.
7. RIGHT CORONARY ARTERY: The right coronary artery is a large and dominant vessel. It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity. Left ventricular ejection fraction is calculated to be 69%. There are no wall motion abnormalities.
8. Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.
ANCILLARY FINDINGS: None.
FINAL IMPRESSION:
1. Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.
2. Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.
Thank you for referring this patient to us.
CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY
PROCEDURE: Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time. Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV. Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.
Retrospective ECG gating was performed. The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan. The average heart rate was 62 beats/min.
The patient had no adverse reaction to the contrast. Multiphase retrospective reconstructions were performed. Small field of view cardiac and coronary images were analyzed on a 3D work station. Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.
CORONARY CTA:
1. The technical quality of the scan is adequate.
2. The coronary ostia are in their normal position. The coronary anatomy is right dominant.
3. LEFT MAIN: The left main coronary artery is patent without angiographic stenosis.
4. LEFT ANTERIOR DESCENDING ARTERY: The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity. Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.
5. The ramus intermedius is a small vessel with minor irregularities.
6. LEFT CIRCUMFLEX: The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.
7. RIGHT CORONARY ARTERY: The right coronary artery is a large and dominant vessel. It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity. Left ventricular ejection fraction is calculated to be 69%. There are no wall motion abnormalities.
8. Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.
ANCILLARY FINDINGS: None.
FINAL IMPRESSION:
1. Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.
2. Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.
Thank you for referring this patient to us.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 3
Description: Coronary Artery CTA with Calcium Scoring and Cardiac Function
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
EXAM: Coronary artery CTA with calcium scoring and cardiac function.
HISTORY: Chest pain.
TECHNIQUE AND FINDINGS: Coronary artery CTA was performed on a Siemens dual-source CT scanner. Post-processing on a Vitrea workstation. 150 mL Ultravist 370 was utilized as the intravenous contrast agent. Patient did receive nitroglycerin sublingually prior to the contrast.
HISTORY: Significant for high cholesterol, overweight, chest pain, family history
Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.
The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque. The distal LAD was unreadable while the proximal was normal. The mid and distal right coronary artery are not well delineated due to beam-hardening artifact. The circumflex is diminutive in size along its proximal portion. Distal is not readable.
Cardiac wall motion within normal limits. No gross pulmonary artery abnormality however they are not well delineated. A full report was placed on the patient's chart. Report was saved to PACS.
HISTORY: Chest pain.
TECHNIQUE AND FINDINGS: Coronary artery CTA was performed on a Siemens dual-source CT scanner. Post-processing on a Vitrea workstation. 150 mL Ultravist 370 was utilized as the intravenous contrast agent. Patient did receive nitroglycerin sublingually prior to the contrast.
HISTORY: Significant for high cholesterol, overweight, chest pain, family history
Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.
The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque. The distal LAD was unreadable while the proximal was normal. The mid and distal right coronary artery are not well delineated due to beam-hardening artifact. The circumflex is diminutive in size along its proximal portion. Distal is not readable.
Cardiac wall motion within normal limits. No gross pulmonary artery abnormality however they are not well delineated. A full report was placed on the patient's chart. Report was saved to PACS.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 4
Description: A 51-year-old male with chest pain and history of coronary artery disease.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
A 51-year-old male with chest pain and history of coronary artery disease.
COMPARISON: None.
MEDICATIONS: Lopressor 5mg IV at 0920 hours.
HEART RATE: Recorded heart rate 55 to 57bpm.
EXAM: Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.
18 gauge IV Intracath was inserted into the right antecubital vein.
A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.
Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.
95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.
FINDINGS:
CALCIUM SCORE: The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.
QUALITY ASSESSMENT: Examination is of good quality with good bolus timing and good demonstration of coronary arteries.
LEFT MAIN CORONARY ARTERY: The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.
Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.
LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.
RIGHT CORONARY ARTERY: The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.
Coronary circulation is right dominant.
FUNCTIONAL ANALYSIS: End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent
ANATOMIC ANALYSIS:
Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial
bridges. Normal left atrial appendage with no evidence of thrombosis.
Cardiac valves are normal.
The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.
Normal pericardium without pericardial thickening or effusion.
There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.
There are two left and two right pulmonary veins.
IMPRESSION:
Ventricular function: Normal.
Single vessel coronary artery analysis:
LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.
LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.
CX: Minimal calcific plaque with no flow-limiting lesion.
RCA: Minimal calcific plaque with no flow-limiting lesion.
Coronary artery dominance: Right.
COMPARISON: None.
MEDICATIONS: Lopressor 5mg IV at 0920 hours.
HEART RATE: Recorded heart rate 55 to 57bpm.
EXAM: Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.
18 gauge IV Intracath was inserted into the right antecubital vein.
A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.
Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.
95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.
FINDINGS:
CALCIUM SCORE: The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.
QUALITY ASSESSMENT: Examination is of good quality with good bolus timing and good demonstration of coronary arteries.
LEFT MAIN CORONARY ARTERY: The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.
Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.
LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.
RIGHT CORONARY ARTERY: The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.
Coronary circulation is right dominant.
FUNCTIONAL ANALYSIS: End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent
ANATOMIC ANALYSIS:
Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial
bridges. Normal left atrial appendage with no evidence of thrombosis.
Cardiac valves are normal.
The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.
Normal pericardium without pericardial thickening or effusion.
There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.
There are two left and two right pulmonary veins.
IMPRESSION:
Ventricular function: Normal.
Single vessel coronary artery analysis:
LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.
LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.
CX: Minimal calcific plaque with no flow-limiting lesion.
RCA: Minimal calcific plaque with no flow-limiting lesion.
Coronary artery dominance: Right.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 5
Description: A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.
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(Medical Transcription Sample Report)
A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.
COMPARISON STUDIES: None.
MEDICATION: Lopressor 5 mg IV.
HEART RATE AFTER MEDICATION: 64bpm
EXAM:TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.
TECHNICAL QUALITY:
Examination is limited secondary to extensive artifact from defibrillator wires.
There is good demonstration of the coronary arteries and there is good bolus timing.
FINDINGS:
LEFT MAIN CORONARY ARTERY:
The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.
LEFT ANTERIOR DESCENDING ARTERY:
The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.
In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.
LEFT CIRCUMFLEX ARTERY:
The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.
RIGHT CORONARY ARTERY:
The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.
There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.
The right coronary artery is dominant.
NONCORONARY CARDIAC STRUCTURE:
CARDIAC CHAMBERS: There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.
CARDIAC VALVES: There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.
PERICARDIUM: Normal.
GREAT VESSELS: There are atherosclerotic changes within the aorta.
VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: Normal.
IMPRESSION:
Limited examination secondary to extensive artifact from the pacemaker wires.
There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.
There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.
There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.
There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.
There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.
COMPARISON STUDIES: None.
MEDICATION: Lopressor 5 mg IV.
HEART RATE AFTER MEDICATION: 64bpm
EXAM:TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.
TECHNICAL QUALITY:
Examination is limited secondary to extensive artifact from defibrillator wires.
There is good demonstration of the coronary arteries and there is good bolus timing.
FINDINGS:
LEFT MAIN CORONARY ARTERY:
The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.
LEFT ANTERIOR DESCENDING ARTERY:
The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.
In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.
LEFT CIRCUMFLEX ARTERY:
The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.
RIGHT CORONARY ARTERY:
The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.
There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.
The right coronary artery is dominant.
NONCORONARY CARDIAC STRUCTURE:
CARDIAC CHAMBERS: There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.
CARDIAC VALVES: There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.
PERICARDIUM: Normal.
GREAT VESSELS: There are atherosclerotic changes within the aorta.
VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: Normal.
IMPRESSION:
Limited examination secondary to extensive artifact from the pacemaker wires.
There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.
There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.
There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.
There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.
There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Angiography
Description: Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
(Medical Transcription Sample Report)
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CT ANGIOGRAPHY CHEST WITH CONTRAST
REASON FOR EXAM: Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.
TECHNIQUE: Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
FINDINGS: There is no evidence for pulmonary arterial embolism.
The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax. No abnormal mediastinal or hilar lymphadenopathy is seen.
Limited images of the upper abdomen are unremarkable. No destructive osseous lesion is detected.
IMPRESSION: Negative for pulmonary arterial embolism.
REASON FOR EXAM: Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.
TECHNIQUE: Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
FINDINGS: There is no evidence for pulmonary arterial embolism.
The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax. No abnormal mediastinal or hilar lymphadenopathy is seen.
Limited images of the upper abdomen are unremarkable. No destructive osseous lesion is detected.
IMPRESSION: Negative for pulmonary arterial embolism.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Angiography - 1
Description: Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
(Medical Transcription Sample Report)
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CT ANGIOGRAPHY CHEST WITH CONTRAST
REASON FOR EXAM: Shortness of breath for two weeks and a history of pneumonia. The patient also has a history of left lobectomy.
TECHNIQUE: Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
FINDINGS: There is no evidence of any acute pulmonary arterial embolism.
The main pulmonary artery is enlarged showing a diameter of 4.7 cm.
Cardiomegaly is seen with mitral valvular calcifications.
Postsurgical changes of a left upper lobectomy are seen. Left lower lobe atelectasis is noted. A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12). A small left pleural effusion is noted.
Right lower lobe atelectasis is present. There is a right pleural effusion, greater than as seen on the left side. A right lower lobe pulmonary nodule measures 1.5 cm. There is a calcified granuloma within the right lower lobe.
IMPRESSION:
1. Negative for pulmonary arterial embolism.
2. Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.
3. Cardiomegaly with mitral valvular calcifications.
4. Postsurgical changes of a left upper lobectomy.
5. Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.
6. Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.
REASON FOR EXAM: Shortness of breath for two weeks and a history of pneumonia. The patient also has a history of left lobectomy.
TECHNIQUE: Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
FINDINGS: There is no evidence of any acute pulmonary arterial embolism.
The main pulmonary artery is enlarged showing a diameter of 4.7 cm.
Cardiomegaly is seen with mitral valvular calcifications.
Postsurgical changes of a left upper lobectomy are seen. Left lower lobe atelectasis is noted. A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12). A small left pleural effusion is noted.
Right lower lobe atelectasis is present. There is a right pleural effusion, greater than as seen on the left side. A right lower lobe pulmonary nodule measures 1.5 cm. There is a calcified granuloma within the right lower lobe.
IMPRESSION:
1. Negative for pulmonary arterial embolism.
2. Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.
3. Cardiomegaly with mitral valvular calcifications.
4. Postsurgical changes of a left upper lobectomy.
5. Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.
6. Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Chest
Description: Common CT Chest template
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TECHNIQUE: Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.
FINDINGS: The heart size is normal and there is no pericardial effusion. The aorta and great vessels are normal in caliber. The central pulmonary arteries are patent with no evidence of embolus. There is no significant mediastinal, hilar, or axillary lymphadenopathy. The trachea and mainstem bronchi are patent. The esophagus is normal in course and caliber. The lungs are clear with no infiltrates, effusions, or masses. There is no pneumothorax. Scans through the upper abdomen are unremarkable. The osseous structures in the chest are intact.
IMPRESSION: No acute abnormalities.
FINDINGS: The heart size is normal and there is no pericardial effusion. The aorta and great vessels are normal in caliber. The central pulmonary arteries are patent with no evidence of embolus. There is no significant mediastinal, hilar, or axillary lymphadenopathy. The trachea and mainstem bronchi are patent. The esophagus is normal in course and caliber. The lungs are clear with no infiltrates, effusions, or masses. There is no pneumothorax. Scans through the upper abdomen are unremarkable. The osseous structures in the chest are intact.
IMPRESSION: No acute abnormalities.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Chest - 1
Description: CT chest with contrast.
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EXAM: CT chest with contrast.
REASON FOR EXAM: Pneumonia, chest pain, short of breath, and coughing up blood.
TECHNIQUE: Postcontrast CT chest 100 mL of Isovue-300 contrast.
FINDINGS: This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are linear fibrotic or atelectatic changes associated with this. Recommend followup to ensure resolution. There is left apical scarring. There is no pleural effusion or pneumothorax. There is lingular and right middle lobe mild atelectasis or fibrosis.
Examination of the mediastinal windows disclosed normal inferior thyroid. Cardiac and aortic contours are unremarkable aside from mild atherosclerosis. The heart is not enlarged. There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.
Very limited assessment of the upper abdomen demonstrates no definite abnormalities.
There are mild degenerative changes in the thoracic spine.
IMPRESSION:
1.Anterior small right upper lobe infiltrate/consolidation. Recommend followup to ensure resolution given its consolidated appearance.
2.Bilateral atelectasis versus fibrosis.
REASON FOR EXAM: Pneumonia, chest pain, short of breath, and coughing up blood.
TECHNIQUE: Postcontrast CT chest 100 mL of Isovue-300 contrast.
FINDINGS: This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are linear fibrotic or atelectatic changes associated with this. Recommend followup to ensure resolution. There is left apical scarring. There is no pleural effusion or pneumothorax. There is lingular and right middle lobe mild atelectasis or fibrosis.
Examination of the mediastinal windows disclosed normal inferior thyroid. Cardiac and aortic contours are unremarkable aside from mild atherosclerosis. The heart is not enlarged. There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.
Very limited assessment of the upper abdomen demonstrates no definite abnormalities.
There are mild degenerative changes in the thoracic spine.
IMPRESSION:
1.Anterior small right upper lobe infiltrate/consolidation. Recommend followup to ensure resolution given its consolidated appearance.
2.Bilateral atelectasis versus fibrosis.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Chest - 2
Description: A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast.
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CLINICAL HISTORY: A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.
TECHNIQUE: Multiple transaxial images utilized in 10 mm sections were obtained through the chest. Intravenous contrast was administered.
FINDINGS: There is a large 3 x 4 cm lymph node seen in the right supraclavicular region. There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm. A subcarinal lymph node is enlarged also. It measures 6 x 2 cm. Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura. There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm. There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit. The liver parenchyma is normal without evidence of any dominant masses. The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.
IMPRESSION:
1. Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.
2. Extensive mediastinal adenopathy as described above.
3. No lesion seen within the left lung at this time.
4. Supraclavicular adenopathy.
TECHNIQUE: Multiple transaxial images utilized in 10 mm sections were obtained through the chest. Intravenous contrast was administered.
FINDINGS: There is a large 3 x 4 cm lymph node seen in the right supraclavicular region. There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm. A subcarinal lymph node is enlarged also. It measures 6 x 2 cm. Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura. There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm. There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit. The liver parenchyma is normal without evidence of any dominant masses. The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.
IMPRESSION:
1. Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.
2. Extensive mediastinal adenopathy as described above.
3. No lesion seen within the left lung at this time.
4. Supraclavicular adenopathy.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT of Chest with Contrast
Description: CT of chest with contrast. Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.
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EXAM: CT chest with contrast.
HISTORY: Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.
TECHNIQUE: Post contrast-enhanced spiral images were obtained through the chest.
FINDINGS: There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.
Images of the upper abdomen are unremarkable.
Osseous windows are without acute pathology.
IMPRESSION: Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.
HISTORY: Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.
TECHNIQUE: Post contrast-enhanced spiral images were obtained through the chest.
FINDINGS: There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.
Images of the upper abdomen are unremarkable.
Osseous windows are without acute pathology.
IMPRESSION: Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.
PHYSICAL EXAMINATION: BP: 122/86. Temp: 96.8. HR: 79. RR: 26. RAS: 100%.
HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. EOMs intact.
NECK: Supple without masses or lymphadenopathy.
LUNGS: Clear to auscultation bilaterally
CARDIAC: Regular rate and rhythm without rubs, murmurs, or gallops.
EXTREMITIES: No cyanosis, clubbing or edema.
HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. EOMs intact.
NECK: Supple without masses or lymphadenopathy.
LUNGS: Clear to auscultation bilaterally
CARDIAC: Regular rate and rhythm without rubs, murmurs, or gallops.
EXTREMITIES: No cyanosis, clubbing or edema.
PHYSICAL EXAMINATION:
VITAL SIGNS: Respiratory rate 20 and pulse 91. Temperature is 100.0 per tympanic membrane. Oximetry is 98% on room air. Height is 128 cm, which is an increase of 1.0 cm from prior visit. Weight is 24.5 kg, which is an increase of 500 grams from prior visit.
GENERAL: He is a cooperative school-aged boy in no apparent distress.
HEENT: Tympanic membranes clear, throat with minimal postnasal drip.
CHEST: Significant for 1+ hyperinflation. Lungs are auscultated with good air entry and clear breath sounds.
CARDIAC: Regular sinus rhythm without murmur.
ABDOMEN: Palpated as soft, without hepatosplenomegaly.
EXTREMITIES: Not clubbed.
VITAL SIGNS: Respiratory rate 20 and pulse 91. Temperature is 100.0 per tympanic membrane. Oximetry is 98% on room air. Height is 128 cm, which is an increase of 1.0 cm from prior visit. Weight is 24.5 kg, which is an increase of 500 grams from prior visit.
GENERAL: He is a cooperative school-aged boy in no apparent distress.
HEENT: Tympanic membranes clear, throat with minimal postnasal drip.
CHEST: Significant for 1+ hyperinflation. Lungs are auscultated with good air entry and clear breath sounds.
CARDIAC: Regular sinus rhythm without murmur.
ABDOMEN: Palpated as soft, without hepatosplenomegaly.
EXTREMITIES: Not clubbed.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: DDDR Permanent Pacemaker
Description: DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURES PERFORMED:
1. DDDR permanent pacemaker.
2. Insertion of a steroid-eluting screw in right atrial lead.
3. Insertion of a steroid-eluting screw in right ventricular apical lead.
4. Pulse generator insertion, model Sigma.
SITE: Left subclavian vein access.
INDICATION: The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length. They all consented for the procedure, and the consent was signed and placed on the chart.
PROCEDURE: The patient was taken to cardiac cath lab where she was monitored throughout all procedure. The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner. We also scrubbed for approximately eight minutes. Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized. Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein. The Cook needles were removed. Then the guidewires were secured in place with hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle. The skin was then undermined making a pocket for the generator. The guidewires were then tunneled through the performed pocket. Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively. Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed. After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead. After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture. The leads were then connected to a pulse generator. The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket. The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique. The area was then cleansed and dry. Steri-Strips and pressure dressing were applied. The patient tolerated the procedure well. There were no complications.
Information on the pacemaker:
The implanted device are as follows:
PULSE GENERATOR
Model Name: Sigma.
Model #: SDR203.
Serial #: 123456.
ATRIAL LEAD
Model #: 4568-45 cm.
Serial #: 123456.
RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:
Model #: 4068-52 cm.
Serial #: 123456.
STIMULATION THRESHOLDS ARE AS FOLLOWS:
The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.
The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.
The brady parameter settings were set as follows:
The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking. Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking. The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.
The patient tolerated the procedure well. There were no complications. The patient went to Recovery in satisfactory condition. Family was updated. Orders are all in the chart. Please see orders.
Again, thank you for allowing to participate in this care.
1. DDDR permanent pacemaker.
2. Insertion of a steroid-eluting screw in right atrial lead.
3. Insertion of a steroid-eluting screw in right ventricular apical lead.
4. Pulse generator insertion, model Sigma.
SITE: Left subclavian vein access.
INDICATION: The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length. They all consented for the procedure, and the consent was signed and placed on the chart.
PROCEDURE: The patient was taken to cardiac cath lab where she was monitored throughout all procedure. The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner. We also scrubbed for approximately eight minutes. Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized. Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein. The Cook needles were removed. Then the guidewires were secured in place with hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle. The skin was then undermined making a pocket for the generator. The guidewires were then tunneled through the performed pocket. Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively. Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed. After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead. After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture. The leads were then connected to a pulse generator. The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket. The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique. The area was then cleansed and dry. Steri-Strips and pressure dressing were applied. The patient tolerated the procedure well. There were no complications.
Information on the pacemaker:
The implanted device are as follows:
PULSE GENERATOR
Model Name: Sigma.
Model #: SDR203.
Serial #: 123456.
ATRIAL LEAD
Model #: 4568-45 cm.
Serial #: 123456.
RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:
Model #: 4068-52 cm.
Serial #: 123456.
STIMULATION THRESHOLDS ARE AS FOLLOWS:
The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.
The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.
The brady parameter settings were set as follows:
The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking. Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking. The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.
The patient tolerated the procedure well. There were no complications. The patient went to Recovery in satisfactory condition. Family was updated. Orders are all in the chart. Please see orders.
Again, thank you for allowing to participate in this care.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.
GENERAL: The child is awake, alert, in moderate respiratory distress.
HEENT: Pupils equal, round, reactive to light. Extraocular movements are intact. The TMs are clear. The nares show some dry secretions. Audible congestion and wheezing is noted. Mucous membranes are dry. Throat is clear. No oral lesions noted.
NECK: Supple without lymphadenopathy or masses. Trachea is midline.
LUNGS: Show inspiratory and expiratory wheezes in all fields. Audible wheezes are noted. There are intercostal and subcostal retractions and suprasternal muscle use is noted.
HEART: Shows tachycardia. Regular rhythm. Normal S1, S2. No murmur.
ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding. No rebound. No hepatosplenomegaly.
EXTREMITIES: Capillary refill is brisk. Good distal pulses.
NEUROLOGIC: Cranial nerves II through XII intact. Moves all 4 extremities equally and normally.
VITAL SIGNS: Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.
GENERAL: The child is awake, alert, in moderate respiratory distress.
HEENT: Pupils equal, round, reactive to light. Extraocular movements are intact. The TMs are clear. The nares show some dry secretions. Audible congestion and wheezing is noted. Mucous membranes are dry. Throat is clear. No oral lesions noted.
NECK: Supple without lymphadenopathy or masses. Trachea is midline.
LUNGS: Show inspiratory and expiratory wheezes in all fields. Audible wheezes are noted. There are intercostal and subcostal retractions and suprasternal muscle use is noted.
HEART: Shows tachycardia. Regular rhythm. Normal S1, S2. No murmur.
ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding. No rebound. No hepatosplenomegaly.
EXTREMITIES: Capillary refill is brisk. Good distal pulses.
NEUROLOGIC: Cranial nerves II through XII intact. Moves all 4 extremities equally and normally.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Direct Laryngoscopy
Description: Direct laryngoscopy and bronchoscopy.
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PREOPERATIVE DIAGNOSIS: Subglottic stenosis.
POSTOPERATIVE DIAGNOSIS: Subglottic stenosis.
OPERATIVE PROCEDURES: Direct laryngoscopy and bronchoscopy.
ANESTHESIA: General inhalation.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operative table. General inhalational anesthesia was administered through the patient's tracheotomy tube. The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway. There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds. The stoma showed some suprastomal fibroma. The remaining tracheobronchial passages were clear. The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to recovery room in stable condition.
POSTOPERATIVE DIAGNOSIS: Subglottic stenosis.
OPERATIVE PROCEDURES: Direct laryngoscopy and bronchoscopy.
ANESTHESIA: General inhalation.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operative table. General inhalational anesthesia was administered through the patient's tracheotomy tube. The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway. There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds. The stoma showed some suprastomal fibroma. The remaining tracheobronchial passages were clear. The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to recovery room in stable condition.
Sample Name: Discharge Summary
Description: Patient had some cold symptoms, was treated as bronchitis with antibiotics.
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DISCHARGE DIAGNOSES:
1. Acute respiratory failure, resolved.
2. Severe bronchitis leading to acute respiratory failure, improving.
3. Acute on chronic renal failure, improved.
4. Severe hypertension, improved.
5. Diastolic dysfunction.
X-ray on discharge did not show any congestion and pro-BNP is normal.
SECONDARY DIAGNOSES:
1. Hyperlipidemia.
2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.
3. Remote history of carcinoma of the breast.
4. Remote history of right nephrectomy.
5. Allergic rhinitis.
HOSPITAL COURSE: This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization.
Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.
DISPOSITION: The patient has been discharged home.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Simvastatin 20 mg p.o. daily.
NEW MEDICATIONS:
1. Prednisone 20 mg p.o. daily for seven days.
2. Flonase nasal spray daily for 30 days.
Results for oximetry pending to evaluate the patient for need for home oxygen.
FOLLOW UP: The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.
1. Acute respiratory failure, resolved.
2. Severe bronchitis leading to acute respiratory failure, improving.
3. Acute on chronic renal failure, improved.
4. Severe hypertension, improved.
5. Diastolic dysfunction.
X-ray on discharge did not show any congestion and pro-BNP is normal.
SECONDARY DIAGNOSES:
1. Hyperlipidemia.
2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.
3. Remote history of carcinoma of the breast.
4. Remote history of right nephrectomy.
5. Allergic rhinitis.
HOSPITAL COURSE: This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization.
Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.
DISPOSITION: The patient has been discharged home.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Simvastatin 20 mg p.o. daily.
NEW MEDICATIONS:
1. Prednisone 20 mg p.o. daily for seven days.
2. Flonase nasal spray daily for 30 days.
Results for oximetry pending to evaluate the patient for need for home oxygen.
FOLLOW UP: The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dobutamine Stress Test
Description: Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine. Nondiagnostic dobutamine stress test. Normal nuclear myocardial perfusion scan.
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EXAM: Dobutamine Stress Test.
INDICATION: Chest pain.
TYPE OF TEST: Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.
INTERPRETATION: Resting heart rate of 66 and blood pressure of 88/45. EKG, normal sinus rhythm. Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate. Blood pressure 120/42. EKG remained the same. No symptoms were noted.
IMPRESSION:
1. Nondiagnostic dobutamine stress test.
2. Nuclear interpretation as below.
NUCLEAR INTERPRETATION: Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated and SPECT revealed normal wall motion and ejection fraction of 75%. End-diastolic volume was 57 and end-systolic volume of 12.
IMPRESSION:
1. Normal nuclear myocardial perfusion scan.
2. Ejection fraction of 75% by gated SPECT.
INDICATION: Chest pain.
TYPE OF TEST: Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.
INTERPRETATION: Resting heart rate of 66 and blood pressure of 88/45. EKG, normal sinus rhythm. Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate. Blood pressure 120/42. EKG remained the same. No symptoms were noted.
IMPRESSION:
1. Nondiagnostic dobutamine stress test.
2. Nuclear interpretation as below.
NUCLEAR INTERPRETATION: Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated and SPECT revealed normal wall motion and ejection fraction of 75%. End-diastolic volume was 57 and end-systolic volume of 12.
IMPRESSION:
1. Normal nuclear myocardial perfusion scan.
2. Ejection fraction of 75% by gated SPECT.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dobutamine Stress Test - 1
Description: Dobutamine Stress Echocardiogram. Chest discomfort, evaluation for coronary artery disease. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate. Negative EKG criteria for ischemia.
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DOBUTAMINE STRESS ECHOCARDIOGRAM
REASON FOR EXAM: Chest discomfort, evaluation for coronary artery disease.
PROCEDURE IN DETAIL: The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.
Wall motion assessed at all levels as well as at recovery.
The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.
The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.
The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.
No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg.
The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.
The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%.
The wall motion score was unchanged.
IMPRESSION:
1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.
2. Negative EKG criteria for ischemia.
3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management.
REASON FOR EXAM: Chest discomfort, evaluation for coronary artery disease.
PROCEDURE IN DETAIL: The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.
Wall motion assessed at all levels as well as at recovery.
The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.
The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.
The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.
No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg.
The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.
The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%.
The wall motion score was unchanged.
IMPRESSION:
1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.
2. Negative EKG criteria for ischemia.
3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Double Lumen Port Inserstion
Description: Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port.
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PREOPERATIVE DIAGNOSIS: Metastatic glossal carcinoma, needing chemotherapy and a port.
POSTOPERATIVE DIAGNOSIS: Metastatic glossal carcinoma, needing chemotherapy and a port.
PROCEDURES
1. Open exploration of the left subclavian/axillary vein.
2. Insertion of a double lumen port through the left femoral vein, radiological guidance.
DESCRIPTION OF PROCEDURE: After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy. The left deltopectoral and cervical areas were prepped and draped in the usual fashion. Local anesthetic was infiltrated in the area. There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful. Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic. I tried to cannulate it, but I could not advance the wire.
At that moment, I decided that there was no way we are going to put a port though that area. I packed the incision and we prepped and redraped the patient including both groins. Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty. The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart. It was done with radiological guidance. Again, I was able to position the catheter in the junction of inferior vena cava and right atrium. The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area. The port had been aspirated satisfactorily and irrigated with heparin solution. The drain incision was closed in layers including subcuticular suture with Monocryl. Then, we went up to the left shoulder and closed that incision in layers. Dressings were applied.
The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.
POSTOPERATIVE DIAGNOSIS: Metastatic glossal carcinoma, needing chemotherapy and a port.
PROCEDURES
1. Open exploration of the left subclavian/axillary vein.
2. Insertion of a double lumen port through the left femoral vein, radiological guidance.
DESCRIPTION OF PROCEDURE: After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy. The left deltopectoral and cervical areas were prepped and draped in the usual fashion. Local anesthetic was infiltrated in the area. There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful. Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic. I tried to cannulate it, but I could not advance the wire.
At that moment, I decided that there was no way we are going to put a port though that area. I packed the incision and we prepped and redraped the patient including both groins. Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty. The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart. It was done with radiological guidance. Again, I was able to position the catheter in the junction of inferior vena cava and right atrium. The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area. The port had been aspirated satisfactorily and irrigated with heparin solution. The drain incision was closed in layers including subcuticular suture with Monocryl. Then, we went up to the left shoulder and closed that incision in layers. Dressings were applied.
The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dual Chamber Generator Replacement
Description: Dual chamber generator replacement. The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.
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REFERRAL INDICATIONS
1. Pacemaker at ERI.
2. History AV block.
PROCEDURES PLANNED AND PERFORMED: Dual chamber generator replacement.
FLUOROSCOPY TIME: 0 minutes.
MEDICATION AT THE TIME OF STUDY
1. Ancef 1 g.
2. Versed 2 mg.
3. Fentanyl 50 mcg.
CLINICAL HISTORY: The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.
RISKS AND BENEFITS: Risks, benefits, and alternatives to generator replacement have been discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient. The patient agreed both verbally and via written consent.
DESCRIPTION OF OPERATION: The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner. Lidocaine 1% (20 mL) was administered to the area of the previous incision. A transverse incision was made through the skin and subcutaneous tissue. Hemostasis was achieved with electrocautery. Using blunt dissection, pacemaker, and leads were removed from the pocket. Leads were disconnected from the pulse generator and interrogated. The pocket was washed with antibiotic impregnated saline. The new pulse generator was obtained and connected securely to the leads and placed back in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.
DEVICE DATA
1. Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.
2. New pulse generator Medronic, product # ADDR01, serial # ABCD1234.
3. Right atrial lead, product # 4068, serial # ABCD1234.
4. Right atrial lead, product # 4068, serial # ABCD1234.
MEASURED INTRAOPERATIVE DATA
1. Right atrial lead impedance 572 ohms. P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.
2. Right ventricular lead impedance 365 ohms. No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.
CONCLUSIONS
1. Successful dual chamber generator replacement.
2. No acute complications.
PLAN
1. She will be monitored for 3 hours and then dismissed home.
2. Resume all medications. Ex-home dismissal instructions.
3. Doxycycline 100 mg one p.o. twice daily for 7 days.
4. Wound check in 7-10 days.
5. Continue followup in device clinic.
1. Pacemaker at ERI.
2. History AV block.
PROCEDURES PLANNED AND PERFORMED: Dual chamber generator replacement.
FLUOROSCOPY TIME: 0 minutes.
MEDICATION AT THE TIME OF STUDY
1. Ancef 1 g.
2. Versed 2 mg.
3. Fentanyl 50 mcg.
CLINICAL HISTORY: The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.
RISKS AND BENEFITS: Risks, benefits, and alternatives to generator replacement have been discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient. The patient agreed both verbally and via written consent.
DESCRIPTION OF OPERATION: The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner. Lidocaine 1% (20 mL) was administered to the area of the previous incision. A transverse incision was made through the skin and subcutaneous tissue. Hemostasis was achieved with electrocautery. Using blunt dissection, pacemaker, and leads were removed from the pocket. Leads were disconnected from the pulse generator and interrogated. The pocket was washed with antibiotic impregnated saline. The new pulse generator was obtained and connected securely to the leads and placed back in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.
DEVICE DATA
1. Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.
2. New pulse generator Medronic, product # ADDR01, serial # ABCD1234.
3. Right atrial lead, product # 4068, serial # ABCD1234.
4. Right atrial lead, product # 4068, serial # ABCD1234.
MEASURED INTRAOPERATIVE DATA
1. Right atrial lead impedance 572 ohms. P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.
2. Right ventricular lead impedance 365 ohms. No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.
CONCLUSIONS
1. Successful dual chamber generator replacement.
2. No acute complications.
PLAN
1. She will be monitored for 3 hours and then dismissed home.
2. Resume all medications. Ex-home dismissal instructions.
3. Doxycycline 100 mg one p.o. twice daily for 7 days.
4. Wound check in 7-10 days.
5. Continue followup in device clinic.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dual Chamber ICD Implantation
Description: Dual Chamber ICD Implantation, fluoroscopy, defibrillation threshold testing, venography.
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PROCEDURE:
1. Implantation, dual chamber ICD.
2. Fluoroscopy.
3. Defibrillation threshold testing.
4. Venography.
PROCEDURE NOTE: After informed consent was obtained, the patient was taken to the operating room. The patient was prepped and draped in a sterile fashion. Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully. Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein. Venogram was then performed. Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava. A second guidewire was placed in a similar fashion. Approximately a 5 cm incision was made in the left upper anterior chest. The skin and subcutaneous tissue was dissected out of the prepectoral fascia. Both guide wires were brought into the pocket area. A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava. The dilator and guidewire were removed. A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle. Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex. After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture. A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava. The dilator and guidewire were removed. An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium. Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area. After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture. The tract was flushed with saline solution. A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture. Deep and superficial layers were closed with 3-0 Vicryl in a running fashion. Steri-strips were placed over the incision. Tegaderm was placed over the Steri-strips. Pressure dressing was applied to the pocket area.
1. Implantation, dual chamber ICD.
2. Fluoroscopy.
3. Defibrillation threshold testing.
4. Venography.
PROCEDURE NOTE: After informed consent was obtained, the patient was taken to the operating room. The patient was prepped and draped in a sterile fashion. Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully. Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein. Venogram was then performed. Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava. A second guidewire was placed in a similar fashion. Approximately a 5 cm incision was made in the left upper anterior chest. The skin and subcutaneous tissue was dissected out of the prepectoral fascia. Both guide wires were brought into the pocket area. A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava. The dilator and guidewire were removed. A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle. Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex. After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture. A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava. The dilator and guidewire were removed. An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium. Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area. After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture. The tract was flushed with saline solution. A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture. Deep and superficial layers were closed with 3-0 Vicryl in a running fashion. Steri-strips were placed over the incision. Tegaderm was placed over the Steri-strips. Pressure dressing was applied to the pocket area.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Duplex Ultrasound - Legs
Description: Duplex ultrasound of legs
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DUPLEX ULTRASOUND OF LEGS
RIGHT LEG: Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.
The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.
LEFT LEG: Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.
The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.
RIGHT LEG: Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.
The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.
LEFT LEG: Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.
The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Echocardiogram
Description: Echocardiogram with color flow and conventional Doppler interrogation.
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REASON FOR EXAMINATION: Cardiac arrhythmia.
INTERPRETATION: No significant pericardial effusion was identified.
The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular systolic function is preserved with an estimated ejection fraction of 60%. The left ventricular wall thickness is within normal limits.
The aortic valve is trileaflet with adequate excursion of the leaflets. The mitral valve and tricuspid valve motion is unremarkable. The pulmonic valve is not well visualized.
Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg. Doppler interrogation of the mitral in-flow pattern is within normal limits for age.
IMPRESSION:
1. Preserved left ventricular systolic function.
2. Mild mitral regurgitation.
3. Mild tricuspid regurgitation.
INTERPRETATION: No significant pericardial effusion was identified.
The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular systolic function is preserved with an estimated ejection fraction of 60%. The left ventricular wall thickness is within normal limits.
The aortic valve is trileaflet with adequate excursion of the leaflets. The mitral valve and tricuspid valve motion is unremarkable. The pulmonic valve is not well visualized.
Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg. Doppler interrogation of the mitral in-flow pattern is within normal limits for age.
IMPRESSION:
1. Preserved left ventricular systolic function.
2. Mild mitral regurgitation.
3. Mild tricuspid regurgitation.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Echocardiogram - 1
Description: Echocardiogram was performed including 2-D and M-mode imaging.
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EXAM: Echocardiogram.
INTERPRETATION: Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode. Cardiac chamber dimensions, left atrial enlargement 4.4 cm. Left ventricle, right ventricle, and right atrium are grossly normal. LV wall thickness and wall motion appeared normal. LV ejection fraction is estimated at 65%. Aortic root and cardiac valves appeared normal. No evidence of pericardial effusion. No evidence of intracardiac mass or thrombus. Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal. There is mild tricuspid regurgitation. Calculated pulmonary systolic pressure 42 mmHg.
ECHOCARDIOGRAPHIC DIAGNOSES:
1. LV Ejection fraction, estimated at 65%.
2. Mild left atrial enlargement.
3. Mild tricuspid regurgitation.
4. Mildly elevated pulmonary systolic pressure.
INTERPRETATION: Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode. Cardiac chamber dimensions, left atrial enlargement 4.4 cm. Left ventricle, right ventricle, and right atrium are grossly normal. LV wall thickness and wall motion appeared normal. LV ejection fraction is estimated at 65%. Aortic root and cardiac valves appeared normal. No evidence of pericardial effusion. No evidence of intracardiac mass or thrombus. Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal. There is mild tricuspid regurgitation. Calculated pulmonary systolic pressure 42 mmHg.
ECHOCARDIOGRAPHIC DIAGNOSES:
1. LV Ejection fraction, estimated at 65%.
2. Mild left atrial enlargement.
3. Mild tricuspid regurgitation.
4. Mildly elevated pulmonary systolic pressure.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Echocardiogram - 2
Description: Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm
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EXAM: Echocardiogram.
INDICATION: Aortic stenosis.
INTERPRETATION: Transthoracic echocardiogram was performed of adequate technical quality. Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. Ejection fraction is 60% without any obvious wall motion abnormality. Left atrium and right side chambers are of normal size and dimensions. Aortic root has normal diameter.
Mitral and tricuspid valves are structurally normal except for minimal annular calcification. Valvular leaflet excursion is adequate. Aortic valve reveals annular calcification. Fibrocalcific valve leaflets with decreased excursion. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.
Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation. Estimated pulmonary pressure of 48. Systolic consistent with mild-to-moderate pulmonary hypertension. Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.
IN SUMMARY:
1. Concentric hypertrophy of the left ventricle with normal function.
2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.
INDICATION: Aortic stenosis.
INTERPRETATION: Transthoracic echocardiogram was performed of adequate technical quality. Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. Ejection fraction is 60% without any obvious wall motion abnormality. Left atrium and right side chambers are of normal size and dimensions. Aortic root has normal diameter.
Mitral and tricuspid valves are structurally normal except for minimal annular calcification. Valvular leaflet excursion is adequate. Aortic valve reveals annular calcification. Fibrocalcific valve leaflets with decreased excursion. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.
Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation. Estimated pulmonary pressure of 48. Systolic consistent with mild-to-moderate pulmonary hypertension. Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.
IN SUMMARY:
1. Concentric hypertrophy of the left ventricle with normal function.
2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Echocardiogram - 3
Description: Echocardiographic Examination Report. Angina and coronary artery disease. Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension.
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REASON FOR EXAM:
1. Angina.
2. Coronary artery disease.
INTERPRETATION: This is a technically acceptable study.
DIMENSIONS: Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. The left atrium is 3.9.
FINDINGS: Left atrium was mildly to moderately dilated. No masses or thrombi were seen. The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall. The EF was moderately reduced with estimated EF of 40% with near normal thickening. The right atrium was mildly dilated. The right ventricle was normal in size.
Mitral valve showed to be structurally normal with no prolapse or vegetation. There was mild mitral regurgitation on color flow interrogation. The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction. The aortic valve appeared to be structurally normal. Normal peak velocity. No significant AI. Pulmonic valve showed mild PI. Tricuspid valve showed mild tricuspid regurgitation. Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg. Anterior septum appeared to be intact. No pericardial effusion was seen.
CONCLUSION:
1. Mild biatrial enlargement.
2. Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%.
3. Mild mitral regurgitation.
4. Diastolic dysfunction grade 2.
5. Mild pulmonary hypertension.
1. Angina.
2. Coronary artery disease.
INTERPRETATION: This is a technically acceptable study.
DIMENSIONS: Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. The left atrium is 3.9.
FINDINGS: Left atrium was mildly to moderately dilated. No masses or thrombi were seen. The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall. The EF was moderately reduced with estimated EF of 40% with near normal thickening. The right atrium was mildly dilated. The right ventricle was normal in size.
Mitral valve showed to be structurally normal with no prolapse or vegetation. There was mild mitral regurgitation on color flow interrogation. The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction. The aortic valve appeared to be structurally normal. Normal peak velocity. No significant AI. Pulmonic valve showed mild PI. Tricuspid valve showed mild tricuspid regurgitation. Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg. Anterior septum appeared to be intact. No pericardial effusion was seen.
CONCLUSION:
1. Mild biatrial enlargement.
2. Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%.
3. Mild mitral regurgitation.
4. Diastolic dysfunction grade 2.
5. Mild pulmonary hypertension.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Echocardiography
Description: Echocardiographic examination. Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.
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REASON FOR EXAM: CVA.
INDICATIONS: CVA.
This is technically acceptable. There is some limitation related to body habitus.
DIMENSIONS: The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.
FINDINGS: The left atrium was mildly dilated. No masses or thrombi were seen. The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%. The right atrium and right ventricle are normal in size.
Mitral valve showed mitral annular calcification in the posterior aspect of the valve. The valve itself was structurally normal. No vegetations seen. No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1. The aortic valve showed minimal thickening with good exposure and coaptation. Peak velocity is normal. No AI.
Pulmonic and tricuspid valves were both structurally normal.
Interatrial septum was appeared to be intact in the views obtained. A bubble study was not performed.
No pericardial effusion was seen. Aortic arch was not assessed.
CONCLUSIONS:
1. Borderline left ventricular hypertrophy with normal ejection fraction at 60%.
2. Mitral annular calcification with structurally normal mitral valve.
3. No intracavitary thrombi is seen.
4. Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.
INDICATIONS: CVA.
This is technically acceptable. There is some limitation related to body habitus.
DIMENSIONS: The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.
FINDINGS: The left atrium was mildly dilated. No masses or thrombi were seen. The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%. The right atrium and right ventricle are normal in size.
Mitral valve showed mitral annular calcification in the posterior aspect of the valve. The valve itself was structurally normal. No vegetations seen. No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1. The aortic valve showed minimal thickening with good exposure and coaptation. Peak velocity is normal. No AI.
Pulmonic and tricuspid valves were both structurally normal.
Interatrial septum was appeared to be intact in the views obtained. A bubble study was not performed.
No pericardial effusion was seen. Aortic arch was not assessed.
CONCLUSIONS:
1. Borderline left ventricular hypertrophy with normal ejection fraction at 60%.
2. Mitral annular calcification with structurally normal mitral valve.
3. No intracavitary thrombi is seen.
4. Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.
PHYSICAL EXAMINATION:
GENERAL: The patient is comfortable, not in distress.
VITAL SIGNS: His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.
HEENT: Atraumatic, normocephalic. Eyes PERRLA.
NECK: Supple. No JVD. No carotid bruit.
CHEST: Clear.
HEART: S1 and S2, regular. No S3. No S4. No murmur.
ABDOMEN: Soft, nontender. Positive bowel sounds.
EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.
CNS: Alert, awake, and oriented x3.
GENERAL: The patient is comfortable, not in distress.
VITAL SIGNS: His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.
HEENT: Atraumatic, normocephalic. Eyes PERRLA.
NECK: Supple. No JVD. No carotid bruit.
CHEST: Clear.
HEART: S1 and S2, regular. No S3. No S4. No murmur.
ABDOMEN: Soft, nontender. Positive bowel sounds.
EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.
CNS: Alert, awake, and oriented x3.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 94, blood pressure 98/57, respiratory rate as per setting.
HEENT: Atraumatic and normocephalic.
NECK: Supple. Neck veins flat.
LUNGS: Air entry bilaterally clear, rales are scattered.
HEART: PMI displaced. S1, S2 regular. Systolic murmur, grade 2/6.
ABDOMEN: Soft, nontender.
EXTREMITIES: Chronic skin changes, markings in the lower extremities noted. Pulses found palpable. Dressing also noted.
LABORATORY AND DIAGNOSTIC DATA: EKG, normal sinus rhythm with wide complex. Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11. Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423. Chest x-ray, no acute changes.
VITAL SIGNS: Pulse of 94, blood pressure 98/57, respiratory rate as per setting.
HEENT: Atraumatic and normocephalic.
NECK: Supple. Neck veins flat.
LUNGS: Air entry bilaterally clear, rales are scattered.
HEART: PMI displaced. S1, S2 regular. Systolic murmur, grade 2/6.
ABDOMEN: Soft, nontender.
EXTREMITIES: Chronic skin changes, markings in the lower extremities noted. Pulses found palpable. Dressing also noted.
LABORATORY AND DIAGNOSTIC DATA: EKG, normal sinus rhythm with wide complex. Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11. Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423. Chest x-ray, no acute changes.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Endotracheal Intubation
Description: Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction.
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PROCEDURE: Endotracheal intubation.
INDICATION: Respiratory failure.
BRIEF HISTORY: The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. He has been on Coumadin for previous PE and currently on heparin drip. He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness. A code blue was called. On my arrival, the patient's vital signs are stable. His blood pressure is systolically in 140s and heart rate 80s. He however has 0 respiratory effort and is unresponsive to even painful stimuli. The patient was given etomidate 20 mg.
DESCRIPTION OF PROCEDURE: The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine. Mac-4 blade was used. A 7.5 ET tube placed to 24th teeth. There is good color change on the capnographer with bilateral breath sounds. Following intubation, the patient's blood pressure began to drop. He was given 2 L of bolus. I started him on dopamine drip at 10 mcg. Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU. Chest x-ray will be reviewed and Pulmonary will be consulted.
INDICATION: Respiratory failure.
BRIEF HISTORY: The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. He has been on Coumadin for previous PE and currently on heparin drip. He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness. A code blue was called. On my arrival, the patient's vital signs are stable. His blood pressure is systolically in 140s and heart rate 80s. He however has 0 respiratory effort and is unresponsive to even painful stimuli. The patient was given etomidate 20 mg.
DESCRIPTION OF PROCEDURE: The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine. Mac-4 blade was used. A 7.5 ET tube placed to 24th teeth. There is good color change on the capnographer with bilateral breath sounds. Following intubation, the patient's blood pressure began to drop. He was given 2 L of bolus. I started him on dopamine drip at 10 mcg. Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU. Chest x-ray will be reviewed and Pulmonary will be consulted.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Endotracheal Intubation - 1
Description: Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.
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PROCEDURE PERFORMED: Endotracheal intubation.
INDICATION FOR PROCEDURE: The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.
NARRATIVE OF PROCEDURE: The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium. He was intubated in a single attempt. Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade. Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture. A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes. The patient tolerated the procedure well.
INDICATION FOR PROCEDURE: The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.
NARRATIVE OF PROCEDURE: The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium. He was intubated in a single attempt. Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade. Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture. A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes. The patient tolerated the procedure well.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Endovascular Brachytherapy
Description: Endovascular Brachytherapy (EBT)
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ENDOVASCULAR BRACHYTHERAPY (EBT)
The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter. The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy. The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter. Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function.
The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter. The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy. The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter. Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5.
GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed.
HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact.
NECK: Supple with full range of motion. No rigidity or meningismus.
CHEST: Nontender.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. No murmur, S3, or S4.
ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness.
EXTREMITIES: Unremarkable.
NEUROLOGIC: Unremarkable.
VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5.
GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed.
HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact.
NECK: Supple with full range of motion. No rigidity or meningismus.
CHEST: Nontender.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. No murmur, S3, or S4.
ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness.
EXTREMITIES: Unremarkable.
NEUROLOGIC: Unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 96 degrees, axillary. Pulse 128. Respirations 48. Blood pressure 156/100. Initial oxygen saturations on room air are 80.
GENERAL: Reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.
HEENT: Head is normocephalic and atraumatic.
NECK: The neck is supple without obvious jugular venous distention.
LUNGS: Auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.
HEART: Cardiac examination reveals sinus tachycardia, without pronounced murmur.
ABDOMEN: Soft to palpation.
Extremities: Without edema.
DIAGNOSTIC DATA: White blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. Chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, CO2 44, BUN 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. Troponin is 0.11. Urinalysis reveals yellow clear urine. Specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. No white cells and 0-2 red cells.
VITAL SIGNS: Temperature 96 degrees, axillary. Pulse 128. Respirations 48. Blood pressure 156/100. Initial oxygen saturations on room air are 80.
GENERAL: Reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.
HEENT: Head is normocephalic and atraumatic.
NECK: The neck is supple without obvious jugular venous distention.
LUNGS: Auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.
HEART: Cardiac examination reveals sinus tachycardia, without pronounced murmur.
ABDOMEN: Soft to palpation.
Extremities: Without edema.
DIAGNOSTIC DATA: White blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. Chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, CO2 44, BUN 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. Troponin is 0.11. Urinalysis reveals yellow clear urine. Specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. No white cells and 0-2 red cells.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Myocardial Perfusion Study
Description: Exercise myocardial perfusion study. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%
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This is a low stress, high rest 1-day protocol; however the patient had the resting study done today.
CLINICAL INDICATION: Chest pain.
INTERPRETATION: The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.
The patient's baseline EKG was normal sinus rhythm. The patient was stressed according to Bruce protocol by Dr. X. Exercise test was supervised and interpreted by Dr. X. Please see the separate report for stress portion of the study.
The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact. There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.
The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.
CONCLUSION:
1. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.
2. Normal LV systolic function with LV ejection fraction of 59%.
CLINICAL INDICATION: Chest pain.
INTERPRETATION: The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.
The patient's baseline EKG was normal sinus rhythm. The patient was stressed according to Bruce protocol by Dr. X. Exercise test was supervised and interpreted by Dr. X. Please see the separate report for stress portion of the study.
The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact. There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.
The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.
CONCLUSION:
1. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.
2. Normal LV systolic function with LV ejection fraction of 59%.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test
Description: Exercise stress test with nuclear scan for chest pain. Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product. Normal nuclear myocardial perfusion scan.
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INDICATION: Chest pain.
INTERPRETATION: Resting heart rate of 71, blood pressure 100/60. EKG normal sinus rhythm. The patient exercised on Bruce for 8 minutes on stage III. Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54. Total METs was 10.1. EKG revealed nonspecific ST depression in inferior and lateral leads. The test was terminated because of fatigue. The patient did have chest pain during exercise that resolved after termination of the exercise.
IN SUMMARY:
1. Positive exercise ischemia with ST depression 0.5 mm.
2. Chest pain resolved after termination of exercise.
3. Good exercise duration, tolerance and double product.
NUCLEAR INTERPRETATION:
Resting and stress images were obtained with 10.1 mCi and 34.1 mCi of tetraphosphate injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 68%. End-diastolic volume of 77, end-systolic volume of 24.
IN SUMMARY:
1. Normal nuclear myocardial perfusion scan.
2. Ejection fraction of 68% by gated SPECT.
INTERPRETATION: Resting heart rate of 71, blood pressure 100/60. EKG normal sinus rhythm. The patient exercised on Bruce for 8 minutes on stage III. Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54. Total METs was 10.1. EKG revealed nonspecific ST depression in inferior and lateral leads. The test was terminated because of fatigue. The patient did have chest pain during exercise that resolved after termination of the exercise.
IN SUMMARY:
1. Positive exercise ischemia with ST depression 0.5 mm.
2. Chest pain resolved after termination of exercise.
3. Good exercise duration, tolerance and double product.
NUCLEAR INTERPRETATION:
Resting and stress images were obtained with 10.1 mCi and 34.1 mCi of tetraphosphate injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 68%. End-diastolic volume of 77, end-systolic volume of 24.
IN SUMMARY:
1. Normal nuclear myocardial perfusion scan.
2. Ejection fraction of 68% by gated SPECT.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test - 1
Description: A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain. MI has been ruled out. She has been referred for an exercise echocardiogram.
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The patient is a pleasant 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain. MI has been ruled out. She has been referred for an exercise echocardiogram.
Informed written consent has been obtained from the patient. I explained the procedure to her prior to initiation of such. The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position. There were no safety concerns noted by staff nor myself.
REST ECHO: EF 60%. No wall motion abnormalities. EKG shows normal sinus rhythm with mild ST depressions. The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen. Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities. There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise. No dysrhythmias noted.
IMPRESSION:
1. Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.
2. Resting hypertension with appropriate response of blood pressure to exercise.
These results have been discussed with the patient. Other management as per the hospital-based internal medicine service.
To be clear, there were no complications of this procedure.
Informed written consent has been obtained from the patient. I explained the procedure to her prior to initiation of such. The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position. There were no safety concerns noted by staff nor myself.
REST ECHO: EF 60%. No wall motion abnormalities. EKG shows normal sinus rhythm with mild ST depressions. The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen. Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities. There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise. No dysrhythmias noted.
IMPRESSION:
1. Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.
2. Resting hypertension with appropriate response of blood pressure to exercise.
These results have been discussed with the patient. Other management as per the hospital-based internal medicine service.
To be clear, there were no complications of this procedure.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test - 2
Description: Reduced exercise capacity for age, no chest pain with exercise, no significant ST segment changes with exercise, symptoms of left anterior chest pain were not provoked with exercise, and hypertensive response noted with exercise.
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INDICATION: This 69-year-old man is undergoing a preoperative evaluation for anticipated prostate surgery. He is having a transurethral prostate resection performed by Dr. X for treatment of severely symptomatic prostatic hypertrophy. He has recently completed radiation therapy to T11 for a plasmacytoma. He has recently complained of left anterior chest pain, which radiates down the left upper arm towards the elbow. This occurs during quiet periods such as in bed at night. It may last all night and still be present in the morning. It usually dissipates as the day progresses. There are no obvious triggers and there are no obvious alleviating factors. The patient has no known cardiac risk factors. He is currently taking Avodart 0.5 mg daily, Wellbutrin 300 mg daily, Xanax 0.25 mg p.r.n., Uroxatral 10 mg daily, and omeprazole 20 mg daily.
PHYSICAL EXAMINATION: On physical examination, the patient appears pale and fatigued. He is 66 inches tall, 205 pounds for a body mass index of 32. His resting heart rate is 80. His resting blood pressure is 120/84. His lungs are clear. His heart exam reveals a regular rhythm and normal S1 and S2 without murmur, gallop, or rub appreciated. The carotid upstroke is normal with no bruit identified. The peripheral pulses are intact. The resting electrocardiogram showed a sinus rhythm at 68 beats per minute and is normal.
DESCRIPTION: The patient exercised according to the standard Bruce protocol stopping at 4 minutes and 39 seconds with fatigue. He did not experience his left anterior chest pain with exercise. He did achieve a maximal heart rate of 129 beats per minute, which is 85% of his maximal predicted heart rate. His maximal blood pressure was 200/84, double product of 24,000 and achieving 7 METs. As noted the resting electrocardiogram was normal. With exercise, there were no significant deviations from baseline and no arrhythmias.
CONCLUSION:
1. Reduced exercise capacity for age.
2. No chest pain with exercise.
3. No significant ST segment changes with exercise.
4. Symptoms of left anterior chest pain were not provoked with exercise.
5. Hypertensive response noted with exercise.
PHYSICAL EXAMINATION: On physical examination, the patient appears pale and fatigued. He is 66 inches tall, 205 pounds for a body mass index of 32. His resting heart rate is 80. His resting blood pressure is 120/84. His lungs are clear. His heart exam reveals a regular rhythm and normal S1 and S2 without murmur, gallop, or rub appreciated. The carotid upstroke is normal with no bruit identified. The peripheral pulses are intact. The resting electrocardiogram showed a sinus rhythm at 68 beats per minute and is normal.
DESCRIPTION: The patient exercised according to the standard Bruce protocol stopping at 4 minutes and 39 seconds with fatigue. He did not experience his left anterior chest pain with exercise. He did achieve a maximal heart rate of 129 beats per minute, which is 85% of his maximal predicted heart rate. His maximal blood pressure was 200/84, double product of 24,000 and achieving 7 METs. As noted the resting electrocardiogram was normal. With exercise, there were no significant deviations from baseline and no arrhythmias.
CONCLUSION:
1. Reduced exercise capacity for age.
2. No chest pain with exercise.
3. No significant ST segment changes with exercise.
4. Symptoms of left anterior chest pain were not provoked with exercise.
5. Hypertensive response noted with exercise.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test - 3
Description: No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.
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INDICATIONS: An 82-year-old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single-vessel coronary bypass graft procedure. The patient has had a complicated postoperative course with rapid atrial fibrillation, pleural effusions, anemia and thrombocytopenia. He is currently stabilized and improving in strength. He is living in Nantucket with his daughter Debra Anderson while he recuperates and completes the cardiac rehabilitation program. He has a few other significant medical problems.
MEDICATIONS:
1. Toprol-XL 25 mg daily.
2. Simvastatin 80 mg daily.
3. Aspirin 81 mg daily.
4. Synthroid 0.5 mg daily.
5. Warfarin 1.5 mg daily.
PHYSICAL EXAMINATION: The patient appears pale and fragile. He is comfortable at rest. His resting heart rate is 80. His resting blood pressure is 112/70. His conjunctivae are pale. His lungs have decreased breath sounds throughout and dullness at the bases bilaterally. Heart exam reveals a distant S1 and S2. There is a short 2/6 systolic ejection murmur. The extremities are normal without clubbing, cyanosis or edema.
The resting echocardiogram showed a sinus rhythm at 70 beats per minute. There is poor R wave progression across the pericardium and Q waves inferiorly.
DESCRIPTION: The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath. He did not experience chest pain with exercise. He did achieve a maximal heart rate of 100, which is 72% of his maximal predicted heart rate. His maximal blood pressure was 190/70 resulting in a double product of 19,000 and achieving 2.3 METS. As noted, the resting electrocardiogram had inferior Q waves and poor R wave progression. There were no significant ST segment changes with exercise. There were only rare ventricular premature beats with exercise.
CONCLUSION:
1. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.
2. No chest pain with exercise.
3. No significant ECG changes with exercise.
4. The patient is considered stable to enter our cardiac rehabilitation program. I recommend the patient have a complete blood count, basic metabolic profile, and TSH obtained prior to entering the rehab program.
MEDICATIONS:
1. Toprol-XL 25 mg daily.
2. Simvastatin 80 mg daily.
3. Aspirin 81 mg daily.
4. Synthroid 0.5 mg daily.
5. Warfarin 1.5 mg daily.
PHYSICAL EXAMINATION: The patient appears pale and fragile. He is comfortable at rest. His resting heart rate is 80. His resting blood pressure is 112/70. His conjunctivae are pale. His lungs have decreased breath sounds throughout and dullness at the bases bilaterally. Heart exam reveals a distant S1 and S2. There is a short 2/6 systolic ejection murmur. The extremities are normal without clubbing, cyanosis or edema.
The resting echocardiogram showed a sinus rhythm at 70 beats per minute. There is poor R wave progression across the pericardium and Q waves inferiorly.
DESCRIPTION: The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath. He did not experience chest pain with exercise. He did achieve a maximal heart rate of 100, which is 72% of his maximal predicted heart rate. His maximal blood pressure was 190/70 resulting in a double product of 19,000 and achieving 2.3 METS. As noted, the resting electrocardiogram had inferior Q waves and poor R wave progression. There were no significant ST segment changes with exercise. There were only rare ventricular premature beats with exercise.
CONCLUSION:
1. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.
2. No chest pain with exercise.
3. No significant ECG changes with exercise.
4. The patient is considered stable to enter our cardiac rehabilitation program. I recommend the patient have a complete blood count, basic metabolic profile, and TSH obtained prior to entering the rehab program.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test - 4
Description: Chest pain. Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.
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INDICATION: Chest pain.
DESCRIPTION OF PROCEDURE: After informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring. The patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90. The patient was started on a Bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12.8 METs. The patient's maximum blood pressure during this stress part was 148/80 and the patient achieved heart rate of 152 with no EKG changes, no chest pain.
FINDINGS:
1. Normal hemodynamic response to exercise.
2. No EKG changes suggestive of ischemia.
3. No chest pain during the stress test.
4. Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.
DESCRIPTION OF PROCEDURE: After informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring. The patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90. The patient was started on a Bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12.8 METs. The patient's maximum blood pressure during this stress part was 148/80 and the patient achieved heart rate of 152 with no EKG changes, no chest pain.
FINDINGS:
1. Normal hemodynamic response to exercise.
2. No EKG changes suggestive of ischemia.
3. No chest pain during the stress test.
4. Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Femoral Artery Cannulation & Aortogram
Description: Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg.
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PREOPERATIVE DIAGNOSES: Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.
POSTOPERATIVE DIAGNOSES: Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD. Significant coronary artery disease, very severe PAD.
PROCEDURES PERFORMED:
1. Right common femoral artery cannulation.
2. Conscious sedation using IV Versed and IV fentanyl.
3. Retrograde bilateral coronary angiography.
4. Abdominal aortogram with pelvic runoff.
5. Left external iliac angiogram with runoff to the patient's left foot.
6. Left external iliac angiogram with runoff to the patient's right leg.
7. Right common femoral artery angiogram runoff to the patient's right leg.
PROCEDURE IN DETAIL: The patient was taken to the cardiac catheterization laboratory after having a valid consent. He was prepped and draped in the usual sterile fashion.
After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery. The arterial sheath was flushed throughout the procedure.
Conscious sedation was obtained using IV Versed and IV fentanyl.
With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta. The wire was removed, the catheter was flushed. The catheter was engaged in the left main. Injections were performed at the left main in different views. The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire. The wire was removed, the catheter was flushed. The catheter was engaged in the RCA. Injections were performed at the RCA in different views.
The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire. The wire was removed. The catheter was flushed. Abdominal aortogram was then performed with runoff to the patient's pelvis.
The Omniflush catheter was then retracted into the aortic bifurcation. Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA. The Omniflush was then removed. Through the wire, a Royal Flush catheter was then advanced into the left external iliac. The wire was removed. Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed. The catheter was then retracted into the left common iliac. Angiograms were performed of the left common iliac with runoff to the patient's left groin. The catheter was then positioned at the level of the right common iliac. Angiogram of the right common iliac with runoff to the patient's right leg was then performed. The catheter was then removed with the help of a J-wire. The J-wire was left in the abdominal aorta. Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.
The wire was then removed. The arterial sheath was then removed after being flushed. Hemostasis was obtained using hand compression.
The patient tolerated the procedure well and had no complications. At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.
Hemodynamic Findings: Aortic pressure 140/70.
ANGIOGRAPHIC FINDINGS: Left main with calcification 25% to 40% lesion.
The left main is very short.
LAD with calcification 25% to 40% proximal lesion.
D1 has 25% lesion. No in-stent restenosis was noted in D1.
D2 and D3 are very small with luminal irregularities.
Circumflex artery was diseased throughout the vessel. The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.
OM1 has 25% to 40% lesion. These OMs are small with luminal irregularities.
RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.
Left ventriculography was not done.
ABDOMINAL AORTOGRAM: Right renal artery with luminal irregularities. Left renal artery with luminal irregularities. The abdominal aorta has 25% lesion.
Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.
The right external iliac has a proximal 75% lesion.
The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.
The right SFA was visualized, although not very well.
Left common iliac with 25% to 50% lesion. Left external iliac with 25% to 40% lesion. Left common femoral with 25% to 40% lesion. Left SFA with 25% lesion. Left popliteal with wall luminal irregularities.
Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.
Conclusions: Severe coronary artery disease. Very severe peripheral arterial disease.
PLAN: Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD. We will proceed with revascularization of the right external iliac as well as right common femoral. Discontinue tobacco.
POSTOPERATIVE DIAGNOSES: Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD. Significant coronary artery disease, very severe PAD.
PROCEDURES PERFORMED:
1. Right common femoral artery cannulation.
2. Conscious sedation using IV Versed and IV fentanyl.
3. Retrograde bilateral coronary angiography.
4. Abdominal aortogram with pelvic runoff.
5. Left external iliac angiogram with runoff to the patient's left foot.
6. Left external iliac angiogram with runoff to the patient's right leg.
7. Right common femoral artery angiogram runoff to the patient's right leg.
PROCEDURE IN DETAIL: The patient was taken to the cardiac catheterization laboratory after having a valid consent. He was prepped and draped in the usual sterile fashion.
After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery. The arterial sheath was flushed throughout the procedure.
Conscious sedation was obtained using IV Versed and IV fentanyl.
With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta. The wire was removed, the catheter was flushed. The catheter was engaged in the left main. Injections were performed at the left main in different views. The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire. The wire was removed, the catheter was flushed. The catheter was engaged in the RCA. Injections were performed at the RCA in different views.
The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire. The wire was removed. The catheter was flushed. Abdominal aortogram was then performed with runoff to the patient's pelvis.
The Omniflush catheter was then retracted into the aortic bifurcation. Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA. The Omniflush was then removed. Through the wire, a Royal Flush catheter was then advanced into the left external iliac. The wire was removed. Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed. The catheter was then retracted into the left common iliac. Angiograms were performed of the left common iliac with runoff to the patient's left groin. The catheter was then positioned at the level of the right common iliac. Angiogram of the right common iliac with runoff to the patient's right leg was then performed. The catheter was then removed with the help of a J-wire. The J-wire was left in the abdominal aorta. Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.
The wire was then removed. The arterial sheath was then removed after being flushed. Hemostasis was obtained using hand compression.
The patient tolerated the procedure well and had no complications. At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.
Hemodynamic Findings: Aortic pressure 140/70.
ANGIOGRAPHIC FINDINGS: Left main with calcification 25% to 40% lesion.
The left main is very short.
LAD with calcification 25% to 40% proximal lesion.
D1 has 25% lesion. No in-stent restenosis was noted in D1.
D2 and D3 are very small with luminal irregularities.
Circumflex artery was diseased throughout the vessel. The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.
OM1 has 25% to 40% lesion. These OMs are small with luminal irregularities.
RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.
Left ventriculography was not done.
ABDOMINAL AORTOGRAM: Right renal artery with luminal irregularities. Left renal artery with luminal irregularities. The abdominal aorta has 25% lesion.
Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.
The right external iliac has a proximal 75% lesion.
The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.
The right SFA was visualized, although not very well.
Left common iliac with 25% to 50% lesion. Left external iliac with 25% to 40% lesion. Left common femoral with 25% to 40% lesion. Left SFA with 25% lesion. Left popliteal with wall luminal irregularities.
Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.
Conclusions: Severe coronary artery disease. Very severe peripheral arterial disease.
PLAN: Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD. We will proceed with revascularization of the right external iliac as well as right common femoral. Discontinue tobacco.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fiberoptic Bronchoscopy
Description: Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage. Bilateral upper lobe cavitary lung masses. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout.
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PREOPERATIVE DIAGNOSIS: Bilateral upper lobe cavitary lung masses.
POSTOPERATIVE DIAGNOSES:
1. Bilateral upper lobe cavitary lung masses.
2. Final pending pathology.
3. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout.
PROCEDURE PERFORMED: Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.
ANESTHESIA: Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.
OPERATIVE REPORT: The patient is residing in the endoscopy suite. After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis. Topical lidocaine was utilized for anesthesia. Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent. This may be normal anatomic variant. The scope was advanced into the trachea. The main carina was sharp in appearance. Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized. Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left. No specific intrinsic masses were noted. Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe. Also cytologic brushings and protected bacteriologic brushing specimens were obtained. Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe. During lavage, some caseous appearing debris appeared intermittently. The specimens were collected and sent to the lab. Procedure was terminated with hemostasis having been verified. The patient tolerated the procedure well.
Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.
The patient will be returned to her room with orders as per usual.
POSTOPERATIVE DIAGNOSES:
1. Bilateral upper lobe cavitary lung masses.
2. Final pending pathology.
3. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout.
PROCEDURE PERFORMED: Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.
ANESTHESIA: Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.
OPERATIVE REPORT: The patient is residing in the endoscopy suite. After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis. Topical lidocaine was utilized for anesthesia. Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent. This may be normal anatomic variant. The scope was advanced into the trachea. The main carina was sharp in appearance. Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized. Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left. No specific intrinsic masses were noted. Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe. Also cytologic brushings and protected bacteriologic brushing specimens were obtained. Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe. During lavage, some caseous appearing debris appeared intermittently. The specimens were collected and sent to the lab. Procedure was terminated with hemostasis having been verified. The patient tolerated the procedure well.
Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.
The patient will be returned to her room with orders as per usual.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fiberoptic Bronchoscopy - 1
Description: Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability.
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PREOPERATIVE DIAGNOSIS:
1. Hemoptysis.
2. History of lung cancer.
POSTOPERATIVE DIAGNOSIS: Tumor occluding right middle lobe with friability.
PROCEDURE PERFORMED: Fiberoptic bronchoscopy, diagnostic.
LOCATION: Endoscopy suite #4.
ANESTHESIA: General per Anesthesia Service.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain. Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis. She was brought to endoscopy suite #4 and informed consent was obtained.
PROCEDURE DETAILS: The patient was placed in the supine position and intubated by the Anesthesia Service. Intravenous sedation was given as per Anesthesia. The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea. The right mainstem bronchus was examined. The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted. Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.
The clot was lavaged with normal saline and there was noted to be tumor behind this clot. Tumor completely occluded both segments of the right middle lobe. Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions. Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus. Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions. The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions. There were some secretions noted throughout the left lung. The scope was retracted and passed again to the right mainstem bronchus. The area of the right middle lobe was reexamined. The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation. It did not appear as if a scope or cannula could be passed distal to the tumor. Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained. The area was examined for approximately one minute for assurance of adequate hemostasis. The scope was then retracted and the patient was sent to the recovery room in stable condition. She will be extubated as per the Anesthesia Service. Cytology and cultures were not sent due to the patient's known diagnosis. Further recommendations are pending at this time.
1. Hemoptysis.
2. History of lung cancer.
POSTOPERATIVE DIAGNOSIS: Tumor occluding right middle lobe with friability.
PROCEDURE PERFORMED: Fiberoptic bronchoscopy, diagnostic.
LOCATION: Endoscopy suite #4.
ANESTHESIA: General per Anesthesia Service.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain. Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis. She was brought to endoscopy suite #4 and informed consent was obtained.
PROCEDURE DETAILS: The patient was placed in the supine position and intubated by the Anesthesia Service. Intravenous sedation was given as per Anesthesia. The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea. The right mainstem bronchus was examined. The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted. Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.
The clot was lavaged with normal saline and there was noted to be tumor behind this clot. Tumor completely occluded both segments of the right middle lobe. Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions. Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus. Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions. The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions. There were some secretions noted throughout the left lung. The scope was retracted and passed again to the right mainstem bronchus. The area of the right middle lobe was reexamined. The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation. It did not appear as if a scope or cannula could be passed distal to the tumor. Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained. The area was examined for approximately one minute for assurance of adequate hemostasis. The scope was then retracted and the patient was sent to the recovery room in stable condition. She will be extubated as per the Anesthesia Service. Cytology and cultures were not sent due to the patient's known diagnosis. Further recommendations are pending at this time.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fiberoptic Bronchoscopy with Lavage
Description: Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Status post multiple trauma/motor vehicle accident.
2. Acute respiratory failure.
3. Acute respiratory distress/ventilator asynchrony.
4. Hypoxemia.
5. Complete atelectasis of left lung.
POSTOPERATIVE DIAGNOSES:
1. Status post multiple trauma/motor vehicle accident.
2. Acute respiratory failure.
3. Acute respiratory distress/ventilator asynchrony.
4. Hypoxemia.
5. Complete atelectasis of left lung.
6. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.
PROCEDURE PERFORMED: Emergent fiberoptic plus bronchoscopy with lavage.
LOCATION OF PROCEDURE: ICU. Room #164.
ANESTHESIA/SEDATION: Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.
HISTORY: The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance. The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation. Chest x-ray as noted above revealed complete atelectasis of the left lung. The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.
PROCEDURE DETAIL: A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots. These were lavaged with several aliquots of normal saline until cleared. The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope. The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina. The endotracheal tube was noted to be in good position. The bronchoscope was advanced through the distal trachea. There was a white tissue completely obstructing the left main stem at the carina. The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned. Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen. The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes. There was diffuse mucus impactions/tissue as well as intermittent clots. There was no evidence of any active bleeding noted. Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted. Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system. There is no plugging or obstruction of the right bronchial system. The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina. The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure. Throughout the procedure, pulse oximetry was greater than 95% throughout. There is no hemodynamic instability or variability noted during the procedure. Postprocedure chest x-ray is pending at this time.
1. Status post multiple trauma/motor vehicle accident.
2. Acute respiratory failure.
3. Acute respiratory distress/ventilator asynchrony.
4. Hypoxemia.
5. Complete atelectasis of left lung.
POSTOPERATIVE DIAGNOSES:
1. Status post multiple trauma/motor vehicle accident.
2. Acute respiratory failure.
3. Acute respiratory distress/ventilator asynchrony.
4. Hypoxemia.
5. Complete atelectasis of left lung.
6. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.
PROCEDURE PERFORMED: Emergent fiberoptic plus bronchoscopy with lavage.
LOCATION OF PROCEDURE: ICU. Room #164.
ANESTHESIA/SEDATION: Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.
HISTORY: The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance. The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation. Chest x-ray as noted above revealed complete atelectasis of the left lung. The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.
PROCEDURE DETAIL: A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots. These were lavaged with several aliquots of normal saline until cleared. The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope. The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina. The endotracheal tube was noted to be in good position. The bronchoscope was advanced through the distal trachea. There was a white tissue completely obstructing the left main stem at the carina. The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned. Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen. The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes. There was diffuse mucus impactions/tissue as well as intermittent clots. There was no evidence of any active bleeding noted. Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted. Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system. There is no plugging or obstruction of the right bronchial system. The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina. The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure. Throughout the procedure, pulse oximetry was greater than 95% throughout. There is no hemodynamic instability or variability noted during the procedure. Postprocedure chest x-ray is pending at this time.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fiberoptic Flexible Bronchoscopy
Description: Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe. Right hyoid mass, rule out carcinomatosis. Chronic obstructive pulmonary disease. Changes consistent with acute and chronic bronchitis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Right hyoid mass, rule out carcinomatosis.
2. Weight loss.
3. Chronic obstructive pulmonary disease.
POSTOPERATIVE DIAGNOSES:
1. Right hyoid mass, rule out carcinomatosis.
2. Weight loss.
3. Chronic obstructive pulmonary disease.
4. Changes consistent with acute and chronic bronchitis.
5. Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.
6. Left vocal cord irregularity.
PROCEDURE PERFORMED: Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.
ANESTHESIA: Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.
LOCATION OF PROCEDURE: Endoscopy suite #4.
After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring. Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air. Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.
The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication. As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx. The cords were noted to oppose bilaterally on phonation. There was some slight mucosal irregularity noted on the vocal cord on the left side. Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature. The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled. At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled. Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion. The mucosa was diffusely friable throughout. Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled. At this point, the bronchoscope was then advanced to the right bronchus intermedius. At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening. The mucosal area throughout this region was severely friable. Additional lidocaine was instilled as well as topical epinephrine. At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed. At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible. So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized. At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty. At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius. At this time, multiple mucosal biopsies were performed with some mild oozing noted. Several aliquots of normal saline lavage followed. After completion of multiple biopsies there was good hemostasis. Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed. Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments. The bronchoscope was then withdrawn to the distal trachea.
At this time, bronchoscope was then advanced to the left main stem. Additional lidocaine was instilled. The bronchoscope was advanced to the left upper and lower lobe subsegments. There was no endobronchial lesion visualized. There is mild diffuse erythema and fibromucosa was noted throughout. No endobronchial lesion was visualized in the left bronchial system. The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system. At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared. There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout. The bronchoscope was subsequently withdrawn and the patient was sent to recovery room. During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%. The patient remained at this level of saturation or greater throughout the remaining of the procedure.
The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea. This was confirmed by her daughter and mother who were also present at the bedside postprocedure. The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well. The patient also admitted to continued smoking in spite of all of the above. The patient was extensively counseled regarding the continued smoking especially with her present symptoms. She was advised regarding smoking cessation. The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off. The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room. There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted. The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis. At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission. However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.
1. Right hyoid mass, rule out carcinomatosis.
2. Weight loss.
3. Chronic obstructive pulmonary disease.
POSTOPERATIVE DIAGNOSES:
1. Right hyoid mass, rule out carcinomatosis.
2. Weight loss.
3. Chronic obstructive pulmonary disease.
4. Changes consistent with acute and chronic bronchitis.
5. Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.
6. Left vocal cord irregularity.
PROCEDURE PERFORMED: Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.
ANESTHESIA: Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.
LOCATION OF PROCEDURE: Endoscopy suite #4.
After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring. Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air. Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.
The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication. As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx. The cords were noted to oppose bilaterally on phonation. There was some slight mucosal irregularity noted on the vocal cord on the left side. Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature. The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled. At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled. Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion. The mucosa was diffusely friable throughout. Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled. At this point, the bronchoscope was then advanced to the right bronchus intermedius. At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening. The mucosal area throughout this region was severely friable. Additional lidocaine was instilled as well as topical epinephrine. At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed. At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible. So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized. At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty. At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius. At this time, multiple mucosal biopsies were performed with some mild oozing noted. Several aliquots of normal saline lavage followed. After completion of multiple biopsies there was good hemostasis. Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed. Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments. The bronchoscope was then withdrawn to the distal trachea.
At this time, bronchoscope was then advanced to the left main stem. Additional lidocaine was instilled. The bronchoscope was advanced to the left upper and lower lobe subsegments. There was no endobronchial lesion visualized. There is mild diffuse erythema and fibromucosa was noted throughout. No endobronchial lesion was visualized in the left bronchial system. The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system. At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared. There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout. The bronchoscope was subsequently withdrawn and the patient was sent to recovery room. During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%. The patient remained at this level of saturation or greater throughout the remaining of the procedure.
The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea. This was confirmed by her daughter and mother who were also present at the bedside postprocedure. The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well. The patient also admitted to continued smoking in spite of all of the above. The patient was extensively counseled regarding the continued smoking especially with her present symptoms. She was advised regarding smoking cessation. The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off. The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room. There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted. The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis. At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission. However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fistulogram & Angioplasty
Description: Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREPROCEDURE DIAGNOSIS: End-stage renal disease.
POSTPROCEDURE DIAGNOSIS: End-stage renal disease.
PROCEDURES PERFORMED
1. Left arm fistulogram.
2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.
3. Ultrasound-guided access of left upper arm brachiocephalic fistula.
ANESTHESIA: Sedation with local.
COMPLICATIONS: None.
CONDITION: Fair.
DISPOSITION: PACU.
ACCESS SITE: Left upper arm brachiocephalic fistula.
SHEATH SIZE: 5 French.
CONTRAST TYPE: JC PEG tube 70.
CONTRAST VOLUME: 48 mL.
FLUOROSCOPY TIME: 16 minutes.
INDICATION FOR PROCEDURE: This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed. The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound. The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate. A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis. The patient presents today for a left arm fistulogram with angioplasty. The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.
PROCEDURE DETAILS: The patient was brought to the angio suite and laid supine on the table. After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion. Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure. The patient was given 1 g of IV Ancef prior to incision.
The left brachiocephalic fistula was visualized with bevel ultrasound. The cephalic vein in the proximal upper arm region appeared to be of adequate caliber. There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis. The cephalic vein in the proximal forearm region was easily compressible. The skin overlying the vessel was injected with 1% lidocaine solution. A small incision was made with the #11 blade. The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath. The sheath was advanced over the wire. A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis. The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire. The sheath was aspirated and flushed with heparinized saline solution. A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery. A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery. After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table. This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated. The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement. However, there is still a remainder of residual stenosis. The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed. The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis. The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery. A 4 x 20 mm cutting balloon was obtained and prepped on the back table. The 5 French sheath was then exchanged for a 6 French sheath. The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg. The balloon was then deflated and removed over the wire. A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg. A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis. The patient actually had a nice palpable thrill at this point. The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis. The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.
After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound. The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution. A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein. A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence. The 5 French introducer sheath was then exchanged for a 5 French sheath. The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis. The balloon was inflated to 14 mmHg. The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results. The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes. After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied. The patient tolerated the procedure without any complications. I was present for the entire case. The sponge, instrument, and needle counts are correct at the end of the case. The patient was subsequently taken to PACU in stable condition.
ANGIOGRAPHIC FINDINGS: The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein. After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis. Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.
Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein. Postangioplasty demonstrated excellent results with the standard balloon. There was no evidence of any contrast extravasation.
IMPRESSION
1. High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally. Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.
2. A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein. Poststandard balloon angioplasty demonstrated excellent results. No evidence of contrast extravasation.
POSTPROCEDURE DIAGNOSIS: End-stage renal disease.
PROCEDURES PERFORMED
1. Left arm fistulogram.
2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.
3. Ultrasound-guided access of left upper arm brachiocephalic fistula.
ANESTHESIA: Sedation with local.
COMPLICATIONS: None.
CONDITION: Fair.
DISPOSITION: PACU.
ACCESS SITE: Left upper arm brachiocephalic fistula.
SHEATH SIZE: 5 French.
CONTRAST TYPE: JC PEG tube 70.
CONTRAST VOLUME: 48 mL.
FLUOROSCOPY TIME: 16 minutes.
INDICATION FOR PROCEDURE: This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed. The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound. The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate. A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis. The patient presents today for a left arm fistulogram with angioplasty. The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.
PROCEDURE DETAILS: The patient was brought to the angio suite and laid supine on the table. After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion. Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure. The patient was given 1 g of IV Ancef prior to incision.
The left brachiocephalic fistula was visualized with bevel ultrasound. The cephalic vein in the proximal upper arm region appeared to be of adequate caliber. There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis. The cephalic vein in the proximal forearm region was easily compressible. The skin overlying the vessel was injected with 1% lidocaine solution. A small incision was made with the #11 blade. The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath. The sheath was advanced over the wire. A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis. The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire. The sheath was aspirated and flushed with heparinized saline solution. A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery. A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery. After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table. This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated. The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement. However, there is still a remainder of residual stenosis. The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed. The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis. The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery. A 4 x 20 mm cutting balloon was obtained and prepped on the back table. The 5 French sheath was then exchanged for a 6 French sheath. The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg. The balloon was then deflated and removed over the wire. A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg. A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis. The patient actually had a nice palpable thrill at this point. The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis. The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.
After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound. The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution. A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein. A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence. The 5 French introducer sheath was then exchanged for a 5 French sheath. The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis. The balloon was inflated to 14 mmHg. The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results. The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes. After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied. The patient tolerated the procedure without any complications. I was present for the entire case. The sponge, instrument, and needle counts are correct at the end of the case. The patient was subsequently taken to PACU in stable condition.
ANGIOGRAPHIC FINDINGS: The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein. After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis. Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.
Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein. Postangioplasty demonstrated excellent results with the standard balloon. There was no evidence of any contrast extravasation.
IMPRESSION
1. High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally. Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.
2. A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein. Poststandard balloon angioplasty demonstrated excellent results. No evidence of contrast extravasation.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Flexible Bronchoscopy
Description: Flexible bronchoscopy to evaluate the airway (chronic wheezing).
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURE: Flexible bronchoscopy.
PREOPERATIVE DIAGNOSIS (ES): Chronic wheezing.
INDICATIONS FOR PROCEDURE: Evaluate the airway.
DESCRIPTION OF PROCEDURE: This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.
ENDOSCOPIC DIAGNOSIS: Left mainstem bronchomalacia.
PREOPERATIVE DIAGNOSIS (ES): Chronic wheezing.
INDICATIONS FOR PROCEDURE: Evaluate the airway.
DESCRIPTION OF PROCEDURE: This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.
ENDOSCOPIC DIAGNOSIS: Left mainstem bronchomalacia.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Flexible Fiberoptic Bronchoscopy
Description: Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE/POSTOPERATIVE DIAGNOSES:
1. Severe tracheobronchitis.
2. Mild venous engorgement with question varicosities associated pulmonary hypertension.
3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.
PROCEDURE PERFORMED: Flexible fiberoptic bronchoscopy with:
a. Right lower lobe bronchoalveolar lavage.
b. Right upper lobe endobronchial biopsy.
SAMPLES: Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.
INDICATIONS: The patient with persistent hemoptysis of unclear etiology.
PROCEDURE: After obtaining informed consent, the patient was brought to Bronchoscopy Suite. The patient had previously been on Coumadin and then heparin. Heparin was discontinued approximately one-and-a-half hours prior to the procedure. The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx. Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure. Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure. The patient was premedicated with 50 mg of Demerol and 2 mg of Versed. After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx. There was minimal redundant oral soft tissue in the oropharynx. There was mild erythema. Clear secretions were suctioned.
Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied. Vocal cord motion was normal. The bronchoscope was then advanced through the larynx into the trachea. There was evidence of moderate inflammation with prominent vascular markings and edema. No frank blood was visualized. The area was suction clear of copious amounts of clear white secretions. Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem. The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe. There was significant amount of inflammation, induration, and vascular tortuosity in these regions. No frank blood was identified. No masses or lesions were identified. There was senile bronchiectasis with slight narrowing and collapse during the exhalation. The air was suctioned clear. The bronchoscope was withdrawn and advanced into the right main stem. Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized. Again significant amounts of tracheobronchitis was noted with vascular infiltration. In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this. The bronchoscope was removed and advanced into the right middle and right lower lobe. There was marked injection and inflammation in these regions. In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region. Again, white clear secretions were identified. No masses or other processes were noted. The area was suctioned clear. A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe. The bronchoscope was then withdrawn and readvanced into the right upper lobe. Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained. Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine. The area remained clear. No further hemorrhage was identified. The bronchoscope was subsequently withdrawn. The patient tolerated the procedure well and was stable throughout the procedure. No further hemoptysis was identified. The patient was sent to Recovery in good condition.
1. Severe tracheobronchitis.
2. Mild venous engorgement with question varicosities associated pulmonary hypertension.
3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.
PROCEDURE PERFORMED: Flexible fiberoptic bronchoscopy with:
a. Right lower lobe bronchoalveolar lavage.
b. Right upper lobe endobronchial biopsy.
SAMPLES: Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.
INDICATIONS: The patient with persistent hemoptysis of unclear etiology.
PROCEDURE: After obtaining informed consent, the patient was brought to Bronchoscopy Suite. The patient had previously been on Coumadin and then heparin. Heparin was discontinued approximately one-and-a-half hours prior to the procedure. The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx. Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure. Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure. The patient was premedicated with 50 mg of Demerol and 2 mg of Versed. After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx. There was minimal redundant oral soft tissue in the oropharynx. There was mild erythema. Clear secretions were suctioned.
Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied. Vocal cord motion was normal. The bronchoscope was then advanced through the larynx into the trachea. There was evidence of moderate inflammation with prominent vascular markings and edema. No frank blood was visualized. The area was suction clear of copious amounts of clear white secretions. Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem. The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe. There was significant amount of inflammation, induration, and vascular tortuosity in these regions. No frank blood was identified. No masses or lesions were identified. There was senile bronchiectasis with slight narrowing and collapse during the exhalation. The air was suctioned clear. The bronchoscope was withdrawn and advanced into the right main stem. Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized. Again significant amounts of tracheobronchitis was noted with vascular infiltration. In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this. The bronchoscope was removed and advanced into the right middle and right lower lobe. There was marked injection and inflammation in these regions. In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region. Again, white clear secretions were identified. No masses or other processes were noted. The area was suctioned clear. A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe. The bronchoscope was then withdrawn and readvanced into the right upper lobe. Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained. Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine. The area remained clear. No further hemorrhage was identified. The bronchoscope was subsequently withdrawn. The patient tolerated the procedure well and was stable throughout the procedure. No further hemoptysis was identified. The patient was sent to Recovery in good condition.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Flexible Fiberoptic Bronchoscopy -1
Description: Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
POSTOPERATIVE DIAGNOSIS: Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.
PROCEDURE PERFORMED: Flexible fiberoptic bronchoscopy diagnostic with:
a. Right middle lobe bronchoalveolar lavage.
b. Right upper lobe bronchoalveolar lavage.
c. Right lower lobe transbronchial biopsies.
COMPLICATIONS: None.
Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.
INDICATION: The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.
PROCEDURE: After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions. The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure. 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved. Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx. Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg. With this, adequate consciousness sedation was achieved. 3 cc of 4% viscous Xylocaine was applied to the right nares. The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.
The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.
There was normal vocal cord motion without masses or lesions. Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc. The bronchoscope was then advanced through the larynx into the trachea. The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions. These were suctioned clear. The bronchoscope was then advanced through the carina, which was sharp. Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized. There was mild tracheobronchitis with mild friability throughout. There was modest amounts of white secretion. There were no other findings including evidence of mass, anatomic distortions, or hemorrhage. The bronchoscope was subsequently withdrawn and advanced into the right mainstem. Again, each segment and subsegment was well visualized. The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments. No specific masses or other lesions were identified throughout the tracheobronchial tree on the right. There was mild tracheal bronchitis with friability. Upon coughing, there was punctate hemorrhage. The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe. These again had no other anatomic lesions identified. The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained. The bronchoscope was withdrawn and the area was suctioned clear. The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed. Samples were taken and the bronchoscope was removed suctioned the area clear. The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe. Minimal hemorrhage was identified and suctioned clear without difficulty. The bronchoscope was then withdrawn to the mainstem. The area was suctioned clear. Fluoroscopy revealed no evidence of pneumothorax. The bronchoscope was then withdrawn. The patient tolerated the procedure well without evidence of desaturation or complications.
PROCEDURE PERFORMED: Flexible fiberoptic bronchoscopy diagnostic with:
a. Right middle lobe bronchoalveolar lavage.
b. Right upper lobe bronchoalveolar lavage.
c. Right lower lobe transbronchial biopsies.
COMPLICATIONS: None.
Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.
INDICATION: The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.
PROCEDURE: After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions. The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure. 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved. Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx. Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg. With this, adequate consciousness sedation was achieved. 3 cc of 4% viscous Xylocaine was applied to the right nares. The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.
The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.
There was normal vocal cord motion without masses or lesions. Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc. The bronchoscope was then advanced through the larynx into the trachea. The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions. These were suctioned clear. The bronchoscope was then advanced through the carina, which was sharp. Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized. There was mild tracheobronchitis with mild friability throughout. There was modest amounts of white secretion. There were no other findings including evidence of mass, anatomic distortions, or hemorrhage. The bronchoscope was subsequently withdrawn and advanced into the right mainstem. Again, each segment and subsegment was well visualized. The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments. No specific masses or other lesions were identified throughout the tracheobronchial tree on the right. There was mild tracheal bronchitis with friability. Upon coughing, there was punctate hemorrhage. The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe. These again had no other anatomic lesions identified. The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained. The bronchoscope was withdrawn and the area was suctioned clear. The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed. Samples were taken and the bronchoscope was removed suctioned the area clear. The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe. Minimal hemorrhage was identified and suctioned clear without difficulty. The bronchoscope was then withdrawn to the mainstem. The area was suctioned clear. Fluoroscopy revealed no evidence of pneumothorax. The bronchoscope was then withdrawn. The patient tolerated the procedure well without evidence of desaturation or complications.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fogarty Thrombectomy
Description: Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Chronic renal failure.
2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.
POSTOPERATIVE DIAGNOSIS:
1. Chronic renal failure.
2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.
PROCEDURE PERFORMED:
1. Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.
2. Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.
ANESTHESIA: General with controlled ventillation.
GROSS FINDINGS: The patient is a 58-year-old black male with chronic renal failure. He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level. There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.
OPERATIVE PROCEDURE: The patient was taken to the OR suite, placed in supine position. General anesthetic was administered. Left arm was prepped and draped in appropriate manner. A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue. Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop. Transverse graftotomy was created. A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow. A fistulogram was performed and the above findings were noted. In a retrograde fashion, the proximal anastomosis was patent. There was no narrowing within the forearm graft. Both veins were flushed with heparinized saline and controlled with a vascular clamp. A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia. Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated. The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself. The vein was controlled with vascular clamps. Longitudinal venotomy created along the anteromedial wall. A 7 mm graft was brought on to the field and this was cut to shape and size. This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures. Good backflow bleeding was confirmed. The vein flushed with heparinized saline and graft was controlled with vascular clamp. The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture. Good backflow bleeding was confirmed. The graftotomy was then closed with interrupted #6-0 Prolene suture. Flow through the fistula was permitted, a good flow passed. The wound was copiously irrigated with antibiotic solution. Sponge, needles, instrument counts were correct. All surgical sites were inspected. Good hemostasis was noted. The incision was closed in layers with absorbable sutures. Sterile dressing was applied. The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.
1. Chronic renal failure.
2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.
POSTOPERATIVE DIAGNOSIS:
1. Chronic renal failure.
2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.
PROCEDURE PERFORMED:
1. Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.
2. Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.
ANESTHESIA: General with controlled ventillation.
GROSS FINDINGS: The patient is a 58-year-old black male with chronic renal failure. He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level. There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.
OPERATIVE PROCEDURE: The patient was taken to the OR suite, placed in supine position. General anesthetic was administered. Left arm was prepped and draped in appropriate manner. A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue. Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop. Transverse graftotomy was created. A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow. A fistulogram was performed and the above findings were noted. In a retrograde fashion, the proximal anastomosis was patent. There was no narrowing within the forearm graft. Both veins were flushed with heparinized saline and controlled with a vascular clamp. A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia. Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated. The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself. The vein was controlled with vascular clamps. Longitudinal venotomy created along the anteromedial wall. A 7 mm graft was brought on to the field and this was cut to shape and size. This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures. Good backflow bleeding was confirmed. The vein flushed with heparinized saline and graft was controlled with vascular clamp. The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture. Good backflow bleeding was confirmed. The graftotomy was then closed with interrupted #6-0 Prolene suture. Flow through the fistula was permitted, a good flow passed. The wound was copiously irrigated with antibiotic solution. Sponge, needles, instrument counts were correct. All surgical sites were inspected. Good hemostasis was noted. The incision was closed in layers with absorbable sutures. Sterile dressing was applied. The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.
OBJECTIVE:
Vital signs: Her weight is 151 pounds. Blood pressure is 110/60. Pulse is 72. Temperature is 97.1 degrees. Respirations are 20.
General: This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. Affect is appropriate and is pleasant.
HEENT: Normocephalic, atraumatic. Tympanic membranes are clear. Conjunctivae are clear. Pupils are equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.
Neck: Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.
Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmur.
Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. No masses or organomegaly to palpation.
Extremities: Without cyanosis or edema.
Skin: Without abnormalities.
Breasts: Normal symmetrical breasts without dimpling or retraction. No nipple discharge. No masses or lesions to palpation. No axillary masses or lymphadenopathy.
Genitourinary: Normal external genitalia. The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. Cervix is visualized without lesion. She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. No cervical motion tenderness. No adnexal tenderness or fullness.
Vital signs: Her weight is 151 pounds. Blood pressure is 110/60. Pulse is 72. Temperature is 97.1 degrees. Respirations are 20.
General: This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. Affect is appropriate and is pleasant.
HEENT: Normocephalic, atraumatic. Tympanic membranes are clear. Conjunctivae are clear. Pupils are equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.
Neck: Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.
Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmur.
Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. No masses or organomegaly to palpation.
Extremities: Without cyanosis or edema.
Skin: Without abnormalities.
Breasts: Normal symmetrical breasts without dimpling or retraction. No nipple discharge. No masses or lesions to palpation. No axillary masses or lymphadenopathy.
Genitourinary: Normal external genitalia. The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. Cervix is visualized without lesion. She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. No cervical motion tenderness. No adnexal tenderness or fullness.
PHYSICAL EXAMINATION:
General: Patient is a 62 year old female who appears pleasant, her given age, well developed,
oriented, well nourished, alert and moderately overweight.
Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.
HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival
hypertrophy, no pyorrhea and no abnormalities.
Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.
Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.
Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.
Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.
Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.
Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.
Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.
Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.
Extremities: Right thumb and left thumb reveals clubbing.
Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.
Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.
Lymphatics: No lymphadenopathy noted.
General: Patient is a 62 year old female who appears pleasant, her given age, well developed,
oriented, well nourished, alert and moderately overweight.
Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.
HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival
hypertrophy, no pyorrhea and no abnormalities.
Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.
Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.
Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.
Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.
Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.
Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.
Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.
Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.
Extremities: Right thumb and left thumb reveals clubbing.
Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.
Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.
Lymphatics: No lymphadenopathy noted.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Cath & Coronary Angiography
Description: Left heart catheterization and bilateral selective coronary angiography. The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.
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PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Bilateral selective coronary angiography.
ANESTHESIA: 1% lidocaine and IV sedation, including fentanyl 25 mcg.
INDICATION: The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest. It was accompanied by diaphoresis and shortness of breath. The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain. He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5. Stress images revealed left ventricular dilatations suggestive of multivessel disease. He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.
PROCEDURE: After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing. The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed. The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.
The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin. The needle was removed and a pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed and the sheath was flushed. A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis. The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter. The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views. This catheter was removed. The sheath was flushed the final time. The patient was taken to the postcatheterization holding area in stable condition.
FINDINGS:
LEFT MAIN CORONARY ARTERY: This vessel is seen to be heavily calcified throughout its course. Begins as a moderate caliber vessel. There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: This vessel is heavily calcified in its proximal portion. It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex. There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches. There is sequential 80% and 90% stenosis in the mid-portion of the vessel. Otherwise, the LAD is seen to be diffusely diseased.
LEFT CIRCUMFLEX CORONARY ARTERY: This vessel is also calcified in its proximal portion. There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery. There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.
RIGHT CORONARY ARTERY: This is a large caliber vessel and is the dominant system. There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.
IMPRESSION:
1. Three-vessel coronary artery disease as described above.
2. Moderate mitral regurgitation per TEE.
3. Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.
4. Long-standing history of phlebitis.
PLAN: Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.
1. Left heart catheterization.
2. Bilateral selective coronary angiography.
ANESTHESIA: 1% lidocaine and IV sedation, including fentanyl 25 mcg.
INDICATION: The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest. It was accompanied by diaphoresis and shortness of breath. The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain. He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5. Stress images revealed left ventricular dilatations suggestive of multivessel disease. He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.
PROCEDURE: After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing. The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed. The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.
The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin. The needle was removed and a pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed and the sheath was flushed. A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis. The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter. The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views. This catheter was removed. The sheath was flushed the final time. The patient was taken to the postcatheterization holding area in stable condition.
FINDINGS:
LEFT MAIN CORONARY ARTERY: This vessel is seen to be heavily calcified throughout its course. Begins as a moderate caliber vessel. There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: This vessel is heavily calcified in its proximal portion. It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex. There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches. There is sequential 80% and 90% stenosis in the mid-portion of the vessel. Otherwise, the LAD is seen to be diffusely diseased.
LEFT CIRCUMFLEX CORONARY ARTERY: This vessel is also calcified in its proximal portion. There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery. There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.
RIGHT CORONARY ARTERY: This is a large caliber vessel and is the dominant system. There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.
IMPRESSION:
1. Three-vessel coronary artery disease as described above.
2. Moderate mitral regurgitation per TEE.
3. Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.
4. Long-standing history of phlebitis.
PLAN: Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization
Description: Right and left heart catheterization, coronary angiography, left ventriculography.
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PROCEDURES:
1. Right and left heart catheterization.
2. Coronary angiography.
3. Left ventriculography.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory. Patient was prepped and draped in sterile fashion. Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire. Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire. The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter. The patient tolerated the procedure well and there were immediate complications were noted. Angio-Seal was used at the end of the procedure to obtain hemostasis.
CORONARY ARTERIES:
LEFT MAIN CORONARY ARTERY: The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery. No significant stenotic lesions were identified in the left main coronary artery.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches. No significant stenotic lesions were identified in the left anterior descending coronary artery system.
CIRCUMFLEX ARTERY: The circumflex artery is a moderate sized vessel. The vessel is a stenotic lesion. After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.
HEMODYNAMIC DATA: Capital wedge pressure was 22. The aortic pressure was 52/24. Right ventricular pressure was 58/14. RA pressure was 14. The aortic pressure was 127/73. Left ventricular pressure was 127/15. Cardiac output of 9.2.
LEFT VENTRICULOGRAM: The left ventriculogram was performed in the RAO projection only. In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%. Severe mitral regurgitation was also noted.
IMPRESSION:
1. Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.
2. Severe mitral regurgitation.
3. No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.
1. Right and left heart catheterization.
2. Coronary angiography.
3. Left ventriculography.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory. Patient was prepped and draped in sterile fashion. Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire. Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire. The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter. The patient tolerated the procedure well and there were immediate complications were noted. Angio-Seal was used at the end of the procedure to obtain hemostasis.
CORONARY ARTERIES:
LEFT MAIN CORONARY ARTERY: The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery. No significant stenotic lesions were identified in the left main coronary artery.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches. No significant stenotic lesions were identified in the left anterior descending coronary artery system.
CIRCUMFLEX ARTERY: The circumflex artery is a moderate sized vessel. The vessel is a stenotic lesion. After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.
HEMODYNAMIC DATA: Capital wedge pressure was 22. The aortic pressure was 52/24. Right ventricular pressure was 58/14. RA pressure was 14. The aortic pressure was 127/73. Left ventricular pressure was 127/15. Cardiac output of 9.2.
LEFT VENTRICULOGRAM: The left ventriculogram was performed in the RAO projection only. In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%. Severe mitral regurgitation was also noted.
IMPRESSION:
1. Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.
2. Severe mitral regurgitation.
3. No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization - 1
Description: Chest pain and non-Q-wave MI with elevation of troponin I only. Left heart catheterization, left ventriculography, and left and right coronary arteriography.
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PROCEDURES: Left heart catheterization, left ventriculography, and left and right coronary arteriography.
INDICATIONS: Chest pain and non-Q-wave MI with elevation of troponin I only.
TECHNIQUE: The patient was brought to the procedure room in satisfactory condition. The right groin was prepped and draped in routine fashion. An arterial sheath was inserted into the right femoral artery.
Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively. Cine coronary angiograms were done in multiple views.
Left heart catheterization was done using the 6-French pigtail catheter. Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.
At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.
FINDINGS:
1. LV is normal in size and shape with good contractility, EF of 60%.
2. LMCA normal.
3. LAD has 20% to 30% stenosis at the origin.
4. LCX is normal.
5. RCA is dominant and normal.
RECOMMENDATIONS: Medical management, diet, and exercise. Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain. Follow up in the clinic.
INDICATIONS: Chest pain and non-Q-wave MI with elevation of troponin I only.
TECHNIQUE: The patient was brought to the procedure room in satisfactory condition. The right groin was prepped and draped in routine fashion. An arterial sheath was inserted into the right femoral artery.
Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively. Cine coronary angiograms were done in multiple views.
Left heart catheterization was done using the 6-French pigtail catheter. Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.
At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.
FINDINGS:
1. LV is normal in size and shape with good contractility, EF of 60%.
2. LMCA normal.
3. LAD has 20% to 30% stenosis at the origin.
4. LCX is normal.
5. RCA is dominant and normal.
RECOMMENDATIONS: Medical management, diet, and exercise. Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain. Follow up in the clinic.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization - 2
Description: Right heart catheterization. Refractory CHF to maximum medical therapy.
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PROCEDURE PERFORMED: Right heart catheterization.
INDICATION: Refractory CHF to maximum medical therapy.
PROCEDURE: After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing. The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein. A steel guidewire was then inserted through the needle into the vessel without resistance. Small nick was then made in the skin and the needle was removed. An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated. Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position. Hemodynamics were measured along the way. Pulmonary artery saturation was obtained. The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration. The patient tolerated the procedure well. The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.
FINDINGS: Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula. Pulmonary artery saturation equals 37.8. Pulse oximetry on 2 liters nasal cannula equals 93%. Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.
IMPRESSION: Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.
PLAN: Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor. The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia. At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy. We will also increase his Lasix to 80 mg IV q.d. We will increase his amiodarone to 400 mg daily. We will also continue with his Coumadin therapy. As stated previously, we will discontinue vasodilator therapy starting with the Isordil.
INDICATION: Refractory CHF to maximum medical therapy.
PROCEDURE: After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing. The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein. A steel guidewire was then inserted through the needle into the vessel without resistance. Small nick was then made in the skin and the needle was removed. An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated. Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position. Hemodynamics were measured along the way. Pulmonary artery saturation was obtained. The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration. The patient tolerated the procedure well. The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.
FINDINGS: Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula. Pulmonary artery saturation equals 37.8. Pulse oximetry on 2 liters nasal cannula equals 93%. Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.
IMPRESSION: Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.
PLAN: Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor. The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia. At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy. We will also increase his Lasix to 80 mg IV q.d. We will increase his amiodarone to 400 mg daily. We will also continue with his Coumadin therapy. As stated previously, we will discontinue vasodilator therapy starting with the Isordil.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Angiography
Description: Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo.
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INDICATION: Coronary artery disease, severe aortic stenosis by echo.
PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Right heart catheterization.
3. Selective coronary angiography.
PROCEDURE: The patient was explained about all the risks, benefits and alternatives to the procedure. The patient agreed to proceed and informed consent was signed.
Both groins were prepped and draped in usual sterile fashion. After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein. Then right heart cath was performed using 7-French Swan-Ganz catheter. Catheter was placed in the pulmonary capillary wedge position. Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained. The right heart catheter _______ pulled out. Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter. Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful. After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure. The patient tolerated the procedure well. There were no complications.
HEMODYNAMICS:
1. Cardiac output was 4.9 per liter per minute. Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.
2. Coronary angiography, left main is calcified _______ dense complex.
3. LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis. Left circumflex has diffuse luminal irregularities. OM1 has 70% stenosis, is a moderate-size vessel. Right coronary is dominant and has minimal luminal irregularities.
SUMMARY: Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.
RECOMMENDATION: Aortic valve replacement with coronary artery bypass surgery.
PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Right heart catheterization.
3. Selective coronary angiography.
PROCEDURE: The patient was explained about all the risks, benefits and alternatives to the procedure. The patient agreed to proceed and informed consent was signed.
Both groins were prepped and draped in usual sterile fashion. After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein. Then right heart cath was performed using 7-French Swan-Ganz catheter. Catheter was placed in the pulmonary capillary wedge position. Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained. The right heart catheter _______ pulled out. Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter. Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful. After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure. The patient tolerated the procedure well. There were no complications.
HEMODYNAMICS:
1. Cardiac output was 4.9 per liter per minute. Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.
2. Coronary angiography, left main is calcified _______ dense complex.
3. LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis. Left circumflex has diffuse luminal irregularities. OM1 has 70% stenosis, is a moderate-size vessel. Right coronary is dominant and has minimal luminal irregularities.
SUMMARY: Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.
RECOMMENDATION: Aortic valve replacement with coronary artery bypass surgery.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Angiography - 1
Description: Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test.
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CLINICAL INDICATION: Normal stress test.
PROCEDURES PERFORMED:
1. Left heart cath.
2. Selective coronary angiography.
3. LV gram.
4. Right femoral arteriogram.
5. Mynx closure device.
PROCEDURE IN DETAIL: The patient was explained about all the risks, benefits, and alternatives of this procedure. The patient agreed to proceed and informed consent was signed.
Both groins were prepped and draped in the usual sterile fashion. After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery. Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters. Then, LV gram was performed using 6-French pigtail catheter. Post LV gram, LV-to-aortic gradient was obtained. Then, the right femoral arteriogram was performed. Then, the Mynx closure device was used for hemostasis. There were no complications.
HEMODYNAMICS: LVEDP was 9. There was no LV-to-aortic gradient.
CORONARY ANGIOGRAPHY:
1. Left main is normal. It bifurcates into LAD and left circumflex.
2. Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present. Rest of the LAD free of disease.
3. Left circumflex is a large vessel and with minor plaque.
4. Right coronary is dominant and also has proximal 40% stenosis.
SUMMARY:
1. Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.
2. RCA has 40% proximal stenosis.
3. Normal LV systolic function with LV ejection fraction of 60%.
PLAN: We will treat with medical therapy. If the patient becomes symptomatic, we will repeat stress test. If there is ischemic event, the patient will need surgery for the LAD lesion. For the time being, we will continue with the medical therapy.
PROCEDURES PERFORMED:
1. Left heart cath.
2. Selective coronary angiography.
3. LV gram.
4. Right femoral arteriogram.
5. Mynx closure device.
PROCEDURE IN DETAIL: The patient was explained about all the risks, benefits, and alternatives of this procedure. The patient agreed to proceed and informed consent was signed.
Both groins were prepped and draped in the usual sterile fashion. After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery. Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters. Then, LV gram was performed using 6-French pigtail catheter. Post LV gram, LV-to-aortic gradient was obtained. Then, the right femoral arteriogram was performed. Then, the Mynx closure device was used for hemostasis. There were no complications.
HEMODYNAMICS: LVEDP was 9. There was no LV-to-aortic gradient.
CORONARY ANGIOGRAPHY:
1. Left main is normal. It bifurcates into LAD and left circumflex.
2. Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present. Rest of the LAD free of disease.
3. Left circumflex is a large vessel and with minor plaque.
4. Right coronary is dominant and also has proximal 40% stenosis.
SUMMARY:
1. Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.
2. RCA has 40% proximal stenosis.
3. Normal LV systolic function with LV ejection fraction of 60%.
PLAN: We will treat with medical therapy. If the patient becomes symptomatic, we will repeat stress test. If there is ischemic event, the patient will need surgery for the LAD lesion. For the time being, we will continue with the medical therapy.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Angiography - 2
Description: Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.
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PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Bilateral selective coronary angiography.
3. Left ventriculogram was not performed.
INDICATION: Non-ST elevation MI.
PROCEDURE: After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter. The catheter was then removed over the guidewire.
Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to manifold and flushed. The catheter did slip into the left ventricle. During the rotation, the LVEDP was then measured. The ostium of the right coronary artery was then engaged. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was then removed. The sheath was lastly flushed for the final time.
FINDINGS:
LEFT MAIN CORONARY ARTERY: The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.
LEFT ANTERIOR DESCENDING ARTERY: The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally. The distal portion was diffusely diseased. The proximal portion otherwise shows minor luminal irregularities. The first diagonal branch demonstrated minor luminal irregularities throughout.
CIRCUMFLEX ARTERY: The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch. The first obtuse marginal branch demonstrates minor luminal irregularities throughout.
RIGHT CORONARY ARTERY: The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion. The dominant coronary artery gives off the posterior descending artery and posterolateral artery. The left ventricular end-diastolic pressure was approximately 22 mmHg. It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.
IMPRESSION:
1. Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.
2. Mildly elevated left-sided filling pressures.
PLAN:
1. The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting. These findings and plan were discussed in detail with the patient and the patient's family. The patient is agreeable.
2. The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy. The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting. In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.
1. Left heart catheterization.
2. Bilateral selective coronary angiography.
3. Left ventriculogram was not performed.
INDICATION: Non-ST elevation MI.
PROCEDURE: After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter. The catheter was then removed over the guidewire.
Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to manifold and flushed. The catheter did slip into the left ventricle. During the rotation, the LVEDP was then measured. The ostium of the right coronary artery was then engaged. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was then removed. The sheath was lastly flushed for the final time.
FINDINGS:
LEFT MAIN CORONARY ARTERY: The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.
LEFT ANTERIOR DESCENDING ARTERY: The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally. The distal portion was diffusely diseased. The proximal portion otherwise shows minor luminal irregularities. The first diagonal branch demonstrated minor luminal irregularities throughout.
CIRCUMFLEX ARTERY: The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch. The first obtuse marginal branch demonstrates minor luminal irregularities throughout.
RIGHT CORONARY ARTERY: The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion. The dominant coronary artery gives off the posterior descending artery and posterolateral artery. The left ventricular end-diastolic pressure was approximately 22 mmHg. It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.
IMPRESSION:
1. Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.
2. Mildly elevated left-sided filling pressures.
PLAN:
1. The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting. These findings and plan were discussed in detail with the patient and the patient's family. The patient is agreeable.
2. The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy. The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting. In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Ventriculogram
Description: Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURE PERFORMED:
1. Right heart catheterization.
2. Left heart catheterization.
3. Left ventriculogram.
4. Aortogram.
5. Bilateral selective coronary angiography.
ANESTHESIA: 1% lidocaine and IV sedation including Versed 1 mg.
INDICATION: The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. She has had atrial fibrillation and previous episodes of congestive heart failure. She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.
PROCEDURE: After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing. The patient was taken to the Cardiac Catheterization Lab where the procedure was performed. The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein. A guidewire was advanced into the lumen of the vein without resistance. The needle was removed and the guidewire was secured to the sterile field. The needle was flushed and then used to cannulate the right femoral artery. A guidewire was advanced through the lumen of the needle without resistance. A small nick was made in the skin and the needle was removed. This pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed. FiO2 sample was obtained and the sheath was flushed. An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed. A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated. An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to a manifold and flushed. Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured. Using dual transducers together and the mitral valve radius was estimated. The balloon was deflated and mixed venous sample was obtained. Hemodynamics were measured. The catheter was pulled back in to the pulmonary artery right ventricle and right atrium. The right atrial sample was obtained and was negative for shunt. The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material. Pullback was then performed which revealed a minimal LV-AO gradient. Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material. The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged. Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views. This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views. This catheter was removed. The sheaths were flushed final time. The patient was taken to the Postcatheterization Holding Area in stable condition.
FINDINGS:
HEMODYNAMICS: Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg. Pulmonary capillary wedge pressure is 29 mmHg. Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram. Cardiac index was 2.4 liters per minute/m2. Cardiac output 4.0 liters per minute. The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2. The aortic valve area is calculated to be 2.08 cm2.
LEFT VENTRICULOGRAM: No segmental wall motion abnormalities were noted. The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%. 2+ to 3+ mitral regurgitation was noted.
AORTOGRAM: There was 2+ to 3+ aortic insufficiency noted. There was no evidence of aortic aneurysm or dissection.
LEFT MAIN CORONARY ARTERY: This was a moderate caliber vessel and it is rather long. It bifurcates into the LAD and left circumflex coronary artery. No angiographically significant stenosis is noted.
LEFT ANTERIOR DESCENDING ARTERY: The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove. It tapers in its mid portion to become small caliber vessel. Luminal irregularities are present, however, no angiographically significant stenosis is noted.
LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex coronary artery begins as a moderate caliber vessel. Small obtuse marginal branches are noted and this is the nondominant system. Lumen irregularities are present throughout the circumflex system. However no angiographically significant stenosis is noted.
RIGHT CORONARY ARTERY: This is the moderate caliber vessel and it is the dominant system. No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.
IMPRESSION:
1. Nonobstructive coronary artery disease.
2. Severe mitral stenosis.
3. 2+ to 3+ mitral regurgitation.
4. 2+ to 3+ aortic insufficiency.
1. Right heart catheterization.
2. Left heart catheterization.
3. Left ventriculogram.
4. Aortogram.
5. Bilateral selective coronary angiography.
ANESTHESIA: 1% lidocaine and IV sedation including Versed 1 mg.
INDICATION: The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. She has had atrial fibrillation and previous episodes of congestive heart failure. She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.
PROCEDURE: After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing. The patient was taken to the Cardiac Catheterization Lab where the procedure was performed. The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein. A guidewire was advanced into the lumen of the vein without resistance. The needle was removed and the guidewire was secured to the sterile field. The needle was flushed and then used to cannulate the right femoral artery. A guidewire was advanced through the lumen of the needle without resistance. A small nick was made in the skin and the needle was removed. This pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed. FiO2 sample was obtained and the sheath was flushed. An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed. A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated. An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to a manifold and flushed. Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured. Using dual transducers together and the mitral valve radius was estimated. The balloon was deflated and mixed venous sample was obtained. Hemodynamics were measured. The catheter was pulled back in to the pulmonary artery right ventricle and right atrium. The right atrial sample was obtained and was negative for shunt. The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material. Pullback was then performed which revealed a minimal LV-AO gradient. Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material. The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged. Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views. This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views. This catheter was removed. The sheaths were flushed final time. The patient was taken to the Postcatheterization Holding Area in stable condition.
FINDINGS:
HEMODYNAMICS: Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg. Pulmonary capillary wedge pressure is 29 mmHg. Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram. Cardiac index was 2.4 liters per minute/m2. Cardiac output 4.0 liters per minute. The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2. The aortic valve area is calculated to be 2.08 cm2.
LEFT VENTRICULOGRAM: No segmental wall motion abnormalities were noted. The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%. 2+ to 3+ mitral regurgitation was noted.
AORTOGRAM: There was 2+ to 3+ aortic insufficiency noted. There was no evidence of aortic aneurysm or dissection.
LEFT MAIN CORONARY ARTERY: This was a moderate caliber vessel and it is rather long. It bifurcates into the LAD and left circumflex coronary artery. No angiographically significant stenosis is noted.
LEFT ANTERIOR DESCENDING ARTERY: The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove. It tapers in its mid portion to become small caliber vessel. Luminal irregularities are present, however, no angiographically significant stenosis is noted.
LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex coronary artery begins as a moderate caliber vessel. Small obtuse marginal branches are noted and this is the nondominant system. Lumen irregularities are present throughout the circumflex system. However no angiographically significant stenosis is noted.
RIGHT CORONARY ARTERY: This is the moderate caliber vessel and it is the dominant system. No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.
IMPRESSION:
1. Nonobstructive coronary artery disease.
2. Severe mitral stenosis.
3. 2+ to 3+ mitral regurgitation.
4. 2+ to 3+ aortic insufficiency.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography
Description: Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Bilateral selective coronary angiography.
3. Saphenous vein graft angiography.
4. Left internal mammary artery angiography.
5. Left ventriculography.
INDICATIONS: Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.
PROCEDURE: After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was then inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin and its pressure was held. The needle was removed over the guidewire. A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The catheter was then advanced into the left ventricle. The guidewire was then removed. The catheter was connected to the manifold and flushed. LVEDP was then measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material. LVEDP was then remeasured. Pullback was then performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was removed. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material. The saphenous vein graft was visualized in several different views. The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material. Right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was retracted. We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire. Next, a multipurpose catheter was advanced over the exchange wire. The wire was then easily passed into the left subclavian artery. The multipurpose catheter was then removed. LIMA catheter was then exchanged over the wire into the left subclavian artery. The guidewire was removed and the catheter was connected to the manifold and flushed. LIMA graft was then engaged using hand injections of non-ionic contrast material. The LIMA graft was evaluated in several different views. Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance. The sheath was flushed for the final time. The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.
FINDINGS:
LEFT VENTRICULOGRAM: There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection. There is no mitral regurgitation. There is no LVAO or pullback.
LEFT MAIN CORONARY ARTERY: The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.
LEFT ANTERIOR DESCENDING ARTERY: The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart. There are luminal irregularities from the mid to distal portion. There is noted to be antegrade flow in the LIMA to LAD graft. There are very small diagonal branches, which are diffusely diseased.
CIRCUMFLEX ARTERY: The circumflex is a small caliber vessel, which traverses through the atrioventricular groove. There are minor luminal irregularities throughout. There are very small obtuse marginal branches, which are diffusely diseased.
RIGHT CORONARY ARTERY: The RCA is a small vessel with luminal irregularities throughout. The RCA is the dominant coronary artery.
Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis. Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch. The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.
IMPRESSION:
1. Diffusely diseased native vessels.
2. Saphenous vein graft to the obtuse marginal branch is widely patent.
3. Left internal mammary artery graft to the left anterior descending artery is patent.
4. Normal left ventricular function with ejection fraction of 60%.
5. Mildly elevated left-sided filling pressures.
PLAN:
1. The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix. The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.
2. We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.
3. Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.
4. The patient will need to be monitored closely for close lipid control as well as blood pressure control.
1. Left heart catheterization.
2. Bilateral selective coronary angiography.
3. Saphenous vein graft angiography.
4. Left internal mammary artery angiography.
5. Left ventriculography.
INDICATIONS: Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.
PROCEDURE: After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was then inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin and its pressure was held. The needle was removed over the guidewire. A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The catheter was then advanced into the left ventricle. The guidewire was then removed. The catheter was connected to the manifold and flushed. LVEDP was then measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material. LVEDP was then remeasured. Pullback was then performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was removed. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material. The saphenous vein graft was visualized in several different views. The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material. Right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was retracted. We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire. Next, a multipurpose catheter was advanced over the exchange wire. The wire was then easily passed into the left subclavian artery. The multipurpose catheter was then removed. LIMA catheter was then exchanged over the wire into the left subclavian artery. The guidewire was removed and the catheter was connected to the manifold and flushed. LIMA graft was then engaged using hand injections of non-ionic contrast material. The LIMA graft was evaluated in several different views. Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance. The sheath was flushed for the final time. The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.
FINDINGS:
LEFT VENTRICULOGRAM: There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection. There is no mitral regurgitation. There is no LVAO or pullback.
LEFT MAIN CORONARY ARTERY: The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.
LEFT ANTERIOR DESCENDING ARTERY: The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart. There are luminal irregularities from the mid to distal portion. There is noted to be antegrade flow in the LIMA to LAD graft. There are very small diagonal branches, which are diffusely diseased.
CIRCUMFLEX ARTERY: The circumflex is a small caliber vessel, which traverses through the atrioventricular groove. There are minor luminal irregularities throughout. There are very small obtuse marginal branches, which are diffusely diseased.
RIGHT CORONARY ARTERY: The RCA is a small vessel with luminal irregularities throughout. The RCA is the dominant coronary artery.
Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis. Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch. The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.
IMPRESSION:
1. Diffusely diseased native vessels.
2. Saphenous vein graft to the obtuse marginal branch is widely patent.
3. Left internal mammary artery graft to the left anterior descending artery is patent.
4. Normal left ventricular function with ejection fraction of 60%.
5. Mildly elevated left-sided filling pressures.
PLAN:
1. The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix. The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.
2. We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.
3. Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.
4. The patient will need to be monitored closely for close lipid control as well as blood pressure control.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 1
Description: Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURE: Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery. This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.
PROCEDURE DETAILS: The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained. Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine. Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery. ACT was checked and was low. Additional heparin was given. A #6-French pigtail catheter was passed. Left ventriculography was performed. The catheter was exchanged for a #6-French JL4 catheter. Nitroglycerin was given in the left main. Left coronary angiography was performed. The catheter was exchanged for a #6-French __________ coronary catheter. Nitroglycerin was given in the right main, and right coronary angiography was performed. Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM. Considering his age and his course, it was elected to stent both these lesions. ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide. ReoPro was given in the RCA to prevent no reflow. A 0.014 Universal wire was passed. The lesion was measured. A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result. The catheter was removed and exchanged for a #6-French JL4 guide. The same wire was passed down the circumflex and the lesion measured. A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result. Plavix was given. The catheter was removed and sheath was in place. The results were explained to the patient and his wife.
FINDINGS
1. Hemodynamics. Please see attached sheet for details. ED was 20. There is no gradient across the aortic valve.
2. Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of diffuse, very minimal global hypokinesis. There is mild MR noted.
3. Coronary angiography.
a. Left main normal.
b. LAD. Some very minimal luminal irregularities. There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.
c. Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.
d. The RCA is large dominant and has a mid somewhat long 70% lesion.
4. Stenting.
a. The RCA revealed a lesion that went from 70% to a -5%.
B. The circumflex went from 95% to -5%.
CONCLUSION
1. Decreased left ventricular compliance.
2. Borderline normal overall ejection fraction with mild mitral regurgitation.
3. Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.
4. Successful stenting of the right coronary artery and the circumflex.
RECOMMENDATION: ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors. I have ordered Zocor and a fasting lipid panel.
AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.
PROCEDURE DETAILS: The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained. Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine. Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery. ACT was checked and was low. Additional heparin was given. A #6-French pigtail catheter was passed. Left ventriculography was performed. The catheter was exchanged for a #6-French JL4 catheter. Nitroglycerin was given in the left main. Left coronary angiography was performed. The catheter was exchanged for a #6-French __________ coronary catheter. Nitroglycerin was given in the right main, and right coronary angiography was performed. Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM. Considering his age and his course, it was elected to stent both these lesions. ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide. ReoPro was given in the RCA to prevent no reflow. A 0.014 Universal wire was passed. The lesion was measured. A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result. The catheter was removed and exchanged for a #6-French JL4 guide. The same wire was passed down the circumflex and the lesion measured. A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result. Plavix was given. The catheter was removed and sheath was in place. The results were explained to the patient and his wife.
FINDINGS
1. Hemodynamics. Please see attached sheet for details. ED was 20. There is no gradient across the aortic valve.
2. Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of diffuse, very minimal global hypokinesis. There is mild MR noted.
3. Coronary angiography.
a. Left main normal.
b. LAD. Some very minimal luminal irregularities. There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.
c. Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.
d. The RCA is large dominant and has a mid somewhat long 70% lesion.
4. Stenting.
a. The RCA revealed a lesion that went from 70% to a -5%.
B. The circumflex went from 95% to -5%.
CONCLUSION
1. Decreased left ventricular compliance.
2. Borderline normal overall ejection fraction with mild mitral regurgitation.
3. Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.
4. Successful stenting of the right coronary artery and the circumflex.
RECOMMENDATION: ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors. I have ordered Zocor and a fasting lipid panel.
AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 10
Description: Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.
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PROCEDURE: Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.
PROCEDURE IN DETAIL: The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The right groin was prepped and draped, and infiltrated with 2% Xylocaine. Percutaneously, #6-French arterial sheath was placed. Selective native left and right coronary angiography was performed followed by left ventricular angiography. The patient had a totally occluded right coronary. We initially started with a JR4 guide. We were able to a sport wire through the total occlusion and saw a very tight stenosis. We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated. We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out. We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion. We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection. That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip. The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire. We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres. Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment. We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres. Final angiography showed resolution of the dissection. We could see a little staining extrinsic to the stent. No perforation and excellent flow. During the intervention, we did give a bolus and drip of Angiomax. At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix. We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop. We transported the patient to his room in stable condition.
ANGIOGRAPHIC DATA: Left main coronary is normal. Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal. The diagonal does appear to have about 50% osteal stenosis. There is a lot of plaquing further down the diagonal, but good flow. The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch. Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel. The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease. Some mild collaterals to the right were seen. Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin. After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve. Following the balloon angioplasty, we established good flow down the distal vessel. We still had about residual 70% stenosis. When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection. We re-dilated and then deployed. Repeat angiography now did show some hang up off dye distally. We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus. After deploying the stent, we had total resolution of the original lesion. We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA. The posterolateral branch appeared to be occluded in its mid portion. We got a wire through and dilated this. We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent. Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent. There were no filling defects in the stent and excellent flow. The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.
IMPRESSION: Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection. Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.
PROCEDURE IN DETAIL: The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The right groin was prepped and draped, and infiltrated with 2% Xylocaine. Percutaneously, #6-French arterial sheath was placed. Selective native left and right coronary angiography was performed followed by left ventricular angiography. The patient had a totally occluded right coronary. We initially started with a JR4 guide. We were able to a sport wire through the total occlusion and saw a very tight stenosis. We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated. We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out. We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion. We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection. That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip. The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire. We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres. Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment. We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres. Final angiography showed resolution of the dissection. We could see a little staining extrinsic to the stent. No perforation and excellent flow. During the intervention, we did give a bolus and drip of Angiomax. At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix. We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop. We transported the patient to his room in stable condition.
ANGIOGRAPHIC DATA: Left main coronary is normal. Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal. The diagonal does appear to have about 50% osteal stenosis. There is a lot of plaquing further down the diagonal, but good flow. The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch. Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel. The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease. Some mild collaterals to the right were seen. Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin. After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve. Following the balloon angioplasty, we established good flow down the distal vessel. We still had about residual 70% stenosis. When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection. We re-dilated and then deployed. Repeat angiography now did show some hang up off dye distally. We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus. After deploying the stent, we had total resolution of the original lesion. We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA. The posterolateral branch appeared to be occluded in its mid portion. We got a wire through and dilated this. We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent. Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent. There were no filling defects in the stent and excellent flow. The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.
IMPRESSION: Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection. Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 11
Description: Selective coronary angiography, left heart catheterization, and left ventriculography. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.
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NAME OF PROCEDURES
1. Selective coronary angiography.
2. Left heart catheterization.
3. Left ventriculography.
PROCEDURE IN DETAIL: The right groin was sterilely prepped and draped in the usual fashion. The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed. Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg. A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery. Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed. This was advanced through the ostium of the left main coronary artery where selective angiograms were performed. Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed. A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram. The left heart pullback was performed. The catheter was removed and a small injection of contrast was given to the sheath. The sheath was removed over a wire and an Angio-Seal was placed. There were no complications. Total contrast media was 200 mL of Optiray 350. Fluoroscopy time 5.3 minutes. Total x-ray dose is 1783 mGy.
HEMODYNAMICS: Rhythm is sinus throughout the procedure. LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg. LV pullback demonstrates no gradient.
The right coronary artery is a nondominant vessel and free of disease. This also gives rise to the conus branch and two RV free wall branches. The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%. This vessel then bifurcates into the LAD and circumflex. The circumflex is a large caliber vessel and is dominant. This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA. There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity. The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity. The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.
The proximal LAD is ectatic. The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal. Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.
The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall. The overall ejection fraction is preserved. There is moderate dilatation of the aortic root. The calculated ejection fraction is 63%.
IMPRESSION
1. Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.
2. Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery. There is subtotal stenosis at the origin of the first obtuse marginal artery.
3. A 60% stenosis in the distal circumflex.
4. Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.
5. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.
1. Selective coronary angiography.
2. Left heart catheterization.
3. Left ventriculography.
PROCEDURE IN DETAIL: The right groin was sterilely prepped and draped in the usual fashion. The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed. Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg. A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery. Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed. This was advanced through the ostium of the left main coronary artery where selective angiograms were performed. Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed. A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram. The left heart pullback was performed. The catheter was removed and a small injection of contrast was given to the sheath. The sheath was removed over a wire and an Angio-Seal was placed. There were no complications. Total contrast media was 200 mL of Optiray 350. Fluoroscopy time 5.3 minutes. Total x-ray dose is 1783 mGy.
HEMODYNAMICS: Rhythm is sinus throughout the procedure. LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg. LV pullback demonstrates no gradient.
The right coronary artery is a nondominant vessel and free of disease. This also gives rise to the conus branch and two RV free wall branches. The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%. This vessel then bifurcates into the LAD and circumflex. The circumflex is a large caliber vessel and is dominant. This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA. There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity. The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity. The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.
The proximal LAD is ectatic. The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal. Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.
The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall. The overall ejection fraction is preserved. There is moderate dilatation of the aortic root. The calculated ejection fraction is 63%.
IMPRESSION
1. Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.
2. Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery. There is subtotal stenosis at the origin of the first obtuse marginal artery.
3. A 60% stenosis in the distal circumflex.
4. Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.
5. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 2
Description: Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.
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NAME OF PROCEDURE: Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.
INDICATION: Recurrent angina. History of coronary disease.
TECHNICAL PROCEDURE: Standard Judkins, right groin.
CATHETERS USED: 6-French pigtail, 6-French JL4, 6-French JR4.
ANTICOAGULATION: 2000 of heparin, 300 of Plavix, was begun on Integrilin.
COMPLICATIONS: None.
STENT: For stenting we used a 6-French left Judkins guide. Stent was a 275 x 13 Zeta.
DESCRIPTION OF PROCEDURE: I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery. All questions were answered and the patient decided to proceed.
HEMODYNAMIC DATA: Aortic pressure was within physiologic range. There was no significant gradient across the aortic valve.
ANGIOGRAPHIC DATA
1. Ventriculogram: Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.
2. Right coronary artery: Dominant. There was a lesion in the proximal portion in the 60% range, insignificant disease distally.
3. Left coronary artery: The left main coronary artery showed insignificant disease. The circumflex arose, showed about 30% proximally. Left anterior descending arose and the previously placed stent was perfectly patent. There was a large diagonal branch which showed 90% stenosis in its proximal portion. There was a lesion in the 30% to 40% range even more proximal.
I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery. He desired that we intervene.
Successful stenting of the left anterior descending, diagonal. The guide was placed in the left main. We easily crossed the lesion in the diagonal branch of the left anterior descending. We advanced, applied and post-dilated the 275 x 13 stent. Final angiography showed 0% residual at the site of previous 90% stenosis. The more proximal 30% to 40% lesion was unchanged.
CONCLUSION
1. Successful stenting of the left anterior descending/diagonal. Initially there was 90% in the diagonal after stenting. There was 0% residual. There was a lesion a bit more proximal in the 40% range.
2. Left anterior descending stent remains patent.
3. 30% in the circumflex.
4. 60% in the right coronary.
5. Ejection fraction and wall motion are normal.
PLAN: We have stented the culprit lesion. The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy. We used 6-French Angio-Seal in the groin. All questions have been answered. I have discussed the possibility of restenosis, need for further procedures.
INDICATION: Recurrent angina. History of coronary disease.
TECHNICAL PROCEDURE: Standard Judkins, right groin.
CATHETERS USED: 6-French pigtail, 6-French JL4, 6-French JR4.
ANTICOAGULATION: 2000 of heparin, 300 of Plavix, was begun on Integrilin.
COMPLICATIONS: None.
STENT: For stenting we used a 6-French left Judkins guide. Stent was a 275 x 13 Zeta.
DESCRIPTION OF PROCEDURE: I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery. All questions were answered and the patient decided to proceed.
HEMODYNAMIC DATA: Aortic pressure was within physiologic range. There was no significant gradient across the aortic valve.
ANGIOGRAPHIC DATA
1. Ventriculogram: Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.
2. Right coronary artery: Dominant. There was a lesion in the proximal portion in the 60% range, insignificant disease distally.
3. Left coronary artery: The left main coronary artery showed insignificant disease. The circumflex arose, showed about 30% proximally. Left anterior descending arose and the previously placed stent was perfectly patent. There was a large diagonal branch which showed 90% stenosis in its proximal portion. There was a lesion in the 30% to 40% range even more proximal.
I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery. He desired that we intervene.
Successful stenting of the left anterior descending, diagonal. The guide was placed in the left main. We easily crossed the lesion in the diagonal branch of the left anterior descending. We advanced, applied and post-dilated the 275 x 13 stent. Final angiography showed 0% residual at the site of previous 90% stenosis. The more proximal 30% to 40% lesion was unchanged.
CONCLUSION
1. Successful stenting of the left anterior descending/diagonal. Initially there was 90% in the diagonal after stenting. There was 0% residual. There was a lesion a bit more proximal in the 40% range.
2. Left anterior descending stent remains patent.
3. 30% in the circumflex.
4. 60% in the right coronary.
5. Ejection fraction and wall motion are normal.
PLAN: We have stented the culprit lesion. The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy. We used 6-French Angio-Seal in the groin. All questions have been answered. I have discussed the possibility of restenosis, need for further procedures.
Description: Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
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NAME OF PROCEDURE: Left heart catheterization with ventriculography, selective coronary angiography.
INDICATIONS: Acute coronary syndrome.
TECHNIQUE OF PROCEDURE: Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
ANTICOAGULATION: The patient was on heparin at the time.
COMPLICATIONS: None.
I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery. All questions were answered, and the patient desired to proceed.
HEMODYNAMIC DATA: Aortic pressure was in the physiologic range. No significant gradient across the aortic valve.
ANGIOGRAPHIC DATA
1. Ventriculogram: The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.
2. Right coronary artery: Dominant. There was insignificant disease in the system.
3. Left coronary: Left main, left anterior descending and circumflex systems showed no significant disease.
CONCLUSIONS
1. Normal left ventricular systolic function.
2. Insignificant coronary disease.
PLAN: Based upon this study, medical therapy is warranted. Six-French Angio-Seal was used in the groin.
INDICATIONS: Acute coronary syndrome.
TECHNIQUE OF PROCEDURE: Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
ANTICOAGULATION: The patient was on heparin at the time.
COMPLICATIONS: None.
I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery. All questions were answered, and the patient desired to proceed.
HEMODYNAMIC DATA: Aortic pressure was in the physiologic range. No significant gradient across the aortic valve.
ANGIOGRAPHIC DATA
1. Ventriculogram: The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.
2. Right coronary artery: Dominant. There was insignificant disease in the system.
3. Left coronary: Left main, left anterior descending and circumflex systems showed no significant disease.
CONCLUSIONS
1. Normal left ventricular systolic function.
2. Insignificant coronary disease.
PLAN: Based upon this study, medical therapy is warranted. Six-French Angio-Seal was used in the groin.
Description: Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.
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NAME OF PROCEDURE
1. Left heart catheterization with left ventriculography and selective coronary angiography.
2. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.
HISTORY: This is a 58-year-old male who presented with atypical chest discomfort. The patient had elevated troponins which were suggestive of a myocardial infarction. The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.
PROCEDURE DETAILS: Informed consent was given prior to the patient was brought to the catheterization laboratory. The patient was brought to the catheterization laboratory in postabsorptive state. The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region. Using modified Seldinger technique, a 6-French arterial sheath was placed. Then, the patient had already been on heparin. Then, a Judkins left 4 catheter was intubated into the left main coronary artery. Several projections were obtained and the catheter was removed. A 3DRC catheter was intubated into the right coronary artery. Several projections were obtained and the catheter was removed. Then, a 3DRC guiding catheter was intubated into the right coronary artery. Then, a universal wire was advanced across the lesion into the distal right coronary artery. Integrilin was given. Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds. Then, a projection was obtained. Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery. The stent was deployed at 15 atmospheres for 25 seconds. Post stent, the patient was given intracoronary nitroglycerin after one projection. Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful. Then, a pilot 150 wire was advanced across the lesion. Then, attempt to place the 2.0 x 8 power saver across the lesion was performed. However, it was felt that there was adequate flow and no further intervention needed to be performed. Then, the stent delivery system was removed. A pigtail catheter was placed into the left ventricle. Hemodynamics followed by left ventriculography was performed. Then, a pullback gradient was performed and the catheter was removed. Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied. The patient was transferred back to his room in good condition.
FINDINGS
1. Hemodynamics: The opening aortic pressure was 116/61 with a mean of 64. The opening left ventricular pressure was 112 with end-diastolic pressure of 23. LV pressure on pullback was 106 with end-diastolic pressure of 21. Aortic pressure was 111/67 with a mean of 87. The closing pressure was 110/67.
2. Left ventriculography: The left ventricle was of normal cavity, size, and wall thickness. There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis. The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%. The mitral valve had no significant prolapse or regurgitation. The aortic valve appeared to be trileaflet and moved normally.
3. Coronary angiography: The left main is a normal-caliber vessel. This bifurcates into the left anterior descending and circumflex arteries. The left main is free of any significant obstructive coronary artery disease. The left anterior descending is a large vessel that extends to the apex. It gives off approximately 10 septal perforators and 5 diagonal branches. The first diagonal branch was large. The left anterior descending had mild irregularities, but no high-grade disease. The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches. The two obtuse marginal branches are large. There is a relatively small left atrial branch. The left circumflex had a 50% stenosis after the first obtuse marginal branch. The rest of the vessel is moderately irregular, but no high-grade disease. The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches. The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease. However, distal between the second and third posterolateral branch, there is a 90% stenosis. The rest of the vessels had mild irregularities, but no high-grade disease. Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis. Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch. Then, a wire was advanced through this and there was improvement of flow. There is improvement from TIMI grade 2 to TIMI grade 3 flow.
CLINICAL IMPRESSION
1. Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.
2. Two-vessel coronary artery disease.
3. Elevated left ventricular end-diastolic pressure.
4. Mild anterolateral and moderate inferoapical hypokinesis.
RECOMMENDATIONS
1. Integrilin.
2. Bed rest.
3. Risk factor modification.
4. Thallium scintigraphy in approximately six weeks.
1. Left heart catheterization with left ventriculography and selective coronary angiography.
2. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.
HISTORY: This is a 58-year-old male who presented with atypical chest discomfort. The patient had elevated troponins which were suggestive of a myocardial infarction. The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.
PROCEDURE DETAILS: Informed consent was given prior to the patient was brought to the catheterization laboratory. The patient was brought to the catheterization laboratory in postabsorptive state. The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region. Using modified Seldinger technique, a 6-French arterial sheath was placed. Then, the patient had already been on heparin. Then, a Judkins left 4 catheter was intubated into the left main coronary artery. Several projections were obtained and the catheter was removed. A 3DRC catheter was intubated into the right coronary artery. Several projections were obtained and the catheter was removed. Then, a 3DRC guiding catheter was intubated into the right coronary artery. Then, a universal wire was advanced across the lesion into the distal right coronary artery. Integrilin was given. Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds. Then, a projection was obtained. Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery. The stent was deployed at 15 atmospheres for 25 seconds. Post stent, the patient was given intracoronary nitroglycerin after one projection. Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful. Then, a pilot 150 wire was advanced across the lesion. Then, attempt to place the 2.0 x 8 power saver across the lesion was performed. However, it was felt that there was adequate flow and no further intervention needed to be performed. Then, the stent delivery system was removed. A pigtail catheter was placed into the left ventricle. Hemodynamics followed by left ventriculography was performed. Then, a pullback gradient was performed and the catheter was removed. Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied. The patient was transferred back to his room in good condition.
FINDINGS
1. Hemodynamics: The opening aortic pressure was 116/61 with a mean of 64. The opening left ventricular pressure was 112 with end-diastolic pressure of 23. LV pressure on pullback was 106 with end-diastolic pressure of 21. Aortic pressure was 111/67 with a mean of 87. The closing pressure was 110/67.
2. Left ventriculography: The left ventricle was of normal cavity, size, and wall thickness. There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis. The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%. The mitral valve had no significant prolapse or regurgitation. The aortic valve appeared to be trileaflet and moved normally.
3. Coronary angiography: The left main is a normal-caliber vessel. This bifurcates into the left anterior descending and circumflex arteries. The left main is free of any significant obstructive coronary artery disease. The left anterior descending is a large vessel that extends to the apex. It gives off approximately 10 septal perforators and 5 diagonal branches. The first diagonal branch was large. The left anterior descending had mild irregularities, but no high-grade disease. The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches. The two obtuse marginal branches are large. There is a relatively small left atrial branch. The left circumflex had a 50% stenosis after the first obtuse marginal branch. The rest of the vessel is moderately irregular, but no high-grade disease. The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches. The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease. However, distal between the second and third posterolateral branch, there is a 90% stenosis. The rest of the vessels had mild irregularities, but no high-grade disease. Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis. Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch. Then, a wire was advanced through this and there was improvement of flow. There is improvement from TIMI grade 2 to TIMI grade 3 flow.
CLINICAL IMPRESSION
1. Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.
2. Two-vessel coronary artery disease.
3. Elevated left ventricular end-diastolic pressure.
4. Mild anterolateral and moderate inferoapical hypokinesis.
RECOMMENDATIONS
1. Integrilin.
2. Bed rest.
3. Risk factor modification.
4. Thallium scintigraphy in approximately six weeks.
Description: Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.
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(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES
1. Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.
2. Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.
3. Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation. He is intubated and ventilated.
POSTOPERATIVE DIAGNOSES: Acute coronary artery syndrome with ST segment elevation in anterior wall distribution. Primary ventricular arrhythmia. Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent. Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.
PROCEDURES: Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.
DESCRIPTION OF PROCEDURE: The patient arrived from the emergency room intubated and ventilated. He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated. The right femoral area was prepped and draped in usual sterile fashion. Lidocaine 2 mL was then filled locally. The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath. A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained. A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized. An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent. An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained. It successfully re-canalized the artery. There is evidence of residual stenosis within the distal aspect of the previous stents. A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres. The intermittent result was improved. An additional inflation was obtained more proximally. His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation. There is patency of the left anterior descending artery and good antegrade flow. The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained. The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve. The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath. A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position. Cardiac catheter was determined by thermal dilution. The procedure was then concluded, well tolerated and without complications. The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring. Fluoroscopy time was 8.2 minutes. Total amount of contrast was 113 mL.
HEMODYNAMICS: The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization. His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg. There was no gradient across the aortic valve. Closing pressure was 97/68 with a mean of 82.
Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19. Cardiac output was 5.87 by thermal dilution.
CORONARIES: On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.
A. Left main coronary: The left main coronary artery is of good caliber and has no evidence of obstructive lesions.
B. Left anterior descending artery: The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment. There is minimal collateral flow.
C. Circumflex: Circumflex is a nondominant circulation. It supplies a first obtuse marginal branch on good caliber. There is an outline of the stent in the midportion, which has mild 30% stenosis. The rest of the vessel has no significant obstructive lesions. It also supplies significant collaterals supplying the occluded right coronary artery.
D. Right coronary artery: The right coronary artery is a weekly dominant circulation. The vessel is occluded in intermittent portion and has a minimal collateral flow distally.
ANGIOPLASTY: The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection. The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent. There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis. The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery. There is good antegrade flow and no evidence of distal embolization.
CONCLUSION: Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.
Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.
Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent. There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.
Right femoral arterial and venous vascular access.
RECOMMENDATION: Integrilin infusion is maintained until tomorrow. He received aspirin and Plavix per nasogastric tube. Titrated doses of beta-blockers and ACE inhibitors are initiated. Additional revascularization therapy will be adjusted according to the clinical evaluation.
1. Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.
2. Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.
3. Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation. He is intubated and ventilated.
POSTOPERATIVE DIAGNOSES: Acute coronary artery syndrome with ST segment elevation in anterior wall distribution. Primary ventricular arrhythmia. Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent. Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.
PROCEDURES: Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.
DESCRIPTION OF PROCEDURE: The patient arrived from the emergency room intubated and ventilated. He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated. The right femoral area was prepped and draped in usual sterile fashion. Lidocaine 2 mL was then filled locally. The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath. A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained. A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized. An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent. An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained. It successfully re-canalized the artery. There is evidence of residual stenosis within the distal aspect of the previous stents. A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres. The intermittent result was improved. An additional inflation was obtained more proximally. His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation. There is patency of the left anterior descending artery and good antegrade flow. The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained. The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve. The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath. A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position. Cardiac catheter was determined by thermal dilution. The procedure was then concluded, well tolerated and without complications. The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring. Fluoroscopy time was 8.2 minutes. Total amount of contrast was 113 mL.
HEMODYNAMICS: The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization. His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg. There was no gradient across the aortic valve. Closing pressure was 97/68 with a mean of 82.
Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19. Cardiac output was 5.87 by thermal dilution.
CORONARIES: On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.
A. Left main coronary: The left main coronary artery is of good caliber and has no evidence of obstructive lesions.
B. Left anterior descending artery: The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment. There is minimal collateral flow.
C. Circumflex: Circumflex is a nondominant circulation. It supplies a first obtuse marginal branch on good caliber. There is an outline of the stent in the midportion, which has mild 30% stenosis. The rest of the vessel has no significant obstructive lesions. It also supplies significant collaterals supplying the occluded right coronary artery.
D. Right coronary artery: The right coronary artery is a weekly dominant circulation. The vessel is occluded in intermittent portion and has a minimal collateral flow distally.
ANGIOPLASTY: The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection. The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent. There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis. The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery. There is good antegrade flow and no evidence of distal embolization.
CONCLUSION: Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.
Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.
Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent. There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.
Right femoral arterial and venous vascular access.
RECOMMENDATION: Integrilin infusion is maintained until tomorrow. He received aspirin and Plavix per nasogastric tube. Titrated doses of beta-blockers and ACE inhibitors are initiated. Additional revascularization therapy will be adjusted according to the clinical evaluation.
Description: Left heart catheterization with left ventriculography and selective coronary angiography. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function. Frequent PVCs. Metabolic syndrome.
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PREOPERATIVE DIAGNOSES
1. Dyspnea on exertion with abnormal stress echocardiography.
2. Frequent PVCs.
3. Metabolic syndrome.
POSTOPERATIVE DIAGNOSES
1. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.
2. Frequent PVCs.
3. Metabolic syndrome.
PROCEDURES
1. Left heart catheterization with left ventriculography.
2. Selective coronary angiography.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state. Both groins were prepped and draped in the usual sterile fashion. Xylocaine 1% was used as local anesthetic. Versed and fentanyl were used for conscious sedation. Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique. Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter. Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter. Next, a #6-French angle pigtail catheter was advanced into the left ventricle. The left ventricular pressure was then recorded. Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds. The left heart pull back was then performed. The catheter was then removed.
Angiography of the right femoral artery was performed. Hemostasis was obtained by Angio-Seal closure device. The patient left the Cardiac Catheterization Laboratory in stable condition.
HEMODYNAMICS
1. LV pressure was 163/0 with end-diastolic pressure of 17. There was no significant gradient across the aortic valve.
2. Left ventriculography showed old inferior wall hypokinesis. Global left ventricular systolic function is normal. Estimated ejection fraction was 58%. There is no significant mitral regurgitation.
3. Significant coronary artery disease.
4. The left main is approximately 7 or 8 mm proximally. It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery. The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.
5. The left anterior descending artery is around 4 mm proximally. It extends slightly beyond the apex into the inferior wall. It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators. At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.
There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.
The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches. There was no significant disease noted in the ramus intermedius artery however.
The left circumflex artery is around 2.5 mm proximally. It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch. The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.
The right coronary artery is around 4 mm in diameter. It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch. In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%. Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%. Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well. The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.
PLAN: Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery. Continue risk factor modification, aspirin, and beta blocker.
1. Dyspnea on exertion with abnormal stress echocardiography.
2. Frequent PVCs.
3. Metabolic syndrome.
POSTOPERATIVE DIAGNOSES
1. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.
2. Frequent PVCs.
3. Metabolic syndrome.
PROCEDURES
1. Left heart catheterization with left ventriculography.
2. Selective coronary angiography.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state. Both groins were prepped and draped in the usual sterile fashion. Xylocaine 1% was used as local anesthetic. Versed and fentanyl were used for conscious sedation. Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique. Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter. Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter. Next, a #6-French angle pigtail catheter was advanced into the left ventricle. The left ventricular pressure was then recorded. Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds. The left heart pull back was then performed. The catheter was then removed.
Angiography of the right femoral artery was performed. Hemostasis was obtained by Angio-Seal closure device. The patient left the Cardiac Catheterization Laboratory in stable condition.
HEMODYNAMICS
1. LV pressure was 163/0 with end-diastolic pressure of 17. There was no significant gradient across the aortic valve.
2. Left ventriculography showed old inferior wall hypokinesis. Global left ventricular systolic function is normal. Estimated ejection fraction was 58%. There is no significant mitral regurgitation.
3. Significant coronary artery disease.
4. The left main is approximately 7 or 8 mm proximally. It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery. The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.
5. The left anterior descending artery is around 4 mm proximally. It extends slightly beyond the apex into the inferior wall. It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators. At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.
There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.
The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches. There was no significant disease noted in the ramus intermedius artery however.
The left circumflex artery is around 2.5 mm proximally. It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch. The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.
The right coronary artery is around 4 mm in diameter. It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch. In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%. Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%. Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well. The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.
PLAN: Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery. Continue risk factor modification, aspirin, and beta blocker.
Description: Left heart catheterization, coronary angiography, left ventriculography. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.
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PROCEDURE: Left heart catheterization, coronary angiography, left ventriculography.
COMPLICATIONS: None.
PROCEDURE DETAIL: The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration. A 6-French arterial sheath was placed in the usual fashion. Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic. The right coronary artery was difficult to cannulate because of its high anterior takeoff. This was nondominant. Several catheters were used. Ultimately, an AL1 diagnostic catheter was used. A pigtail catheter was advanced across the aortic valve. Left ventriculogram was then done in the RAO view using 30 mL of contrast. Pullback gradient was obtained across the aortic valve. Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results. There were no complications. He tolerated this procedure well and returned to his room in good condition.
FINDINGS
1. Right coronary artery: This has an unusual high anterior takeoff. The vessel is nondominant, has diffuse mild-to-moderate disease.
2. Left main trunk: A 30% to 40% distal narrowing is present.
3. Left anterior descending: Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing. The diagonal is a large vessel about 3 mm in size.
4. Circumflex: Dominant vessel, 50% narrowing at the origin of the obtuse marginal. After this, there is 40% narrowing in the AV trunk. The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.
5. Left ventriculogram: Normal volume in diastole and systole. Normal systolic function is present. There is no mitral insufficiency or left ventricular outflow obstruction.
DIAGNOSES
1. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch. Dominant circumflex system. Severe disease of the posterior descending. Mild left main trunk disease.
2. Normal left ventricular systolic function.
Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery. The patient also has severe disease of the circumflex which is dominant. This anatomy is not appropriate for percutaneous intervention. The case will be reviewed with a cardiac surgeon.
COMPLICATIONS: None.
PROCEDURE DETAIL: The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration. A 6-French arterial sheath was placed in the usual fashion. Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic. The right coronary artery was difficult to cannulate because of its high anterior takeoff. This was nondominant. Several catheters were used. Ultimately, an AL1 diagnostic catheter was used. A pigtail catheter was advanced across the aortic valve. Left ventriculogram was then done in the RAO view using 30 mL of contrast. Pullback gradient was obtained across the aortic valve. Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results. There were no complications. He tolerated this procedure well and returned to his room in good condition.
FINDINGS
1. Right coronary artery: This has an unusual high anterior takeoff. The vessel is nondominant, has diffuse mild-to-moderate disease.
2. Left main trunk: A 30% to 40% distal narrowing is present.
3. Left anterior descending: Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing. The diagonal is a large vessel about 3 mm in size.
4. Circumflex: Dominant vessel, 50% narrowing at the origin of the obtuse marginal. After this, there is 40% narrowing in the AV trunk. The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.
5. Left ventriculogram: Normal volume in diastole and systole. Normal systolic function is present. There is no mitral insufficiency or left ventricular outflow obstruction.
DIAGNOSES
1. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch. Dominant circumflex system. Severe disease of the posterior descending. Mild left main trunk disease.
2. Normal left ventricular systolic function.
Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery. The patient also has severe disease of the circumflex which is dominant. This anatomy is not appropriate for percutaneous intervention. The case will be reviewed with a cardiac surgeon.
Description: Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure.
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PROCEDURES
1. Left heart catheterization.
2. Coronary angiography.
3. Left ventriculogram.
PREPROCEDURE DIAGNOSIS: Atypical chest pain.
POSTPROCEDURE DIAGNOSES
1. No angiographic evidence of coronary artery disease.
2. Normal left ventricular systolic function.
3. Normal left ventricular end diastolic pressure.
INDICATION: The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.
PROCEDURE IN DETAIL: After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. He was prepped and draped in the usual sterile manner. The right inguinal area was anesthetized with 2% Xylocaine. A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique. JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively. Coronary angiographies were performed. These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle. Left ventriculography was performed. The patient tolerated the procedure well. At the end of the procedure, all catheters and sheaths were removed. The patient was then transferred to telemetry in a stable condition.
HEMODYNAMIC DATA: Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.
AORTIC VALVE: There is no significant gradient across this valve noted.
LV GRAM: A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL. Ejection fraction was calculated to be 69%. There were no wall motion abnormalities noted.
ANGIOGRAM
LEFT MAIN CORONARY ARTERY: Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.
LAD: LAD is a long, tortuous vessel which wraps around the apex. The LAD is small in caliber. In addition, there is a long bifurcating small-caliber diagonal branch noted. LAD and its branches are free of disease.
RAMUS INTERMEDIUS: Ramus intermedius is a long small-caliber vessel free of disease.
LCX: LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch. LCX and its branches are free of disease.
RCA: RCA is a dominant small-caliber vessel with long small-caliber PDA branch. RCA and its branches are free of disease.
IMPRESSION
1. No angiographic evidence of coronary artery disease.
2. Normal left ventricular systolic function.
3. Normal left ventricular end diastolic pressure.
RECOMMENDATION: Recommend to look for alternative causes of chest pain.
1. Left heart catheterization.
2. Coronary angiography.
3. Left ventriculogram.
PREPROCEDURE DIAGNOSIS: Atypical chest pain.
POSTPROCEDURE DIAGNOSES
1. No angiographic evidence of coronary artery disease.
2. Normal left ventricular systolic function.
3. Normal left ventricular end diastolic pressure.
INDICATION: The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.
PROCEDURE IN DETAIL: After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. He was prepped and draped in the usual sterile manner. The right inguinal area was anesthetized with 2% Xylocaine. A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique. JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively. Coronary angiographies were performed. These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle. Left ventriculography was performed. The patient tolerated the procedure well. At the end of the procedure, all catheters and sheaths were removed. The patient was then transferred to telemetry in a stable condition.
HEMODYNAMIC DATA: Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.
AORTIC VALVE: There is no significant gradient across this valve noted.
LV GRAM: A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL. Ejection fraction was calculated to be 69%. There were no wall motion abnormalities noted.
ANGIOGRAM
LEFT MAIN CORONARY ARTERY: Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.
LAD: LAD is a long, tortuous vessel which wraps around the apex. The LAD is small in caliber. In addition, there is a long bifurcating small-caliber diagonal branch noted. LAD and its branches are free of disease.
RAMUS INTERMEDIUS: Ramus intermedius is a long small-caliber vessel free of disease.
LCX: LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch. LCX and its branches are free of disease.
RCA: RCA is a dominant small-caliber vessel with long small-caliber PDA branch. RCA and its branches are free of disease.
IMPRESSION
1. No angiographic evidence of coronary artery disease.
2. Normal left ventricular systolic function.
3. Normal left ventricular end diastolic pressure.
RECOMMENDATION: Recommend to look for alternative causes of chest pain.
Description: Left heart catheterization, left ventriculography, selective coronary angiography.
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PROCEDURE: Left heart catheterization, left ventriculography, selective coronary angiography.
INDICATION: This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing. This was felt to be related largely to chronic obstructive lung disease. She had dynamic T-wave changes in precordial leads. Cardiac enzymes were indeterminate. She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.
Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail. The patient understood and agreed to proceed.
DESCRIPTION OF THE PROCEDURE: The patient was brought to the cardiac catheterization laboratory. Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped. Local anesthesia was obtained with 2% Xylocaine. The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel. Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed. Ascending aortic root pressures obtained. This catheter was utilized in an attempt to cannulate the left coronary ostium. This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.
This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta. The catheter appropriately aspirated and flushed. The catheter was advanced in the right coronary artery. Multiple views of that vessel were obtained. The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained. This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta. The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.
Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds. Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve. Videotapes were then reviewed. It was elected to terminate the procedure at that point in time.
The vascular sheath was removed and manual compression carried out. Excellent hemostasis was obtained. The patient tolerated the procedure without complication.
RESULTS OF PROCEDURE
1. HEMODYNAMICS: Left ventricular end-diastolic filling pressure was 24. There was no gradient across the aortic valve.
2. LEFT VENTRICULOGRAPHY: Left ventriculography demonstrated well-preserved left ventricular systolic function. Mild inferobasilar hypokinesis was noted. No significant mitral regurgitation noted. Ejection fraction was estimated at 60%.
3. CORONARY ARTERIOGRAPHY
A. LEFT MAIN CORONARY: The left main coronary was patent.
B. LEFT ANTERIOR DESCENDING CORONARY ARTERY: Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.
C. CIRCUMFLEX CORONARY ARTERY: Circumflex coronary artery was occluded at its origin.
D. RIGHT CORONARY ARTERY. Right coronary artery was occluded in its mid portion.
4. SAPHENOUS VEIN GRAFT ANGIOGRAPHY
A. SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites. Excellent flow was noted in the diagonal system with some retrograde flow.
B. There was retrograde flow as well in the left anterior descending system.
C. SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM: Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites. There was no graft disease noted. Excellent flow was noted in the bifurcating marginal system.
D. SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY: Saphenous vein graft to right coronary was widely patent with no graft disease. Origin and insertion sites were free of disease. Distal flow in the graft to the posterior descending was normal.
5. LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites. There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel. Retrograde filling of a small septal system was noted.
SUMMARY OF RESULTS
1. Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.
2. Occluded native right coronary, left anterior descending, and circumflex coronary arteries.
3. Widely patent saphenous vein graft to the right coronary artery, obtuse marginal system, diagonal system.
4. Widely patent left internal mammary artery and left anterior descending.
RECOMMENDATIONS: The patient needs no additional cardiovascular evaluation or workup. Her full-dose Lovenox should be discontinued and low-dose Lovenox for DVT prophylaxis should be carried out. The usual medications for risk control and medicines for diabetic control will be appropriate.
INDICATION: This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing. This was felt to be related largely to chronic obstructive lung disease. She had dynamic T-wave changes in precordial leads. Cardiac enzymes were indeterminate. She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.
Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail. The patient understood and agreed to proceed.
DESCRIPTION OF THE PROCEDURE: The patient was brought to the cardiac catheterization laboratory. Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped. Local anesthesia was obtained with 2% Xylocaine. The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel. Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed. Ascending aortic root pressures obtained. This catheter was utilized in an attempt to cannulate the left coronary ostium. This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.
This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta. The catheter appropriately aspirated and flushed. The catheter was advanced in the right coronary artery. Multiple views of that vessel were obtained. The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained. This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta. The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.
Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds. Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve. Videotapes were then reviewed. It was elected to terminate the procedure at that point in time.
The vascular sheath was removed and manual compression carried out. Excellent hemostasis was obtained. The patient tolerated the procedure without complication.
RESULTS OF PROCEDURE
1. HEMODYNAMICS: Left ventricular end-diastolic filling pressure was 24. There was no gradient across the aortic valve.
2. LEFT VENTRICULOGRAPHY: Left ventriculography demonstrated well-preserved left ventricular systolic function. Mild inferobasilar hypokinesis was noted. No significant mitral regurgitation noted. Ejection fraction was estimated at 60%.
3. CORONARY ARTERIOGRAPHY
A. LEFT MAIN CORONARY: The left main coronary was patent.
B. LEFT ANTERIOR DESCENDING CORONARY ARTERY: Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.
C. CIRCUMFLEX CORONARY ARTERY: Circumflex coronary artery was occluded at its origin.
D. RIGHT CORONARY ARTERY. Right coronary artery was occluded in its mid portion.
4. SAPHENOUS VEIN GRAFT ANGIOGRAPHY
A. SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites. Excellent flow was noted in the diagonal system with some retrograde flow.
B. There was retrograde flow as well in the left anterior descending system.
C. SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM: Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites. There was no graft disease noted. Excellent flow was noted in the bifurcating marginal system.
D. SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY: Saphenous vein graft to right coronary was widely patent with no graft disease. Origin and insertion sites were free of disease. Distal flow in the graft to the posterior descending was normal.
5. LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites. There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel. Retrograde filling of a small septal system was noted.
SUMMARY OF RESULTS
1. Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.
2. Occluded native right coronary, left anterior descending, and circumflex coronary arteries.
3. Widely patent saphenous vein graft to the right coronary artery, obtuse marginal system, diagonal system.
4. Widely patent left internal mammary artery and left anterior descending.
RECOMMENDATIONS: The patient needs no additional cardiovascular evaluation or workup. Her full-dose Lovenox should be discontinued and low-dose Lovenox for DVT prophylaxis should be carried out. The usual medications for risk control and medicines for diabetic control will be appropriate.
Description: Placement of a subclavian single-lumen tunneled Hickman central venous catheter. Surgeon-interpreted fluoroscopy.
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PROCEDURE PERFORMED
1. Placement of a subclavian single-lumen tunneled Hickman central venous catheter.
2. Surgeon-interpreted fluoroscopy.
OPERATION IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered. Next, a #18-gauge needle was used to locate the subclavian vein. After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique. The needle was withdrawn. The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site. A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff. The catheter was cut to the appropriate length. A dilator and sheath were passed over the J wire. The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn. The catheter was flushed and aspirated without difficulty. The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy. A 2-0 nylon was used to secure the cuff down to the catheter at the skin level. The skin stab site was closed with a 4-0 Monocryl. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.
1. Placement of a subclavian single-lumen tunneled Hickman central venous catheter.
2. Surgeon-interpreted fluoroscopy.
OPERATION IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered. Next, a #18-gauge needle was used to locate the subclavian vein. After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique. The needle was withdrawn. The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site. A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff. The catheter was cut to the appropriate length. A dilator and sheath were passed over the J wire. The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn. The catheter was flushed and aspirated without difficulty. The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy. A 2-0 nylon was used to secure the cuff down to the catheter at the skin level. The skin stab site was closed with a 4-0 Monocryl. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.
Description: Holter Monitor Report
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INTERPRETATION:
1. Predominant rhythm is normal sinus rhythm.
2. No supraventricular arrhythmia.
3. Frequent premature ventricular contractions.
4. Trigemini and couplets.
5. No high-grade atrial ventricular block was noted.
6. Diary was not kept.
IMPRESSION: Frequent premature atrial contractions, couplets, and trigemini.
1. Predominant rhythm is normal sinus rhythm.
2. No supraventricular arrhythmia.
3. Frequent premature ventricular contractions.
4. Trigemini and couplets.
5. No high-grade atrial ventricular block was noted.
6. Diary was not kept.
IMPRESSION: Frequent premature atrial contractions, couplets, and trigemini.
Description: Holter monitor report. Predominant rhythm is sinus. Triplet maximum rate of 178 beats per minute noted.
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INDICATIONS: Predominant rhythm is sinus. Heart rate varied between 56-128 beats per minute, average heart rate of 75 beats per minute. Minimum heart rate of 50 beats per minute.
640 ventricular ectopic isolated beats noted. Rare isolated APCs and supraventricular couplets.
One supraventricular triplet reported.
Triplet maximum rate of 178 beats per minute noted.
640 ventricular ectopic isolated beats noted. Rare isolated APCs and supraventricular couplets.
One supraventricular triplet reported.
Triplet maximum rate of 178 beats per minute noted.
Description: Holter monitoring for syncope. Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.
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INDICATION: Syncope.
HOLTER MONITOR SUMMARY ANALYSIS: Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds. Total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m. Average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m. Total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions. No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm.
IMPRESSION OF THE FINDINGS: Predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and Mobitz type 1 Wenckebach, several episodes, Mobitz type II, 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted. No significant pauses noted.
HOLTER MONITOR SUMMARY ANALYSIS: Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds. Total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m. Average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m. Total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions. No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm.
IMPRESSION OF THE FINDINGS: Predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and Mobitz type 1 Wenckebach, several episodes, Mobitz type II, 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted. No significant pauses noted.
Description: Holter monitoring - For bradycardia and dizziness.
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INDICATION: Bradycardia and dizziness.
COMMENTS:
1. The patient was monitored for 24 hours.
2. The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.
3. There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.
4. There was a frequent premature ventricular contraction seen. Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time. During rest of the monitoring period, there were just occasional premature ventricular contractions seen. No ventricular tachycardia was seen.
5. There were no pathological pauses noted.
6. The longest RR interval was 1.1 second.
7. There were no symptoms reported.
COMMENTS:
1. The patient was monitored for 24 hours.
2. The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.
3. There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.
4. There was a frequent premature ventricular contraction seen. Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time. During rest of the monitoring period, there were just occasional premature ventricular contractions seen. No ventricular tachycardia was seen.
5. There were no pathological pauses noted.
6. The longest RR interval was 1.1 second.
7. There were no symptoms reported.
Description: Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.
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CLINICAL HISTORY: Patient is a 37-year-old female with a history of colectomy for adenoma. During her preop evaluation it was noted that she had a lesion on her chest x-ray. CT scan of the chest confirmed a left lower mass.
SPECIMEN: Lung, left lower lobe resection.
IMMUNOHISTOCHEMICAL STUDIES: Tumor cells show no reactivity with cytokeratin AE1/AE3. No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen. Tumor cells show partial reactivity with cytokeratin-7. PAS with diastase demonstrates no convincing intracytoplasmic mucin. No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains. Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody. No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A. Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1). The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.
FINAL DIAGNOSIS:
Histologic Tumor Type: Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.
Tumor Size: 2.7 x 2.0 x 1.4 cm.
Visceral Pleura Involvement: The tumor closely approaches the pleural surface but does not invade the pleura.
Vascular Invasion: Present.
Margins: Bronchial resection margins and vascular margins are free of tumor.
Lymph Nodes: Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.
Pathologic Stage: pT1N1MX.
SPECIMEN: Lung, left lower lobe resection.
IMMUNOHISTOCHEMICAL STUDIES: Tumor cells show no reactivity with cytokeratin AE1/AE3. No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen. Tumor cells show partial reactivity with cytokeratin-7. PAS with diastase demonstrates no convincing intracytoplasmic mucin. No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains. Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody. No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A. Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1). The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.
FINAL DIAGNOSIS:
Histologic Tumor Type: Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.
Tumor Size: 2.7 x 2.0 x 1.4 cm.
Visceral Pleura Involvement: The tumor closely approaches the pleural surface but does not invade the pleura.
Vascular Invasion: Present.
Margins: Bronchial resection margins and vascular margins are free of tumor.
Lymph Nodes: Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.
Pathologic Stage: pT1N1MX.
Description: Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.
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PREOPERATIVE DIAGNOSIS: Syncopal episodes with injury. See electrophysiology consultation.
POSTOPERATIVE DIAGNOSES:
1. Normal electrophysiologic studies.
2. No inducible arrhythmia.
3. Procainamide infusion negative for Brugada syndrome.
PROCEDURES:
1. Comprehensive electrophysiology studies with attempted arrhythmia induction.
2. IV Procainamide infusion for Brugada syndrome.
DESCRIPTION OF PROCEDURE: The patient gave informed consent for comprehensive electrophysiologic studies. She received small amounts of intravenous fentanyl and Versed for conscious sedation. Then 1% lidocaine local anesthesia was used. Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle. Later in the procedure, the RV apical catheter was moved to RV outflow tract.
ELECTROPHYSIOLOGICAL FINDINGS: Conduction intervals in sinus rhythm were normal. Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms. Sinus node recovery times were also normal at 1114 ms. Corrected sinus node recovery time was normal at 330 ms. One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms. AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms. RA-ERP was 250 ms. With ventricular pacing, there was VA disassociation present.
Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.
Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts. Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness. There was no inducible VT. Longest run was 5 beats of polymorphic VT, which is a nonspecific finding. From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.
Procainamide was then infused, 20 mg/kg over 10 minutes. There were no ST segment changes. HV interval after IV Procainamide remained normal at 50 ms.
ASSESSMENT: Normal electrophysiologic studies. No evidence for sinus node dysfunction or atrioventricular block. No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.
PLAN: The patient will follow up with Dr. X. She recently had an ambulatory EEG. I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes. Reveal event monitor was considered, but not placed since she has only had one single episode.
POSTOPERATIVE DIAGNOSES:
1. Normal electrophysiologic studies.
2. No inducible arrhythmia.
3. Procainamide infusion negative for Brugada syndrome.
PROCEDURES:
1. Comprehensive electrophysiology studies with attempted arrhythmia induction.
2. IV Procainamide infusion for Brugada syndrome.
DESCRIPTION OF PROCEDURE: The patient gave informed consent for comprehensive electrophysiologic studies. She received small amounts of intravenous fentanyl and Versed for conscious sedation. Then 1% lidocaine local anesthesia was used. Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle. Later in the procedure, the RV apical catheter was moved to RV outflow tract.
ELECTROPHYSIOLOGICAL FINDINGS: Conduction intervals in sinus rhythm were normal. Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms. Sinus node recovery times were also normal at 1114 ms. Corrected sinus node recovery time was normal at 330 ms. One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms. AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms. RA-ERP was 250 ms. With ventricular pacing, there was VA disassociation present.
Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.
Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts. Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness. There was no inducible VT. Longest run was 5 beats of polymorphic VT, which is a nonspecific finding. From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.
Procainamide was then infused, 20 mg/kg over 10 minutes. There were no ST segment changes. HV interval after IV Procainamide remained normal at 50 ms.
ASSESSMENT: Normal electrophysiologic studies. No evidence for sinus node dysfunction or atrioventricular block. No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.
PLAN: The patient will follow up with Dr. X. She recently had an ambulatory EEG. I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes. Reveal event monitor was considered, but not placed since she has only had one single episode.
Description: Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions.
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PREOPERATIVE DIAGNOSIS: Left adrenal mass, 5.5 cm.
POSTOPERATIVE DIAGNOSES:
1. Left adrenal mass, 5.5 cm.
2. Intraabdominal adhesions.
PROCEDURE PERFORMED:
1. Laparoscopic lysis of adhesions.
2. Laparoscopic left adrenalectomy.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 100 cc.
FLUIDS: 3500 cc crystalloids.
DRAINS: None.
DISPOSITION: The patient was taken to recovery room in stable condition. Sponge, needle, and instrument counts were correct per OR staff.
HISTORY: This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size. She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass. Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.
INTRAOPERATIVE FINDINGS: Showed multiple intraabdominal adhesions in the anterior abdominal wall. The spleen and liver were unremarkable. The gallbladder was surgically absent.
There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized. There was no evidence of peritoneal studding or masses. The stomach was well decompressed as well as the bladder.
PROCEDURE DETAILS: After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia. She was placed on a bean bag and secured to the table. The table was rotated to the right to allow gravity to aid in our retraction of the bowel.
Prep was performed. Sterile drapes were applied. Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left. Laparoscopy was performed with ___________. At this point, we had a second trocar, which was 10 mm to 11 mm port. Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus. The adhesions were taken down off the entire anterior abdominal wall.
At this point, secondary and tertiary ports were placed. We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.
At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia. Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen. The colon was further mobilized medially again using gravity to aid in our retraction. After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland. We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected. There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected. Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.
At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis. Repeat laparoscopy showed no additional findings. The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.
The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding. The abdominal cavity was desufflated and was reinspected. There was no evidence of bleeding.
At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture. At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.
At this point, the procedure was terminated. The abdominal cavity was desufflated as stated. The patient was sent to Recovery in stable condition. Postoperative orders were written. The procedure was discussed with the patient's family at length.
POSTOPERATIVE DIAGNOSES:
1. Left adrenal mass, 5.5 cm.
2. Intraabdominal adhesions.
PROCEDURE PERFORMED:
1. Laparoscopic lysis of adhesions.
2. Laparoscopic left adrenalectomy.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 100 cc.
FLUIDS: 3500 cc crystalloids.
DRAINS: None.
DISPOSITION: The patient was taken to recovery room in stable condition. Sponge, needle, and instrument counts were correct per OR staff.
HISTORY: This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size. She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass. Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.
INTRAOPERATIVE FINDINGS: Showed multiple intraabdominal adhesions in the anterior abdominal wall. The spleen and liver were unremarkable. The gallbladder was surgically absent.
There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized. There was no evidence of peritoneal studding or masses. The stomach was well decompressed as well as the bladder.
PROCEDURE DETAILS: After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia. She was placed on a bean bag and secured to the table. The table was rotated to the right to allow gravity to aid in our retraction of the bowel.
Prep was performed. Sterile drapes were applied. Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left. Laparoscopy was performed with ___________. At this point, we had a second trocar, which was 10 mm to 11 mm port. Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus. The adhesions were taken down off the entire anterior abdominal wall.
At this point, secondary and tertiary ports were placed. We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.
At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia. Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen. The colon was further mobilized medially again using gravity to aid in our retraction. After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland. We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected. There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected. Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.
At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis. Repeat laparoscopy showed no additional findings. The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.
The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding. The abdominal cavity was desufflated and was reinspected. There was no evidence of bleeding.
At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture. At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.
At this point, the procedure was terminated. The abdominal cavity was desufflated as stated. The patient was sent to Recovery in stable condition. Postoperative orders were written. The procedure was discussed with the patient's family at length.
Description: Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.
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PREOPERATIVE DIAGNOSIS
Subglottic upper tracheal stenosis.
POSTOPERATIVE DIAGNOSIS
Subglottic upper tracheal stenosis.
OPERATION PREFORMED
Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.
INDICATIONS FOR THE SURGERY
The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis. She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007. She returns with some increasing shortness of breath and dyspnea on exertion. Endoscopic reevaluation is offered to her. The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms. An endoscopic treatment was offered to her. Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length. The patient states she understood and wished to proceed.
DESCRIPTION OF THE OPERATION
The patient was taken to the operating room, placed on table in supine position. Following adequate general anesthesia, the patient was prepared for endoscopy. The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition. Tongue and buccal cavity mucosa were without ulcers, masses, or lesions. The oropharynx was clear. The larynx was then manually suspended. Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent. The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds. At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred. Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated. Remainder of the bronchi was then examined. The mid and distal trachea were widely patent. Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring. The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out. Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished. Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia. The patient tolerated the procedure well without complication.
Subglottic upper tracheal stenosis.
POSTOPERATIVE DIAGNOSIS
Subglottic upper tracheal stenosis.
OPERATION PREFORMED
Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.
INDICATIONS FOR THE SURGERY
The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis. She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007. She returns with some increasing shortness of breath and dyspnea on exertion. Endoscopic reevaluation is offered to her. The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms. An endoscopic treatment was offered to her. Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length. The patient states she understood and wished to proceed.
DESCRIPTION OF THE OPERATION
The patient was taken to the operating room, placed on table in supine position. Following adequate general anesthesia, the patient was prepared for endoscopy. The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition. Tongue and buccal cavity mucosa were without ulcers, masses, or lesions. The oropharynx was clear. The larynx was then manually suspended. Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent. The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds. At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred. Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated. Remainder of the bronchi was then examined. The mid and distal trachea were widely patent. Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring. The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out. Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished. Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia. The patient tolerated the procedure well without complication.
Sample Name: Lexiscan Nuclear Scan
Description: Lexiscan Nuclear Myocardial Perfusion Scan. Chest pain. Patient unable to walk on a treadmill. Nondiagnostic Lexiscan. Normal nuclear myocardial perfusion scan.
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EXAM: Lexiscan Nuclear Myocardial Perfusion Scan.
INDICATION: Chest pain.
TYPE OF TEST: Lexiscan, unable to walk on a treadmill.
INTERPRETATION: Resting heart rate of 96, blood pressure of 141/76. EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block. Post Lexiscan 0.4 mg injected intravenously by standard protocol. Peak heart rate was 105, blood pressure of 135/72. EKG remains the same. No symptoms are noted.
SUMMARY:
1. Nondiagnostic Lexiscan.
2. Nuclear interpretation as below.
NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL: Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol. Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. There is no evidence of reversible or fixed defect. Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. Ejection fraction calculated at 41%. End-diastolic volume of 115, end-systolic volume of 68.
IMPRESSION:
1. Normal nuclear myocardial perfusion scan.
2. Ejection fraction 41% by gated SPECT.
INDICATION: Chest pain.
TYPE OF TEST: Lexiscan, unable to walk on a treadmill.
INTERPRETATION: Resting heart rate of 96, blood pressure of 141/76. EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block. Post Lexiscan 0.4 mg injected intravenously by standard protocol. Peak heart rate was 105, blood pressure of 135/72. EKG remains the same. No symptoms are noted.
SUMMARY:
1. Nondiagnostic Lexiscan.
2. Nuclear interpretation as below.
NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL: Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol. Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. There is no evidence of reversible or fixed defect. Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. Ejection fraction calculated at 41%. End-diastolic volume of 115, end-systolic volume of 68.
IMPRESSION:
1. Normal nuclear myocardial perfusion scan.
2. Ejection fraction 41% by gated SPECT.
Description: Left lower lobectomy.
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OPERATION: Left lower lobectomy.
OPERATIVE PROCEDURE IN DETAIL: The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The left chest and back were prepped and draped in a sterile fashion. A right lateral thoracotomy incision was made. Subcutaneous flaps were raised. The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly. The posterior border of the pectoralis was freed up and it was retracted anteriorly. The 5th intercostal space was entered.
The inferior pulmonary ligament was then taken down with electrocautery. The major fissure was then taken down and arteries identified. The artery was dissected free and it was divided with an Endo GIA stapler. The vein was then dissected free and divided with an Endo GIA stapler. The bronchus was then cleaned of all nodal tissue. A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.
Then the lobe was removed and sent to pathology where margins were found to be free of tumor. Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen. Hemostasis noted. Posterior 28-French and anterior 24-French chest tubes were placed.
The wounds were closed with #2 Vicryl. A subcutaneous drain was placed. Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.
OPERATIVE PROCEDURE IN DETAIL: The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The left chest and back were prepped and draped in a sterile fashion. A right lateral thoracotomy incision was made. Subcutaneous flaps were raised. The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly. The posterior border of the pectoralis was freed up and it was retracted anteriorly. The 5th intercostal space was entered.
The inferior pulmonary ligament was then taken down with electrocautery. The major fissure was then taken down and arteries identified. The artery was dissected free and it was divided with an Endo GIA stapler. The vein was then dissected free and divided with an Endo GIA stapler. The bronchus was then cleaned of all nodal tissue. A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.
Then the lobe was removed and sent to pathology where margins were found to be free of tumor. Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen. Hemostasis noted. Posterior 28-French and anterior 24-French chest tubes were placed.
The wounds were closed with #2 Vicryl. A subcutaneous drain was placed. Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.
Description: VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.
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PREOPERATIVE DIAGNOSIS: Right middle lobe lung cancer.
POSTOPERATIVE DIAGNOSIS: Right middle lobe lung cancer.
PROCEDURES PERFORMED:
1. VATS right middle lobectomy.
2. Fiberoptic bronchoscopy thus before and after the procedure.
3. Mediastinal lymph node sampling including levels 4R and 7.
4. Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.
5. Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.
ANESTHESIA: General endotracheal anesthesia with double-lumen endotracheal tube.
DISPOSITION OF SPECIMENS: To pathology both for frozen and permanent analysis.
FINDINGS: The right middle lobe tumor was adherent to the anterior chest wall. The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. The final frozen pathology on this entire area returned as negative for tumor. Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. Several other biopsies were taken and sent for permanent analysis of the chest wall. All of the biopsy sites were additionally marked with Hemoclips. The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.
ESTIMATED BLOOD LOSS: Less than 100 mL.
CONDITION OF THE PATIENT AFTER SURGERY: Stable.
HISTORY OF PROCEDURE: This patient is well known to our service. He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident. Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. Sterile DuraPrep preparation on the right chest was placed. A sterile drape around that was also placed. The table was flexed to open up the intercostal spaces. A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. Marcaine was infused into all incision areas prior to making an incision. The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. All of these incisions were eventually created during the procedure. The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. The right middle lobe was noted to be adherent to the anterior chest wall. This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler. Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. This was encircled and divided with a blue load stapler with a 45-mm EndoGIA. Following division of this, the pulmonary artery was easily identified. Two branches of the pulmonary artery were noted to be going into the right middle lobe. These were individually divided with a vascular load after encircling with a right angle clamp. The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. This was divided with a blue load stapler 45 mm EndoGIA. Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port. Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package. Node station 8 or 9 nodes were easily identified, therefore none were taken. The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position. Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion. The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.
POSTOPERATIVE DIAGNOSIS: Right middle lobe lung cancer.
PROCEDURES PERFORMED:
1. VATS right middle lobectomy.
2. Fiberoptic bronchoscopy thus before and after the procedure.
3. Mediastinal lymph node sampling including levels 4R and 7.
4. Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.
5. Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.
ANESTHESIA: General endotracheal anesthesia with double-lumen endotracheal tube.
DISPOSITION OF SPECIMENS: To pathology both for frozen and permanent analysis.
FINDINGS: The right middle lobe tumor was adherent to the anterior chest wall. The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. The final frozen pathology on this entire area returned as negative for tumor. Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. Several other biopsies were taken and sent for permanent analysis of the chest wall. All of the biopsy sites were additionally marked with Hemoclips. The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.
ESTIMATED BLOOD LOSS: Less than 100 mL.
CONDITION OF THE PATIENT AFTER SURGERY: Stable.
HISTORY OF PROCEDURE: This patient is well known to our service. He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident. Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. Sterile DuraPrep preparation on the right chest was placed. A sterile drape around that was also placed. The table was flexed to open up the intercostal spaces. A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. Marcaine was infused into all incision areas prior to making an incision. The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. All of these incisions were eventually created during the procedure. The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. The right middle lobe was noted to be adherent to the anterior chest wall. This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler. Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. This was encircled and divided with a blue load stapler with a 45-mm EndoGIA. Following division of this, the pulmonary artery was easily identified. Two branches of the pulmonary artery were noted to be going into the right middle lobe. These were individually divided with a vascular load after encircling with a right angle clamp. The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. This was divided with a blue load stapler 45 mm EndoGIA. Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port. Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package. Node station 8 or 9 nodes were easily identified, therefore none were taken. The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position. Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion. The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.
Description: Right upper lung lobectomy. Mediastinal lymph node dissection
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OPERATION
1. Right upper lung lobectomy.
2. Mediastinal lymph node dissection.
ANESTHESIA
1. General endotracheal anesthesia with dual-lumen tube.
2. Thoracic epidural.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery. The 5th rib was counted, and the 6th interspace was entered. The lung was deflated. We identified the major fissure. We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery. Next, we used Bovie electrocautery to dissect the pleura off the lung. The pulmonary artery branches to the right upper lobe of the lung were identified. Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. This was done with suture ligature in combination with clips. After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. This likewise was ligated with a 0 silk. It was stick-tied with a 2-0 silk. It was then divided. Next we dissected out the bronchial branch to the right upper lobe of the lung. A curved Glover was placed around the bronchus. Next a TA-30 stapler was fired across the bronchus. The bronchus was divided with a #10-blade scalpel. The specimen was handed off. We next performed a mediastinal lymph node dissection. Clips were applied to the base of the feeding vessels to the lymph nodes. We inspected for any signs of bleeding. There was minimal bleeding. We placed a #32-French anterior chest tube, and a #32-French posterior chest tube. The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap. The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the PACU in good condition.
1. Right upper lung lobectomy.
2. Mediastinal lymph node dissection.
ANESTHESIA
1. General endotracheal anesthesia with dual-lumen tube.
2. Thoracic epidural.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery. The 5th rib was counted, and the 6th interspace was entered. The lung was deflated. We identified the major fissure. We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery. Next, we used Bovie electrocautery to dissect the pleura off the lung. The pulmonary artery branches to the right upper lobe of the lung were identified. Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. This was done with suture ligature in combination with clips. After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. This likewise was ligated with a 0 silk. It was stick-tied with a 2-0 silk. It was then divided. Next we dissected out the bronchial branch to the right upper lobe of the lung. A curved Glover was placed around the bronchus. Next a TA-30 stapler was fired across the bronchus. The bronchus was divided with a #10-blade scalpel. The specimen was handed off. We next performed a mediastinal lymph node dissection. Clips were applied to the base of the feeding vessels to the lymph nodes. We inspected for any signs of bleeding. There was minimal bleeding. We placed a #32-French anterior chest tube, and a #32-French posterior chest tube. The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap. The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the PACU in good condition.
Description: Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.
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PREOPERATIVE DIAGNOSIS: Right lower lobe mass, possible cancer.
POSTOPERATIVE DIAGNOSIS: Non-small cell carcinoma of the right lower lobe.
PROCEDURES:
1. Right thoracotomy.
2. Extensive lysis of adhesions.
3. Right lower lobectomy.
4. Mediastinal lymphadenectomy.
ANESTHESIA: General.
DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating room and placed on the operating table in the supine position. After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion. Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue. The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly. The chest was entered through the fifth intercostal space. A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection. The right lower lobe was identified. There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not. Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe. Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected. The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected. Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected. The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis. The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free. The mediastinum was then explored. No nodes were identified around the pulmonary ligament or around the esophagus. Subcarinal nodes were dissected, and hemostasis was obtained with clips. The space below and above the osseous was opened, and the station R4 nodes were dissected. Hemostasis was obtained with clips and with electrocautery. All nodal tissue were sent to Pathology as permanent specimen. Following this, the chest was thoroughly irrigated and aspirated. Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures. Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches. The incision was then closed with interrupted #2-0 Vicryl pericostal stitches. A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin. A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.
ESTIMATED BLOOD LOSS: 100 mL.
TRANSFUSIONS: None.
COMPLICATIONS: None.
CONDITION: Condition of the patient on arrival to the intensive care unit was satisfactory.
POSTOPERATIVE DIAGNOSIS: Non-small cell carcinoma of the right lower lobe.
PROCEDURES:
1. Right thoracotomy.
2. Extensive lysis of adhesions.
3. Right lower lobectomy.
4. Mediastinal lymphadenectomy.
ANESTHESIA: General.
DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating room and placed on the operating table in the supine position. After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion. Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue. The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly. The chest was entered through the fifth intercostal space. A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection. The right lower lobe was identified. There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not. Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe. Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected. The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected. Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected. The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis. The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free. The mediastinum was then explored. No nodes were identified around the pulmonary ligament or around the esophagus. Subcarinal nodes were dissected, and hemostasis was obtained with clips. The space below and above the osseous was opened, and the station R4 nodes were dissected. Hemostasis was obtained with clips and with electrocautery. All nodal tissue were sent to Pathology as permanent specimen. Following this, the chest was thoroughly irrigated and aspirated. Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures. Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches. The incision was then closed with interrupted #2-0 Vicryl pericostal stitches. A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin. A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.
ESTIMATED BLOOD LOSS: 100 mL.
TRANSFUSIONS: None.
COMPLICATIONS: None.
CONDITION: Condition of the patient on arrival to the intensive care unit was satisfactory.
Description: Lower Extremity Arterial Doppler
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RIGHT LOWER EXTREMITY: The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.
LEFT LOWER EXTREMITY: The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery. Ankle brachial index of 0.9.
IMPRESSION: Mild bilateral lower extremity arterial obstructive disease.
LEFT LOWER EXTREMITY: The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery. Ankle brachial index of 0.9.
IMPRESSION: Mild bilateral lower extremity arterial obstructive disease.
Description: Left lower extremity venous Doppler ultrasound
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LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND
REASON FOR EXAM: Status post delivery five weeks ago presenting with left calf pain.
INTERPRETATIONS: There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins. Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.
IMPRESSION: Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.
REASON FOR EXAM: Status post delivery five weeks ago presenting with left calf pain.
INTERPRETATIONS: There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins. Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.
IMPRESSION: Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.
Description: Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".
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CLINICAL HISTORY: Probable right upper lobe lung adenocarcinoma.
SPECIMEN: Lung, right upper lobe resection.
GROSS DESCRIPTION: Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung". It consists of one lobectomy specimen measuring 16.1 x 10.6 x
4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.
FINAL DIAGNOSIS: Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type
COMMENT: Right upper lobe, lobectomy.
Tumor type: Bronchioloalveolar carcinoma, mucinous type.
Histologic grade: Well differentiated.
Tumor size (greatest diameter): 3.6 cm.
Blood/lymphatic vessel invasion: Absent.
Perineural invasion: Absent.
Bronchial margin: Negative.
Vascular margin: Negative.
Inked surgical margin: Negative.
Visceral pleura: Not involved.
In situ carcinoma: Absent.
Non-neoplastic lung: Emphysema.
Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.
P53 immunohistochemical stain is negative in the tumor.
SPECIMEN: Lung, right upper lobe resection.
GROSS DESCRIPTION: Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung". It consists of one lobectomy specimen measuring 16.1 x 10.6 x
4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.
FINAL DIAGNOSIS: Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type
COMMENT: Right upper lobe, lobectomy.
Tumor type: Bronchioloalveolar carcinoma, mucinous type.
Histologic grade: Well differentiated.
Tumor size (greatest diameter): 3.6 cm.
Blood/lymphatic vessel invasion: Absent.
Perineural invasion: Absent.
Bronchial margin: Negative.
Vascular margin: Negative.
Inked surgical margin: Negative.
Visceral pleura: Not involved.
In situ carcinoma: Absent.
Non-neoplastic lung: Emphysema.
Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.
P53 immunohistochemical stain is negative in the tumor.
Description: Patient is here to discuss possible open lung biopsy.
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CHART NOTE: She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow. Dr. XYZ had seen her because of her complaints of shortness of breath. Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep. He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy. She was ready to go ahead with this and felt that it was important she find out why she is short of breath. She is very concerned about the findings on her CAT scan and pulmonary function test. She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal. However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function. And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time. After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy. In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed. I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those. And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.
I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it. I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests. And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy. But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her. She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.
We are going to see her back in a month to see how her breathing is doing. We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time. I told her I would try to talk to her sister sometime in the next day or two.
I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it. I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests. And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy. But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her. She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.
We are going to see her back in a month to see how her breathing is doing. We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time. I told her I would try to talk to her sister sometime in the next day or two.
Description: Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.
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CLINICAL HISTORY: A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter. The patient was referred for surgical treatment.
SPECIMEN:
A. Lung, wedge biopsy right lower lobe
B. Lung, resection right upper lobe
C. Lymph node, biopsy level 2 and 4
D. Lymph node, biopsy level 7 subcarinal
FINAL DIAGNOSIS:
A. Wedge biopsy of right lower lobe showing: Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.
B. Right upper lobe lung resection showing: Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin. Two (2) hilar lymph nodes with no metastatic tumor.
C. Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.
D. Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.
COMMENT: The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe. This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces. Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule. The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.
SPECIMEN:
A. Lung, wedge biopsy right lower lobe
B. Lung, resection right upper lobe
C. Lymph node, biopsy level 2 and 4
D. Lymph node, biopsy level 7 subcarinal
FINAL DIAGNOSIS:
A. Wedge biopsy of right lower lobe showing: Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.
B. Right upper lobe lung resection showing: Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin. Two (2) hilar lymph nodes with no metastatic tumor.
C. Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.
D. Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.
COMMENT: The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe. This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces. Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule. The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.
Description: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.
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GROSS DESCRIPTION:
A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an
8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x
0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.
B. Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.
C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x
14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.
D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.
E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a
2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .
FINAL DIAGNOSIS:
A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.
B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.
C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma
(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.
D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.
E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.
COMMENTS: Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.
A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an
8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x
0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.
B. Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.
C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x
14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.
D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.
E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a
2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .
FINAL DIAGNOSIS:
A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.
B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.
C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma
(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.
D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.
E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.
COMMENTS: Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.
Description: Resting Myoview and adenosine Myoview SPECT
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PROCEDURE DONE: Resting Myoview and adenosine Myoview SPECT.
INDICATIONS: Chest pain.
PROCEDURE: 13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained. Pharmacologic stress testing was done using adenosine infusion. Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes. Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected. Resting heart rate was 90 beats per minute. Resting blood pressure was 130/70. Peak heart rate obtained during adenosine infusion was 102 beats per minute. Blood pressure obtained during adenosine infusion was 112/70. During adenosine infusion, patient experienced dizziness and shortness of breath. No significant ST segment, T wave changes, or arrhythmias were seen.
Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect. Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium. Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%. Lung heart ratio was 0.40. TID ratio was 0.88.
IMPRESSION: Normal adenosine Myoview myocardial perfusion SPECT. Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.
INDICATIONS: Chest pain.
PROCEDURE: 13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained. Pharmacologic stress testing was done using adenosine infusion. Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes. Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected. Resting heart rate was 90 beats per minute. Resting blood pressure was 130/70. Peak heart rate obtained during adenosine infusion was 102 beats per minute. Blood pressure obtained during adenosine infusion was 112/70. During adenosine infusion, patient experienced dizziness and shortness of breath. No significant ST segment, T wave changes, or arrhythmias were seen.
Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect. Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium. Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%. Lung heart ratio was 0.40. TID ratio was 0.88.
IMPRESSION: Normal adenosine Myoview myocardial perfusion SPECT. Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.
Description: Myoview nuclear stress study. Angina, coronary artery disease. Large fixed defect, inferior and apical wall, related to old myocardial infarction.
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MYOVIEW NUCLEAR STRESS STUDY
REASON FOR THE TEST: Angina, coronary artery disease.
FINDINGS: The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan. At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.
The data analyzed using Cedars-Sinai software.
The resting heart rate was 49 with the resting blood pressure of 149/86. Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.
EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH. Maximal stress test EKG showed no change from baseline.
IMPRESSION: Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.
MYOVIEW INTERPRETATIONS
FINDINGS: The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall. EF was calculated at 32%, estimated 35% to 40%.
Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall. Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI. No reversible defects indicative of myocardium at risk. The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.
IMPRESSION:
1. Large fixed defect, inferior and apical wall, related to old myocardial infarction.
2. No reversible ischemia identified.
3. Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.
REASON FOR THE TEST: Angina, coronary artery disease.
FINDINGS: The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan. At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.
The data analyzed using Cedars-Sinai software.
The resting heart rate was 49 with the resting blood pressure of 149/86. Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.
EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH. Maximal stress test EKG showed no change from baseline.
IMPRESSION: Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.
MYOVIEW INTERPRETATIONS
FINDINGS: The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall. EF was calculated at 32%, estimated 35% to 40%.
Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall. Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI. No reversible defects indicative of myocardium at risk. The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.
IMPRESSION:
1. Large fixed defect, inferior and apical wall, related to old myocardial infarction.
2. No reversible ischemia identified.
3. Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.
Sample Name: Mayoview - 2
Description: Lexiscan myoview stress study. Chest discomfort. Normal stress/rest cardiac perfusion with no indication of ischemia. Normal LV function and low likelihood of significant epicardial coronary narrowing.
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LEXISCAN MYOVIEW STRESS STUDY
REASON FOR THE EXAM: Chest discomfort.
INTERPRETATION: The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection. At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software. The patient did not walk because of prior history of inability to exercise long enough on treadmill.
The resting heart rate was 57 with the resting blood pressure 143/94. Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.
EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury. Subtle nonspecific in III and aVF were seen. Maximum stress test EKG showed inverted T wave from V4 to V6. Normal response to Lexiscan.
CONCLUSION: Maximal Lexiscan perfusion with subtle abnormalities non-conclusive. Please refer to the Myoview interpretation.
MYOVIEW INTERPRETATION: The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51. EF estimated and calculated at 56%.
Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.
IMPRESSION:
1. Normal stress/rest cardiac perfusion with no indication of ischemia.
2. Normal LV function and low likelihood of significant epicardial coronary narrow
REASON FOR THE EXAM: Chest discomfort.
INTERPRETATION: The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection. At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software. The patient did not walk because of prior history of inability to exercise long enough on treadmill.
The resting heart rate was 57 with the resting blood pressure 143/94. Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.
EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury. Subtle nonspecific in III and aVF were seen. Maximum stress test EKG showed inverted T wave from V4 to V6. Normal response to Lexiscan.
CONCLUSION: Maximal Lexiscan perfusion with subtle abnormalities non-conclusive. Please refer to the Myoview interpretation.
MYOVIEW INTERPRETATION: The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51. EF estimated and calculated at 56%.
Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.
IMPRESSION:
1. Normal stress/rest cardiac perfusion with no indication of ischemia.
2. Normal LV function and low likelihood of significant epicardial coronary narrow
Description: Mediastinal exploration and delayed primary chest closure. The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.
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TITLE OF OPERATION: Mediastinal exploration and delayed primary chest closure.
INDICATION FOR SURGERY: The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass. The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago. She did not meet the criteria for delayed primary chest closure.
PREOP DIAGNOSIS: Open chest status post modified stage I Norwood procedure.
POSTOP DIAGNOSIS: Open chest status post modified stage I Norwood procedure.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
FINDINGS: No evidence of intramediastinal purulence or hematoma. At completion of the procedure no major changes in hemodynamic performance.
DETAILS OF THE PROCEDURE: After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position. Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed. The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed. The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned. Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy. The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires. The subcutaneous tissue and skin were closed in layers. There was no evidence of significant increase in central venous pressure or desaturation. The patient tolerated the procedure well. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.
I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case.
INDICATION FOR SURGERY: The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass. The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago. She did not meet the criteria for delayed primary chest closure.
PREOP DIAGNOSIS: Open chest status post modified stage I Norwood procedure.
POSTOP DIAGNOSIS: Open chest status post modified stage I Norwood procedure.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
FINDINGS: No evidence of intramediastinal purulence or hematoma. At completion of the procedure no major changes in hemodynamic performance.
DETAILS OF THE PROCEDURE: After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position. Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed. The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed. The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned. Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy. The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires. The subcutaneous tissue and skin were closed in layers. There was no evidence of significant increase in central venous pressure or desaturation. The patient tolerated the procedure well. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.
I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case.
Sample Name: Mediastinal Exploration & Right Atrium Repair
Description: The patient had undergone mitral valve repair about seven days ago.
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PREOPERATIVE DIAGNOSES:
1. Cardiac tamponade.
2. Status post mitral valve repair.
POSTOPERATIVE DIAGNOSES:
1. Cardiac tamponade.
2. Status post mitral valve repair.
PROCEDURE PERFORMED: Mediastinal exploration with repair of right atrium.
ANESTHESIA: General endotracheal.
INDICATIONS: The patient had undergone mitral valve repair about seven days ago. He had epicardial pacing wires removed at the bedside. Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic. He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires. He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.
DETAILS OF PROCEDURE: The patient was taken emergently to the operating room and placed supine on the operating room table. His chest was prepped and draped prior to induction under general anesthesia. Incision was made through the previous median sternotomy chest incision. Wires were removed in the usual manner and the sternum was retracted. There were large amounts of dark blood filling the mediastinal chest cavity. Large amounts of clot were also removed from the pericardial well and chest. Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation. This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures. An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis. No other sites of bleeding were identified. The mediastinum was then irrigated with copious amounts of antibiotic saline solution. Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube. The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures. The skin was then closed with a running subcuticular stitch. The patient was then taken to the Intensive Care Unit in a critical but stable condition.
1. Cardiac tamponade.
2. Status post mitral valve repair.
POSTOPERATIVE DIAGNOSES:
1. Cardiac tamponade.
2. Status post mitral valve repair.
PROCEDURE PERFORMED: Mediastinal exploration with repair of right atrium.
ANESTHESIA: General endotracheal.
INDICATIONS: The patient had undergone mitral valve repair about seven days ago. He had epicardial pacing wires removed at the bedside. Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic. He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires. He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.
DETAILS OF PROCEDURE: The patient was taken emergently to the operating room and placed supine on the operating room table. His chest was prepped and draped prior to induction under general anesthesia. Incision was made through the previous median sternotomy chest incision. Wires were removed in the usual manner and the sternum was retracted. There were large amounts of dark blood filling the mediastinal chest cavity. Large amounts of clot were also removed from the pericardial well and chest. Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation. This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures. An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis. No other sites of bleeding were identified. The mediastinum was then irrigated with copious amounts of antibiotic saline solution. Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube. The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures. The skin was then closed with a running subcuticular stitch. The patient was then taken to the Intensive Care Unit in a critical but stable condition.
Sample Name: Mediastinal Mass Resection
Description: Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass.
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PREOPERATIVE DIAGNOSIS: Posterior mediastinal mass with possible neural foraminal involvement.
POSTOPERATIVE DIAGNOSIS: Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).
OPERATION PERFORMED: Left thoracotomy with resection of posterior mediastinal mass.
INDICATIONS FOR PROCEDURE: The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.
POSTOPERATIVE DIAGNOSIS: Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).
OPERATION PERFORMED: Left thoracotomy with resection of posterior mediastinal mass.
INDICATIONS FOR PROCEDURE: The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.
Description: Right pleural effusion and suspected malignant mesothelioma.
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PREOPERATIVE DIAGNOSIS: Right pleural effusion and suspected malignant mesothelioma.
POSTOPERATIVE DIAGNOSIS: Right pleural effusion, suspected malignant mesothelioma.
PROCEDURE: Right VATS pleurodesis and pleural biopsy.
ANESTHESIA: General double-lumen endotracheal.
DESCRIPTION OF FINDINGS: Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.
SPECIMEN: Pleural biopsies for pathology and microbiology.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Crystalloid 1.2 L and 1.9 L of pleural effusion drained.
INDICATIONS: Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma. Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion. The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to the operating room and placed in supine position. A double-lumen endotracheal tube was placed. SCDs were also placed and he was given preoperative Kefzol. The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion. A needle was inserted in the axillary line to determine position of the effusion. At this time, a 10-mm port was placed using the knife and Bovie cautery. The effusion was drained by placing a sucker into this port site. Upon feeling the surface of the pleura, there were multiple firm nodules. An additional anterior port was then placed in similar fashion. The effusion was then drained with a sucker. Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura. Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease. This will be worked up with further imaging study later in his hospitalization. After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc. The lungs were then inflated and noted to inflate well. A 32 curved chest tube chest tube was placed and secured with nylon. The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin. The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.
Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.
The counts were correct x2 at the end of the case.
POSTOPERATIVE DIAGNOSIS: Right pleural effusion, suspected malignant mesothelioma.
PROCEDURE: Right VATS pleurodesis and pleural biopsy.
ANESTHESIA: General double-lumen endotracheal.
DESCRIPTION OF FINDINGS: Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.
SPECIMEN: Pleural biopsies for pathology and microbiology.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Crystalloid 1.2 L and 1.9 L of pleural effusion drained.
INDICATIONS: Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma. Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion. The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to the operating room and placed in supine position. A double-lumen endotracheal tube was placed. SCDs were also placed and he was given preoperative Kefzol. The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion. A needle was inserted in the axillary line to determine position of the effusion. At this time, a 10-mm port was placed using the knife and Bovie cautery. The effusion was drained by placing a sucker into this port site. Upon feeling the surface of the pleura, there were multiple firm nodules. An additional anterior port was then placed in similar fashion. The effusion was then drained with a sucker. Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura. Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease. This will be worked up with further imaging study later in his hospitalization. After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc. The lungs were then inflated and noted to inflate well. A 32 curved chest tube chest tube was placed and secured with nylon. The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin. The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.
Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.
The counts were correct x2 at the end of the case.
ESTIMATED BLOOD LOSS: Less than 100 mL.
CONDITION OF THE PATIENT AFTER SURGERY: Stable.
HISTORY OF PROCEDURE: The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into. The patient agreed based on the risks and the benefits of the procedure, which were presented to him and was taken to the operating room. A correct time out procedure was performed. The patient was placed into the supine position. He was given general anesthesia, was endotracheally intubated without incident with a double-lumen endotracheal tube. Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double-lumen tube. Following this, the decision was made to proceed with the surgery. The patient was rolled into the right lateral decubitus position with the left side up. All pressure points were padded. The patient had a sterile DuraPrep preparation to the left chest. A sterile drape around that was applied. Also, the patient had Marcaine infused into the incision area. Following this, the patient had a posterolateral thoracotomy incision, which was a muscle-sparing incision with a posterior approach just over the ausculatory triangle. The incision was approximately 10 cm in size. This was created with a 10-blade scalpel. Bovie electrocautery was used to dissect the subcutaneous tissues. The auscultatory triangle was opened. The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly. The muscle was not divided. After the latissimus muscle was retracted anteriorly, the ribs were counted, and the sixth rib was identified. The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears. Following this, the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach. The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions, which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges. The patient tolerated the procedure well without any complications. The largest lesion was the left upper lobe apex lesion, which was possibly multiple lesions, which was taken in one large wedge segment, and this was also adjacent to another area of the wedges. The patient had multiple pleural abnormalities, which were identified on the surface of the lung. These were small white spotty looking lesions and were not confirmed to be tumor implants, but were suspicious to be multiple areas of tumor. Based on this, the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions. Following this, the patient had a 32-French chest tube placed in the anteroapical position. A 19-French Blake was placed in the posterior apical position. The patient had the intercostal space reapproximated with #2-0 Vicryl suture, and the lung was allowed to be re-expanded under direct visualization. Following this, the chest tubes were placed to Pleur-evac suction and the auscultatory triangle was closed with 2-0 Vicryl sutures. The deeper tissue was closed with 3-0 Vicryl suture, and the skin was closed with running 4-0 Monocryl suture in a subcuticular fashion. The patient tolerated the procedure well and had no complications.
Sample Name: Microlaryngoscopy
Description: Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.
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PREOPERATIVE DIAGNOSIS: Airway obstruction secondary to laryngeal subglottic stenosis.
POSTOPERATIVE DIAGNOSIS: Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.
OPERATION PERFORMED: Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.
INDICATIONS FOR SURGERY: The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway. She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation. Endoscopic reevaluation of her tube and nature of the proposed procedure done. Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice. Cardiorespiratory anesthetic results were discussed in length. The patient states she understood and wished to proceed.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted. The patient was then prepared for endoscopy. The Kantor laryngoscope was then inserted. Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions. Larynx was then ***** short epiglottis. Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords. This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable. However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes. The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube. The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed. The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out. Mid and distal trachea were widely patent. Trachea and mainstem bronchi were patent without obvious disease. The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant. This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted. The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.
POSTOPERATIVE DIAGNOSIS: Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.
OPERATION PERFORMED: Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.
INDICATIONS FOR SURGERY: The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway. She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation. Endoscopic reevaluation of her tube and nature of the proposed procedure done. Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice. Cardiorespiratory anesthetic results were discussed in length. The patient states she understood and wished to proceed.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted. The patient was then prepared for endoscopy. The Kantor laryngoscope was then inserted. Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions. Larynx was then ***** short epiglottis. Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords. This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable. However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes. The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube. The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed. The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out. Mid and distal trachea were widely patent. Trachea and mainstem bronchi were patent without obvious disease. The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant. This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted. The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.
Sample Name: Mitral Valve Repair & Annuloplasty
Description: Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band. Posterior leaflet abscess resection.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
OPERATIONS
1. Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.
2. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.
3. Posterior leaflet abscess resection.
ANESTHESIA: General endotracheal anesthesia
TIMES: Aortic cross-clamp time was ** minutes. Cardiopulmonary bypass time total was ** minutes.
PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the patient's chest and legs were prepped and draped in standard surgical fashion. A #10-blade scalpel was used to make a midline median sternotomy incision. Dissection was carried down to the level of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw, and full-dose heparinization was given. Next, the chest retractor was positioned. The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned. We then prepared to place the patient on cardiopulmonary bypass. A 2-0 Ethibond double pursestring was placed in the ascending aorta. Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine. Next, double cannulation with venous cannulas was instituted. A 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our SEC cannula. This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit. Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium. Through this was passed our inferior vena cava cannula. This was likewise connected to the Y connection of our venous cannula portion. We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted. Cardiopulmonary bypass was instituted. Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape. Sondergaard's groove was taken down. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. This was connected appropriately as was the retrograde cardioplegia catheter. Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole. Next a #15-blade scalpel was used to open the left atrium. The left atrium was decompressed with pump sucker. Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view. Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it. The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk. After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel. Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture. This was done so as to reconstruct the posterior annular portion. Prior to doing so, care was taken to remove any debris and abscess-type material. The pledgeted stitch was lowered into place and tied. Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it. This was done without difficulty. The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle. There was noted to be a small amount of central regurgitation. It was felt that this would be corrected with our annuloplasty portion of the procedure. Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion. Care was taken to go from trigone to trigone. Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic. After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band. The suture band was lowered into position and tied in place. We then tested our repair and noted that there was very mild regurgitation. We subsequently removed our self-retaining retractor. We closed our left atriotomy using 4-0 Prolene in a running fashion. This was done without difficulty. We de-aired the heart. We then gave another round of antegrade and retrograde cardioplegia in warm fashion. The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity. We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene. We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin. The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed. We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula. This site was buttressed with a 4-0 Prolene on an SH needle. The patient tolerated the procedure well. We placed a mediastinal #32-French chest tube as well as a right chest Blake drain. The mediastinum was inspected for any signs of bleeding. There were none. We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion. The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
1. Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.
2. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.
3. Posterior leaflet abscess resection.
ANESTHESIA: General endotracheal anesthesia
TIMES: Aortic cross-clamp time was ** minutes. Cardiopulmonary bypass time total was ** minutes.
PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the patient's chest and legs were prepped and draped in standard surgical fashion. A #10-blade scalpel was used to make a midline median sternotomy incision. Dissection was carried down to the level of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw, and full-dose heparinization was given. Next, the chest retractor was positioned. The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned. We then prepared to place the patient on cardiopulmonary bypass. A 2-0 Ethibond double pursestring was placed in the ascending aorta. Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine. Next, double cannulation with venous cannulas was instituted. A 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our SEC cannula. This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit. Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium. Through this was passed our inferior vena cava cannula. This was likewise connected to the Y connection of our venous cannula portion. We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted. Cardiopulmonary bypass was instituted. Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape. Sondergaard's groove was taken down. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. This was connected appropriately as was the retrograde cardioplegia catheter. Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole. Next a #15-blade scalpel was used to open the left atrium. The left atrium was decompressed with pump sucker. Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view. Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it. The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk. After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel. Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture. This was done so as to reconstruct the posterior annular portion. Prior to doing so, care was taken to remove any debris and abscess-type material. The pledgeted stitch was lowered into place and tied. Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it. This was done without difficulty. The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle. There was noted to be a small amount of central regurgitation. It was felt that this would be corrected with our annuloplasty portion of the procedure. Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion. Care was taken to go from trigone to trigone. Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic. After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band. The suture band was lowered into position and tied in place. We then tested our repair and noted that there was very mild regurgitation. We subsequently removed our self-retaining retractor. We closed our left atriotomy using 4-0 Prolene in a running fashion. This was done without difficulty. We de-aired the heart. We then gave another round of antegrade and retrograde cardioplegia in warm fashion. The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity. We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene. We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin. The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed. We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula. This site was buttressed with a 4-0 Prolene on an SH needle. The patient tolerated the procedure well. We placed a mediastinal #32-French chest tube as well as a right chest Blake drain. The mediastinum was inspected for any signs of bleeding. There were none. We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion. The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
Sample Name: MRI of Lung - Adenocarcinoma
Description: MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis.
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CC: Found unresponsive.
HX: 39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with "stiff straight arms" and a "strange breathing pattern." A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.
PMH: 1)Myasthenia Gravis for 15 years, s/p Thymectomy
MEDS: Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS
FHX/SHX: Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.
EXAM: 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.
HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.
COURSE: Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.
In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.
She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.
HX: 39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with "stiff straight arms" and a "strange breathing pattern." A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.
PMH: 1)Myasthenia Gravis for 15 years, s/p Thymectomy
MEDS: Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS
FHX/SHX: Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.
EXAM: 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.
HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.
COURSE: Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.
In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.
She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.
Sample Name: Multiple Stent Placements
Description: Multiple stent placements with Impella circulatory assist device.
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PROCEDURE PERFORMED:
1. Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.
2. PCI of the LAD and left main coronary artery with Impella assist device.
INDICATIONS FOR PROCEDURE: Unstable angina and congestive heart failure with impaired LV function.
TECHNIQUE OF PROCEDURE: After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile manner. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein. Through the arterial sheath, angiography of the right common femoral artery was obtained. Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained. Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique. Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view. Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.
ANGIOGRAPHIC FINDINGS:
1. LV-gram: LVEDP was 15 mmHg. LV ejection fraction 10% to 15% with global hypokinesis. Only anterior wall is contracting. There was no mitral regurgitation. There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.
2. The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated. The left main coronary artery calcified vessel with disease.
2. The left anterior descending artery had an 80% to 90% mid-stenosis. First diagonal branch had a more than 90% stenosis.
3. The circumflex coronary artery had a patent stent.
INTERVENTION: After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery. The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle. The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire. The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min. Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch. The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD. The stent delivery balloon was used to post-dilate the overlapping segment. The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres. At this point, it was noted that the left main had a retrograde dissection. A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery. The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery. Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.
RESULTS: Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained. Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained. Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.
The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability. The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened. From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes. The right common femoral artery and vein sheaths were both sutured in place for further observation. Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.
IMPRESSION:
1. Left ventricular dysfunction with ejection fraction of 10% to 15%.
2. High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.
COMPLICATIONS: None.
The patient tolerated the procedure well with no complications. The estimated blood loss was 200 ml. Estimated dye used was 200 ml of Visipaque. The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.
PLAN:
1. Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.
2. Hydration.
3. The patient will be observed over night for any hemodynamic instability or ischemia. If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.
1. Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.
2. PCI of the LAD and left main coronary artery with Impella assist device.
INDICATIONS FOR PROCEDURE: Unstable angina and congestive heart failure with impaired LV function.
TECHNIQUE OF PROCEDURE: After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile manner. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein. Through the arterial sheath, angiography of the right common femoral artery was obtained. Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained. Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique. Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view. Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.
ANGIOGRAPHIC FINDINGS:
1. LV-gram: LVEDP was 15 mmHg. LV ejection fraction 10% to 15% with global hypokinesis. Only anterior wall is contracting. There was no mitral regurgitation. There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.
2. The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated. The left main coronary artery calcified vessel with disease.
2. The left anterior descending artery had an 80% to 90% mid-stenosis. First diagonal branch had a more than 90% stenosis.
3. The circumflex coronary artery had a patent stent.
INTERVENTION: After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery. The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle. The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire. The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min. Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch. The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD. The stent delivery balloon was used to post-dilate the overlapping segment. The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres. At this point, it was noted that the left main had a retrograde dissection. A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery. The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery. Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.
RESULTS: Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained. Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained. Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.
The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability. The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened. From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes. The right common femoral artery and vein sheaths were both sutured in place for further observation. Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.
IMPRESSION:
1. Left ventricular dysfunction with ejection fraction of 10% to 15%.
2. High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.
COMPLICATIONS: None.
The patient tolerated the procedure well with no complications. The estimated blood loss was 200 ml. Estimated dye used was 200 ml of Visipaque. The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.
PLAN:
1. Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.
2. Hydration.
3. The patient will be observed over night for any hemodynamic instability or ischemia. If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.
Sample Name: Myocardial Perfusion Imaging - 1
Description: Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.
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MEDICATIONS: Plavix, atenolol, Lipitor, and folic acid.
CLINICAL HISTORY: This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.
With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.
PROCEDURE AND INTERPRETATION: The patient exercised for a total of 12 minutes on the standard Bruce protocol. The peak workload was 12.8 METS. The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response. The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90. The test was stopped due to fatigue and leg pain. EKG at rest showed normal sinus rhythm. The peak stress EKG did not reveal any ischemic ST-T wave abnormalities. There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen. At peak, there was no chest pain noted. The test was stopped due to fatigue and left pain. At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.
MYOCARDIAL PERFUSION IMAGING:
1. The overall quality of the scan was good.
2. There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.
3. The left ventricular cavity appeared normal in size.
4. Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis. Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.
CONCLUSIONS:
1. Good exercise tolerance.
2. Less than adequate cardiac stress. The patient was on beta-blocker therapy.
3. No EKG evidence of stress induced ischemia.
4. No chest pain with stress.
5. Mild ventricular bigeminy with exercise.
6. No diagnostic abnormality on the rest and stress myocardial perfusion imaging.
7. Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.
CLINICAL HISTORY: This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.
With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.
PROCEDURE AND INTERPRETATION: The patient exercised for a total of 12 minutes on the standard Bruce protocol. The peak workload was 12.8 METS. The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response. The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90. The test was stopped due to fatigue and leg pain. EKG at rest showed normal sinus rhythm. The peak stress EKG did not reveal any ischemic ST-T wave abnormalities. There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen. At peak, there was no chest pain noted. The test was stopped due to fatigue and left pain. At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.
MYOCARDIAL PERFUSION IMAGING:
1. The overall quality of the scan was good.
2. There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.
3. The left ventricular cavity appeared normal in size.
4. Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis. Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.
CONCLUSIONS:
1. Good exercise tolerance.
2. Less than adequate cardiac stress. The patient was on beta-blocker therapy.
3. No EKG evidence of stress induced ischemia.
4. No chest pain with stress.
5. Mild ventricular bigeminy with exercise.
6. No diagnostic abnormality on the rest and stress myocardial perfusion imaging.
7. Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.
Sample Name: Myocardial Perfusion Imaging - 2
Description: Myocardial perfusion imaging - patient had previous abnormal stress test. Stress test with imaging for further classification of CAD and ischemia.
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CLINICAL HISTORY: This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.
PERTINENT MEDICATIONS: Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.
With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.
PROCEDURE AND INTERPRETATION: The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol. The peak workload was 7 METs. The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response. The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90. EKG at rest showed normal sinus rhythm with a right-bundle branch block. The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery. There were occasional PVCs, but no sustained arrhythmia. The patient had an episode of supraventricular tachycardia at peak stress. The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs. At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.
MYOCARDIAL PERFUSION IMAGING:
1. The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.
2. There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex. This appeared to be partially reversible in the resting images.
3. The left ventricle appeared normal in size.
4. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening. The calculated ejection fraction was 70% at rest.
CONCLUSIONS:
1. Average exercise tolerance.
2. Adequate cardiac stress.
3. Abnormal EKG response to stress, consistent with ischemia. No symptoms of chest pain at rest.
4. Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.
5. The patient had run of SVT at peak stress.
6. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.
PERTINENT MEDICATIONS: Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.
With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.
PROCEDURE AND INTERPRETATION: The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol. The peak workload was 7 METs. The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response. The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90. EKG at rest showed normal sinus rhythm with a right-bundle branch block. The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery. There were occasional PVCs, but no sustained arrhythmia. The patient had an episode of supraventricular tachycardia at peak stress. The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs. At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.
MYOCARDIAL PERFUSION IMAGING:
1. The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.
2. There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex. This appeared to be partially reversible in the resting images.
3. The left ventricle appeared normal in size.
4. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening. The calculated ejection fraction was 70% at rest.
CONCLUSIONS:
1. Average exercise tolerance.
2. Adequate cardiac stress.
3. Abnormal EKG response to stress, consistent with ischemia. No symptoms of chest pain at rest.
4. Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.
5. The patient had run of SVT at peak stress.
6. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.
Sample Name: Myocardial Perfusion Imaging - 3
Description: Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.
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DIAGNOSIS: Shortness of breath. Fatigue and weakness. Hypertension. Hyperlipidemia.
INDICATION: To evaluate for coronary artery disease.
TEST: Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.
RADIOPHARMACEUTICAL: Technetium 99m and Tetrofosmin.
DOSE: Dose was 10.8mCi at rest and 30.7mCi at stress intravenous.
DESCRIPTION: Stress test was performed on Bruce protocol for 5 minutes and 3 seconds.
Baseline heart rate was 75 bpm. Maximum heart rate was 98 bpm. The patient did not achieve submax target heart rate. Stress test was nondiagnostic for ischemia.
Blood pressure response was flat during the stress test. Resting blood pressure was 138/78 reaching 130/80 at peak exercise. The patient did not experience chest pain during exercise or post exercise. Resting EKG shows normal sinus rhythm with anteroseptal wall myocardial infarction, age undetermined, and nonspecific ST-T changes. Nonspecific ST-T changes at post exercise. The EKG did not show ST segment changes diagnostic for ischemia. The patient had myocardial perfusion imaging performed using Technetium 99m and Tetrofosmin, 10.8mCi at rest and 30.7mCi at peak exercise. Imaging was performed using tomographic technique.
FINDING: The left ventricle was normal in size. There was no myocardial perfusion defect noted.
Resting gated SPECT wall motion study reveals normal left ventricular wall motion with ejection fraction of 77%.
Regional wall motion was normal.
IMPRESSION:
1. Normal myocardial perfusion study.
2. Normal response to exercise.
3. Normal left ventricular wall motion with ejection fraction of 77%.
4. Resting right ventricular function was normal.
INDICATION: To evaluate for coronary artery disease.
TEST: Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.
RADIOPHARMACEUTICAL: Technetium 99m and Tetrofosmin.
DOSE: Dose was 10.8mCi at rest and 30.7mCi at stress intravenous.
DESCRIPTION: Stress test was performed on Bruce protocol for 5 minutes and 3 seconds.
Baseline heart rate was 75 bpm. Maximum heart rate was 98 bpm. The patient did not achieve submax target heart rate. Stress test was nondiagnostic for ischemia.
Blood pressure response was flat during the stress test. Resting blood pressure was 138/78 reaching 130/80 at peak exercise. The patient did not experience chest pain during exercise or post exercise. Resting EKG shows normal sinus rhythm with anteroseptal wall myocardial infarction, age undetermined, and nonspecific ST-T changes. Nonspecific ST-T changes at post exercise. The EKG did not show ST segment changes diagnostic for ischemia. The patient had myocardial perfusion imaging performed using Technetium 99m and Tetrofosmin, 10.8mCi at rest and 30.7mCi at peak exercise. Imaging was performed using tomographic technique.
FINDING: The left ventricle was normal in size. There was no myocardial perfusion defect noted.
Resting gated SPECT wall motion study reveals normal left ventricular wall motion with ejection fraction of 77%.
Regional wall motion was normal.
IMPRESSION:
1. Normal myocardial perfusion study.
2. Normal response to exercise.
3. Normal left ventricular wall motion with ejection fraction of 77%.
4. Resting right ventricular function was normal.
Sample Name: Myoview Perfusion Scan
Description: Resting Myoview perfusion scan and gated myocardial scan. Findings consistent with an inferior non-transmural scar
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INDICATIONS: Previously markedly abnormal dobutamine Myoview stress test and gated scan.
PROCEDURE DONE: Resting Myoview perfusion scan and gated myocardial scan.
MYOCARDIAL PERFUSION IMAGING: Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview. Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY. The lung heart ratio is 0.34. There appears to be a moderate size inferoapical perfusion defect of moderate degree. The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.
CONCLUSIONS: Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree. The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY. We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.
PROCEDURE DONE: Resting Myoview perfusion scan and gated myocardial scan.
MYOCARDIAL PERFUSION IMAGING: Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview. Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY. The lung heart ratio is 0.34. There appears to be a moderate size inferoapical perfusion defect of moderate degree. The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.
CONCLUSIONS: Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree. The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY. We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.
Sample Name: Nuclear Cardiac Stress Report
Description: Nuclear cardiac stress report. Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.
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NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT
INDICATION FOR STUDY: Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.
PROCEDURE: The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes. At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol. During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion. No diagnostic electrocardiographic abnormalities were elaborated during this study.
REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time. A fixed defect is seen in the high anterolateral segment. A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum. There is no evidence for active ischemia in either distribution. Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity. When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall. A limited segment of apical myocardium is still viable.
No gated wall motion study was obtained.
CONCLUSIONS: Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above. There is no indication for active ischemia at this time.
INDICATION FOR STUDY: Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.
PROCEDURE: The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes. At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol. During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion. No diagnostic electrocardiographic abnormalities were elaborated during this study.
REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time. A fixed defect is seen in the high anterolateral segment. A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum. There is no evidence for active ischemia in either distribution. Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity. When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall. A limited segment of apical myocardium is still viable.
No gated wall motion study was obtained.
CONCLUSIONS: Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above. There is no indication for active ischemia at this time.
Sample Name: Pacemaker - DDDR
Description: DDDR permanent pacemaker. Tachybrady syndrome. A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.
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PROCEDURE PERFORMED: DDDR permanent pacemaker.
INDICATION: Tachybrady syndrome.
PROCEDURE: After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein. A steel guidewire was inserted through the needle into the vascular lumen without resistance. The needle was then removed over the guidewire and the guidewire was secured to the field. A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. A #11-knife blade was used to make a deeper incision. Hemostasis was made complete. The edges of the incision were grasped and retracted. Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. Metzenbaum scissors were then used to dissect cephalad to expose the guide wires. The guidewires were then pulled through the pacemaker pocket. One guidewire was secured to the field.
A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. The guidewire and dilator were then removed. Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. The pacemaker lead was then placed in the appropriate position in the right ventricle. Pacing and sensing thresholds were obtained. The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. Pacing and sensing threshold were then reconfirmed. Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. The guidewire and dilator were then removed. Under fluoroscopic guidance, the atrial lead was passed into the right atrium. The sheath was then turned away in standard fashion. Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. Pacing and sensing thresholds were obtained. The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. Sensing and pacing thresholds were then reconfirmed. The leads were wiped free of blood and placed into the pacemaker generator. The pacemaker generator leads were then placed into pocket with the leads posteriorly. The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion. A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. Steri-Strips overlaid. A sterile gauge dressing was placed over the site. The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.
PACEMAKER DATA (GENERATOR DATA):
Manufacturer: Medtronics.
Model: Sigma.
Model #: SDR203B.
Serial #: 123456789.
LEAD INFORMATION:
Right Atrial Lead:
Manufacturer: Medtronics.
Model #: 4568.
Serial #: 123456789.
VENTRICULAR LEAD:
Manufacturer: Medtronics.
Model #: 509252.
Serial #: 123456789.
PACING AND SENSING THRESHOLDS:
Right Atrial Bipolar Lead: Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.
Ventricular Bipolar Lead: Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.
PARAMETER SETTINGS: Pacing mode DDDR: Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.
IMPRESSION: Successful implantation of DDDR permanent pacemaker.
PLAN:
1. The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.
2. The patient will be placed on antibiotics for five days to avoid pacemaker infection.
INDICATION: Tachybrady syndrome.
PROCEDURE: After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein. A steel guidewire was inserted through the needle into the vascular lumen without resistance. The needle was then removed over the guidewire and the guidewire was secured to the field. A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. A #11-knife blade was used to make a deeper incision. Hemostasis was made complete. The edges of the incision were grasped and retracted. Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. Metzenbaum scissors were then used to dissect cephalad to expose the guide wires. The guidewires were then pulled through the pacemaker pocket. One guidewire was secured to the field.
A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. The guidewire and dilator were then removed. Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. The pacemaker lead was then placed in the appropriate position in the right ventricle. Pacing and sensing thresholds were obtained. The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. Pacing and sensing threshold were then reconfirmed. Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. The guidewire and dilator were then removed. Under fluoroscopic guidance, the atrial lead was passed into the right atrium. The sheath was then turned away in standard fashion. Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. Pacing and sensing thresholds were obtained. The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. Sensing and pacing thresholds were then reconfirmed. The leads were wiped free of blood and placed into the pacemaker generator. The pacemaker generator leads were then placed into pocket with the leads posteriorly. The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion. A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. Steri-Strips overlaid. A sterile gauge dressing was placed over the site. The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.
PACEMAKER DATA (GENERATOR DATA):
Manufacturer: Medtronics.
Model: Sigma.
Model #: SDR203B.
Serial #: 123456789.
LEAD INFORMATION:
Right Atrial Lead:
Manufacturer: Medtronics.
Model #: 4568.
Serial #: 123456789.
VENTRICULAR LEAD:
Manufacturer: Medtronics.
Model #: 509252.
Serial #: 123456789.
PACING AND SENSING THRESHOLDS:
Right Atrial Bipolar Lead: Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.
Ventricular Bipolar Lead: Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.
PARAMETER SETTINGS: Pacing mode DDDR: Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.
IMPRESSION: Successful implantation of DDDR permanent pacemaker.
PLAN:
1. The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.
2. The patient will be placed on antibiotics for five days to avoid pacemaker infection.
Sample Name: Pacemaker (Dual Chamber)
Description: Implantation of a dual chamber permanent pacemaker
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CLINICAL HISTORY: This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.
PROCEDURE: Implantation of a dual chamber permanent pacemaker.
APPROACH: Left cephalic vein.
LEADS IMPLANTED: Medtronic model 5076-45 in the right atrium, serial number PJN983322V. Medtronic 5076-52 in the right ventricle, serial number PJN961008V.
DEVICE IMPLANTED: Medtronic EnRhythm model P1501VR, serial number PNP422256H.
LEAD PERFORMANCE: Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.
ESTIMATED BLOOD LOSS: 20 mL.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.
IMPRESSION: Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.
PROCEDURE: Implantation of a dual chamber permanent pacemaker.
APPROACH: Left cephalic vein.
LEADS IMPLANTED: Medtronic model 5076-45 in the right atrium, serial number PJN983322V. Medtronic 5076-52 in the right ventricle, serial number PJN961008V.
DEVICE IMPLANTED: Medtronic EnRhythm model P1501VR, serial number PNP422256H.
LEAD PERFORMANCE: Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.
ESTIMATED BLOOD LOSS: 20 mL.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.
IMPRESSION: Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.
Sample Name: Pacemaker (Dual Chamber) - 1
Description: Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.
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PREPROCEDURE DIAGNOSIS: Complete heart block.
POSTPROCEDURE DIAGNOSIS: Complete heart block.
PROCEDURES PLANNED AND PERFORMED
1. Implantation of a dual-chamber pacemaker.
2. Fluoroscopic guidance for implantation of a dual-chamber pacemaker.
FLUOROSCOPY TIME: 2.6 minutes.
MEDICATIONS AT THE TIME OF STUDY
1. Versed 2.5 mg.
2. Fentanyl 150 mcg.
3. Benadryl 50 mg.
CLINICAL HISTORY: the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. She has been referred for a pacemaker implantation.
RISKS AND BENEFITS: Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent.
DESCRIPTION OF PROCEDURE: The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. A guide wire was advanced into the vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision. A pocket was then fashioned in the medial direction. Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein. The dilator was then removed over the wire. A second wire was then advanced into the sheath into the left axillary vein. The sheath was then removed over the top of the two wires. One wire was then pinned to the drape. Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein. The dilator and wire were removed. A passive pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical location. Adequate pacing and sensing functions were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein. The wire and dilating sheaths were removed. An active pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. Preformed J stylet was then advanced into the lead. The lead was positioned in the appendage location. Lead body was then turned, and the active fix screw was fixed to the tissue. Adequate pacing and sensing function were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.
DEVICE DATA
1. Pulse generator, manufacturer Boston Scientific, model # SSNCRF403, serial #1234.
2. Right atrial lead, manufacturer Guidant, model #4469, serial #1234.
3. Right ventricular lead, manufacturer Guidant, model #4457, serial #1234.
MEASURED INTRAOPERATIVE DATA
1. Right atrial lead impedance 534 ohms. P waves measured at 1.2 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.
2. Right ventricular lead impedance 900 ohms. R-waves measured 6.0 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.
DEVICE SETTINGS: DDD 60 to 130.
CONCLUSIONS
1. Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.
2. No acute complications.
PLAN
1. The patient will be taken back to her room for continued observation. She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.
2. Chest x-ray to rule out pneumothorax and verified lead position.
3. Completion of the course of antibiotics.
4. Home dismissal instructions provided in written format.
5. Device interrogation in the morning.
6. Wound check in 7 to 10 days.
7. Enrollment in device clinic.
POSTPROCEDURE DIAGNOSIS: Complete heart block.
PROCEDURES PLANNED AND PERFORMED
1. Implantation of a dual-chamber pacemaker.
2. Fluoroscopic guidance for implantation of a dual-chamber pacemaker.
FLUOROSCOPY TIME: 2.6 minutes.
MEDICATIONS AT THE TIME OF STUDY
1. Versed 2.5 mg.
2. Fentanyl 150 mcg.
3. Benadryl 50 mg.
CLINICAL HISTORY: the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. She has been referred for a pacemaker implantation.
RISKS AND BENEFITS: Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent.
DESCRIPTION OF PROCEDURE: The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. A guide wire was advanced into the vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision. A pocket was then fashioned in the medial direction. Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein. The dilator was then removed over the wire. A second wire was then advanced into the sheath into the left axillary vein. The sheath was then removed over the top of the two wires. One wire was then pinned to the drape. Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein. The dilator and wire were removed. A passive pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical location. Adequate pacing and sensing functions were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein. The wire and dilating sheaths were removed. An active pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. Preformed J stylet was then advanced into the lead. The lead was positioned in the appendage location. Lead body was then turned, and the active fix screw was fixed to the tissue. Adequate pacing and sensing function were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.
DEVICE DATA
1. Pulse generator, manufacturer Boston Scientific, model # SSNCRF403, serial #1234.
2. Right atrial lead, manufacturer Guidant, model #4469, serial #1234.
3. Right ventricular lead, manufacturer Guidant, model #4457, serial #1234.
MEASURED INTRAOPERATIVE DATA
1. Right atrial lead impedance 534 ohms. P waves measured at 1.2 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.
2. Right ventricular lead impedance 900 ohms. R-waves measured 6.0 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.
DEVICE SETTINGS: DDD 60 to 130.
CONCLUSIONS
1. Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.
2. No acute complications.
PLAN
1. The patient will be taken back to her room for continued observation. She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.
2. Chest x-ray to rule out pneumothorax and verified lead position.
3. Completion of the course of antibiotics.
4. Home dismissal instructions provided in written format.
5. Device interrogation in the morning.
6. Wound check in 7 to 10 days.
7. Enrollment in device clinic.
Sample Name: Pacemaker (Single Chamber)
Description: Single chamber pacemaker implantation. Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.
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(Medical Transcription Sample Report)
SINGLE CHAMBER PACEMAKER IMPLANTATION
PREOPERATIVE DIAGNOSIS: Mobitz type II block with AV dissociation and syncope.
POSTOPERATIVE DIAGNOSIS: Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.
PROCEDURES:
1. Left subclavian access under fluoroscopic guidance.
2. Left subclavian venogram under fluoroscopic evaluation.
3. Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 4136, serial number 123456.
4. Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.
5. Closure of the pocket after formation of pocket for pacemaker.
PROCEDURE IN DETAIL: The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.
Access to the right subclavian was successful after the second attempt. The first attempt accessed the left subclavian artery. The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully. The J-wire was introduced into the left subclavian vein.
The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.
The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis. The patient went asystole during the procedure. The transcutaneous pacer was used. The patient was oxygenating well. The patient had several compression applied by the nurse. However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.
After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein. The lead from the Boston Scientific Dextrose model 4136, serial number 28520361 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium. The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different. At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.
At that point, the lead was actively fixated. The stylet was removed. The R-wave measured at 40 millivolts. The impedance was 580 and the threshold was 1.3 volt. The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high. I decided to proceed with a single-chamber pacemaker as a backup system.
After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.
The lead was attached to the pacemaker in the header. The pacemaker was single-chamber pacemaker Altura 60, serial number 123456. After that, the pacemaker was put in the pocket. Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.
The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute. The lead position will be evaluated with chest x-ray.
No significant bleeding noticed.
CONCLUSION: Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure. No significant bleed.
PREOPERATIVE DIAGNOSIS: Mobitz type II block with AV dissociation and syncope.
POSTOPERATIVE DIAGNOSIS: Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.
PROCEDURES:
1. Left subclavian access under fluoroscopic guidance.
2. Left subclavian venogram under fluoroscopic evaluation.
3. Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 4136, serial number 123456.
4. Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.
5. Closure of the pocket after formation of pocket for pacemaker.
PROCEDURE IN DETAIL: The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.
Access to the right subclavian was successful after the second attempt. The first attempt accessed the left subclavian artery. The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully. The J-wire was introduced into the left subclavian vein.
The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.
The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis. The patient went asystole during the procedure. The transcutaneous pacer was used. The patient was oxygenating well. The patient had several compression applied by the nurse. However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.
After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein. The lead from the Boston Scientific Dextrose model 4136, serial number 28520361 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium. The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different. At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.
At that point, the lead was actively fixated. The stylet was removed. The R-wave measured at 40 millivolts. The impedance was 580 and the threshold was 1.3 volt. The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high. I decided to proceed with a single-chamber pacemaker as a backup system.
After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.
The lead was attached to the pacemaker in the header. The pacemaker was single-chamber pacemaker Altura 60, serial number 123456. After that, the pacemaker was put in the pocket. Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.
The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute. The lead position will be evaluated with chest x-ray.
No significant bleeding noticed.
CONCLUSION: Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure. No significant bleed.
Sample Name: Pacemaker (Single Chamber) - 1
Description: Implantation of a single-chamber pacemaker. Fluoroscopic guidance for implantation of single-chamber pacemaker.
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(Medical Transcription Sample Report)
REFERRAL INDICATION
1. Tachybrady syndrome.
2. Chronic atrial fibrillation.
PROCEDURES PLANNED AND PERFORMED
1. Implantation of a single-chamber pacemaker.
2. Fluoroscopic guidance for implantation of single-chamber pacemaker.
FLUOROSCOPY TIME: 1.2 minutes.
MEDICATIONS AT THE TIME OF STUDY
1. Ancef 1 g.
2. Benadryl 50 mg.
3. Versed 3 mg.
4. Fentanyl 150 mcg.
CLINICAL HISTORY: The patient is a pleasant 73-year-old female with chronic atrial fibrillation. She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.
RISKS AND BENEFITS: Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent. Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.
DESCRIPTION OF PROCEDURE: The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. Percutaneous access of the left axillary vein was then performed. A wire was then advanced in the left axillary vein using fluoroscopy. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein. The dilator and wire were removed. An active pacing lead was then advanced down in the right atrium. The peel-away sheath was removed. Lead was passed across the tricuspid valve and positioned in an apical septal location. This was an active fixed lead and the screw was deployed. Adequate pacing and sensing function were established. The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue. The pocket was washed with antibiotic-impregnated saline. A pulse generator was obtained and connected securely to the lead. The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. No acute complications were noted.
DEVICE DATA
1. Pulse generator, manufacturer St. Jude model 5626, serial #123456.
2. Right ventricular lead, manufacturer St. Jude model 1688TC\52, serial #ABCD123456.
MEASURED INTRAOPERATIVE DATA: Right ventricular lead impedance 630 ohms. R wave measures 17.5 mV. Pacing threshold of 0.8 V at 0.5 msec.
DEVICE SETTINGS: VVI 70 to 120.
CONCLUSIONS
1. Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.
2. No acute complications.
PLAN
1. The patient will be admitted for overnight observation and dismissed at the discretion of primary service.
2. Chest x-ray to rule out pneumothorax and verify lead position.
3. Completion of course of antibiotics.
4. Device interrogation in the morning.
5. Home dismissal instructions provided in a written format.
6. Wound check in 7 to 10 days.
7. Enrollment in Device Clinic.
1. Tachybrady syndrome.
2. Chronic atrial fibrillation.
PROCEDURES PLANNED AND PERFORMED
1. Implantation of a single-chamber pacemaker.
2. Fluoroscopic guidance for implantation of single-chamber pacemaker.
FLUOROSCOPY TIME: 1.2 minutes.
MEDICATIONS AT THE TIME OF STUDY
1. Ancef 1 g.
2. Benadryl 50 mg.
3. Versed 3 mg.
4. Fentanyl 150 mcg.
CLINICAL HISTORY: The patient is a pleasant 73-year-old female with chronic atrial fibrillation. She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.
RISKS AND BENEFITS: Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent. Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.
DESCRIPTION OF PROCEDURE: The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. Percutaneous access of the left axillary vein was then performed. A wire was then advanced in the left axillary vein using fluoroscopy. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein. The dilator and wire were removed. An active pacing lead was then advanced down in the right atrium. The peel-away sheath was removed. Lead was passed across the tricuspid valve and positioned in an apical septal location. This was an active fixed lead and the screw was deployed. Adequate pacing and sensing function were established. The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue. The pocket was washed with antibiotic-impregnated saline. A pulse generator was obtained and connected securely to the lead. The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. No acute complications were noted.
DEVICE DATA
1. Pulse generator, manufacturer St. Jude model 5626, serial #123456.
2. Right ventricular lead, manufacturer St. Jude model 1688TC\52, serial #ABCD123456.
MEASURED INTRAOPERATIVE DATA: Right ventricular lead impedance 630 ohms. R wave measures 17.5 mV. Pacing threshold of 0.8 V at 0.5 msec.
DEVICE SETTINGS: VVI 70 to 120.
CONCLUSIONS
1. Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.
2. No acute complications.
PLAN
1. The patient will be admitted for overnight observation and dismissed at the discretion of primary service.
2. Chest x-ray to rule out pneumothorax and verify lead position.
3. Completion of course of antibiotics.
4. Device interrogation in the morning.
5. Home dismissal instructions provided in a written format.
6. Wound check in 7 to 10 days.
7. Enrollment in Device Clinic.
Sample Name: Pacemaker Insertion
Description: Insertion of transvenous pacemaker for tachybrady syndrome
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(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Tachybrady syndrome.
POSTOPERATIVE DIAGNOSIS: Tachybrady syndrome.
OPERATIVE PROCEDURE: Insertion of transvenous pacemaker.
ANESTHESIA: Local
PROCEDURE AND GROSS FINDINGS: The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated. In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava. An introducer was then placed over the wire. The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.
The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples. Sterile dressings were placed, and the patient was returned to the ICU in good condition.
POSTOPERATIVE DIAGNOSIS: Tachybrady syndrome.
OPERATIVE PROCEDURE: Insertion of transvenous pacemaker.
ANESTHESIA: Local
PROCEDURE AND GROSS FINDINGS: The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated. In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava. An introducer was then placed over the wire. The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.
The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples. Sterile dressings were placed, and the patient was returned to the ICU in good condition.
Sample Name: Pacemaker Interrogation
Description: Pacemaker ICD interrogation. Severe nonischemic cardiomyopathy with prior ventricular tachycardia.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROCEDURE NOTE: Pacemaker ICD interrogation.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS, 2207-36 pacemaker.
DIAGNOSIS: Severe nonischemic cardiomyopathy with prior ventricular tachycardia.
FINDINGS: The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec. Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms. The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only. VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2. VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5. The patient is in normal sinus rhythm.
IMPRESSION: Normally functioning pacemaker ICD post implant day number 1.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS, 2207-36 pacemaker.
DIAGNOSIS: Severe nonischemic cardiomyopathy with prior ventricular tachycardia.
FINDINGS: The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec. Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms. The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only. VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2. VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5. The patient is in normal sinus rhythm.
IMPRESSION: Normally functioning pacemaker ICD post implant day number 1.
Sample Name: Pacemaker Lead Placement & Rrevision.
Description: Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead. Right ventricular pacemaker lead placement and lead revision.
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(Medical Transcription Sample Report)
PROCEDURE: Right ventricular pacemaker lead placement and lead revision.
INDICATIONS: Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.
EQUIPMENT: A new lead is a Medtronic model #507652, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1. The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.
ESTIMATED BLOOD LOSS: 5 mL.
PROCEDURE DESCRIPTION: Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine. The patient received a venogram documenting patency of the subclavian vein. Skin incision with blunt and sharp dissection. Electrocautery for hemostasis. The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads. The leads were sequentially checked. Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava. Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture. Pocket was irrigated with antibiotic solution. The pocket was packed with bacitracin-soaked gauze. This was removed during the case and then irrigated once again. The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.
CONCLUSION: Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # C60A1B.
INDICATIONS: Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.
EQUIPMENT: A new lead is a Medtronic model #507652, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1. The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.
ESTIMATED BLOOD LOSS: 5 mL.
PROCEDURE DESCRIPTION: Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine. The patient received a venogram documenting patency of the subclavian vein. Skin incision with blunt and sharp dissection. Electrocautery for hemostasis. The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads. The leads were sequentially checked. Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava. Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture. Pocket was irrigated with antibiotic solution. The pocket was packed with bacitracin-soaked gauze. This was removed during the case and then irrigated once again. The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.
CONCLUSION: Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # C60A1B.
Sample Name: Patent Ductus Arteriosus
Description: Coil embolization of patent ductus arteriosus.
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HISTORY: The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821. An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy. The patient underwent cardiac catheterization for device closure of a ductus arteriosus.
PROCEDURE: After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.
Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. The atrial septum was not probe patent.
Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt. Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.
Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.
Cineangiograms were obtained with injection in the descending aorta.
After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.
DISCUSSION: Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. The left-sided heart was fully saturated. The phasic right-sided and left-sided pressures were normal. The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. The branch pulmonary arteries appeared normal. There is otherwise a normal left aortic arch.
Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. No evidence of residual left-to-right shunt. There is no change in right-sided pressures. There is a slight increase in the left-sided phasic pressures. Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1. Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. There is a trace residual shunt through the center of coil mass.
INITIAL DIAGNOSES: Patent ductus arteriosus.
SURGERIES (INTERVENTIONS): Coil embolization of patent ductus arteriosus.
MANAGEMENT: The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. Further patient care be directed by Dr. X.
PROCEDURE: After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.
Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. The atrial septum was not probe patent.
Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt. Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.
Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.
Cineangiograms were obtained with injection in the descending aorta.
After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.
DISCUSSION: Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. The left-sided heart was fully saturated. The phasic right-sided and left-sided pressures were normal. The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. The branch pulmonary arteries appeared normal. There is otherwise a normal left aortic arch.
Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. No evidence of residual left-to-right shunt. There is no change in right-sided pressures. There is a slight increase in the left-sided phasic pressures. Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1. Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. There is a trace residual shunt through the center of coil mass.
INITIAL DIAGNOSES: Patent ductus arteriosus.
SURGERIES (INTERVENTIONS): Coil embolization of patent ductus arteriosus.
MANAGEMENT: The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. Further patient care be directed by Dr. X.
Sample Name: Patent Ductus Arteriosus Ligation
Description: Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.
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TITLE OF OPERATION: Ligation (clip interruption) of patent ductus arteriosus.
INDICATION FOR SURGERY: This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. She has now been put forward for operative intervention.
PREOP DIAGNOSIS:
1. Patent ductus arteriosus.
2. Severe prematurity.
3. Operative weight less than 4 kg (600 grams).
COMPLICATIONS: None.
FINDINGS: Large patent ductus arteriosus with evidence of pulmonary over circulation. After completion of the procedure, left recurrent laryngeal nerve visualized and preserved. Substantial rise in diastolic blood pressure.
DETAILS OF THE PROCEDURE: After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced. The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed. Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma. The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus. The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion. It was then test occluded and then interrupted with a medium titanium clip. There was preserved pulsatile flow in the descending aorta. The left recurrent laryngeal nerve was identified and preserved. With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers. The skin was closed with a running 6-0 Caprosyn suture. A sterile dressing was placed. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.
I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.
INDICATION FOR SURGERY: This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. She has now been put forward for operative intervention.
PREOP DIAGNOSIS:
1. Patent ductus arteriosus.
2. Severe prematurity.
3. Operative weight less than 4 kg (600 grams).
COMPLICATIONS: None.
FINDINGS: Large patent ductus arteriosus with evidence of pulmonary over circulation. After completion of the procedure, left recurrent laryngeal nerve visualized and preserved. Substantial rise in diastolic blood pressure.
DETAILS OF THE PROCEDURE: After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced. The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed. Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma. The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus. The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion. It was then test occluded and then interrupted with a medium titanium clip. There was preserved pulsatile flow in the descending aorta. The left recurrent laryngeal nerve was identified and preserved. With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers. The skin was closed with a running 6-0 Caprosyn suture. A sterile dressing was placed. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.
I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.
apular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.
The patient and I decided to admit him for a period of observation at least overnight.
He tolerated the procedure well and the postprocedure chest x-ray showed no complications.
The patient and I decided to admit him for a period of observation at least overnight.
He tolerated the procedure well and the postprocedure chest x-ray showed no complications.
Sample Name: Pigtail Catheter Insertion
Description: Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.
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PREOPERATIVE DIAGNOSIS: Left hemothorax, rule out empyema.
POSTOPERATIVE DIAGNOSIS: Left hemothorax rule out empyema.
PROCEDURE: Insertion of a 12-French pigtail catheter in the left pleural space.
PROCEDURE DETAIL: After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.
The patient and I decided to admit him for a period of observation at least overnight.
He tolerated the procedure well and the postprocedure chest x-ray showed no complications.
POSTOPERATIVE DIAGNOSIS: Left hemothorax rule out empyema.
PROCEDURE: Insertion of a 12-French pigtail catheter in the left pleural space.
PROCEDURE DETAIL: After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.
The patient and I decided to admit him for a period of observation at least overnight.
He tolerated the procedure well and the postprocedure chest x-ray showed no complications.
Sample Name: Pleurocentesis
Description: Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.
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PREOPERATIVE DIAGNOSIS: Right pleural effusion with respiratory failure and dyspnea.
POSTOPERATIVE DIAGNOSIS: Right pleural effusion with respiratory failure and dyspnea.
PROCEDURE: Ultrasound-guided right pleurocentesis.
ANESTHESIA: Local with lidocaine.
TECHNIQUE IN DETAIL: After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound. Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right. Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L. The patient tolerated the procedure well. Portable x-ray is pending.
POSTOPERATIVE DIAGNOSIS: Right pleural effusion with respiratory failure and dyspnea.
PROCEDURE: Ultrasound-guided right pleurocentesis.
ANESTHESIA: Local with lidocaine.
TECHNIQUE IN DETAIL: After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound. Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right. Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L. The patient tolerated the procedure well. Portable x-ray is pending.
Sample Name: Pleurodesis
Description: Chest tube talc pleurodesis of the right chest.
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PREOPERATIVE DIAGNOSIS: Large recurrent right pleural effusion.
POSTOPERATIVE DIAGNOSIS: Large recurrent right pleural effusion.
PROCEDURE:
1. Conscious sedation.
2. Chest tube talc pleurodesis of the right chest.
INDICATIONS: The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: Zero.
NARRATIVE: After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning.
POSTOPERATIVE DIAGNOSIS: Large recurrent right pleural effusion.
PROCEDURE:
1. Conscious sedation.
2. Chest tube talc pleurodesis of the right chest.
INDICATIONS: The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: Zero.
NARRATIVE: After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning.
Sample Name: Port-A-Cath Insertion
Description: Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.
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PROCEDURE PERFORMED: Port-A-Cath insertion.
ANESTHESIA: MAC.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
PROCEDURE IN DETAIL: Patient was prepped and draped in sterile fashion. The left subclavian vein was cannulated with a wire. Fluoroscopic confirmation of the wire in appropriate position was performed. Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed. Once the catheter was advanced through the sheath, the sheath was peeled away. Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed. No hemorrhage was identified. The port was in appropriate position with fluoroscopic confirmation. The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch. Dressed with Steri-Strips and 4 x 4's. Port was checked. Had good blood return, flushed readily with heparinized saline.
ANESTHESIA: MAC.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
PROCEDURE IN DETAIL: Patient was prepped and draped in sterile fashion. The left subclavian vein was cannulated with a wire. Fluoroscopic confirmation of the wire in appropriate position was performed. Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed. Once the catheter was advanced through the sheath, the sheath was peeled away. Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed. No hemorrhage was identified. The port was in appropriate position with fluoroscopic confirmation. The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch. Dressed with Steri-Strips and 4 x 4's. Port was checked. Had good blood return, flushed readily with heparinized saline.
Sample Name: Port-A-Cath Insertion - 5
Description: Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.
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PROCEDURES PERFORMED
1. Insertion of subclavian dual-port Port-A-Cath.
2. Surgeon-interpreted fluoroscopy.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the chest was prepped and draped in a standard surgical fashion. A #18-gauge spinal needle was used to aspirate blood from the subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire. The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next a #15-blade scalpel was used to make an incision in the skin. Dissection was carried down to the level of the pectoralis muscle. A pocket was created. A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene. Both ports were flushed. The distal tip was pulled through to the wire exit site with a Kelly clamp. It was cut to the appropriate length. Next a dilator and sheath were threaded over the J wire. The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn. Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty. The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. The wire access site was closed with a 4-0 Monocryl. The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition
1. Insertion of subclavian dual-port Port-A-Cath.
2. Surgeon-interpreted fluoroscopy.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the chest was prepped and draped in a standard surgical fashion. A #18-gauge spinal needle was used to aspirate blood from the subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire. The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next a #15-blade scalpel was used to make an incision in the skin. Dissection was carried down to the level of the pectoralis muscle. A pocket was created. A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene. Both ports were flushed. The distal tip was pulled through to the wire exit site with a Kelly clamp. It was cut to the appropriate length. Next a dilator and sheath were threaded over the J wire. The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn. Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty. The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. The wire access site was closed with a 4-0 Monocryl. The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition
Description: Pulmonary Function Test in a patient with smoking history.
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HISTORY: Smoking history 50-pack years of smoking.
INDICATION: Dyspnea.
PROCEDURE: FVC was 59%. FEV1 was 45%. FEV1/FVC ratio was 52%. The predicted was 67%. FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator. SVC was 91%. Inspiratory capacity was 70%. Residual volume was 225% of its predicted. Total lung capacity was 128%.
IMPRESSION:
1. Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.
2. Probably there is some restrictive element because of fibrosis. The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.
3. Diffusion capacity was not measured. The flow volume loop was consistent with the above.
INDICATION: Dyspnea.
PROCEDURE: FVC was 59%. FEV1 was 45%. FEV1/FVC ratio was 52%. The predicted was 67%. FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator. SVC was 91%. Inspiratory capacity was 70%. Residual volume was 225% of its predicted. Total lung capacity was 128%.
IMPRESSION:
1. Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.
2. Probably there is some restrictive element because of fibrosis. The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.
3. Diffusion capacity was not measured. The flow volume loop was consistent with the above.
Sample Name: Pulmonary Function Test - 2
Description: Pulmonary Function Test to evaluate dyspnea.
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HISTORY: Smoking history zero.
INDICATION: Dyspnea with walking less than 100 yards.
PROCEDURE: FVC was 59%. FEV1 was 61%. FEV1/FVC ratio was 72%. The predicted was 70%. The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement. SVC was 69%. Inspiratory capacity was 71%. Expiratory residual volume was 61%. The TGV was 94%. Residual volume was 113% of its predicted. Total lung capacity was 83%. Diffusion capacity was diminished.
IMPRESSION:
1. Moderate restrictive lung disease.
2. Some reversible small airway obstruction with improvement with bronchodilator.
3. Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.
4. Flow volume loop was consistent with the above and no upper airway obstruction.
INDICATION: Dyspnea with walking less than 100 yards.
PROCEDURE: FVC was 59%. FEV1 was 61%. FEV1/FVC ratio was 72%. The predicted was 70%. The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement. SVC was 69%. Inspiratory capacity was 71%. Expiratory residual volume was 61%. The TGV was 94%. Residual volume was 113% of its predicted. Total lung capacity was 83%. Diffusion capacity was diminished.
IMPRESSION:
1. Moderate restrictive lung disease.
2. Some reversible small airway obstruction with improvement with bronchodilator.
3. Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.
4. Flow volume loop was consistent with the above and no upper airway obstruction.
Sample Name: Pulmonary Function Test - 3
Description: Sample of Pulmonary Function Test
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SPIROMETRY: Spirometry reveals the FVC to be adequate.
FEV1 is also normal at 98% predicted and FVC is 90.5% predicted. FEF25-75% is also within normal limits at 110% predicted. FEV1/FVC ratio is within normal limits at 108% predicted.
After the use of bronchodilator, there is some improvement with 10%. MVV is within normal limits.
LUNG VOLUMES: Shows total lung capacity to be normal. RV as well as RV/TLC ratio they are within normal limits.
DIFFUSION CAPACITY: Shows that after correction for alveolar ventilation, is also normal.
Oxygen Saturation on Room Air: 98%.
FINAL INTERPRETATION: Pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease. There is some improvement after the use bronchodilator. Diffusion capacity is within normal limits. Oxygen saturation on room air is also normal. Clinical correlation will be necessary in this case.
FEV1 is also normal at 98% predicted and FVC is 90.5% predicted. FEF25-75% is also within normal limits at 110% predicted. FEV1/FVC ratio is within normal limits at 108% predicted.
After the use of bronchodilator, there is some improvement with 10%. MVV is within normal limits.
LUNG VOLUMES: Shows total lung capacity to be normal. RV as well as RV/TLC ratio they are within normal limits.
DIFFUSION CAPACITY: Shows that after correction for alveolar ventilation, is also normal.
Oxygen Saturation on Room Air: 98%.
FINAL INTERPRETATION: Pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease. There is some improvement after the use bronchodilator. Diffusion capacity is within normal limits. Oxygen saturation on room air is also normal. Clinical correlation will be necessary in this case.
Sample Name: Pulmonary Function Test - 4
Description: Sample of Pulmonary Function Test
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SPIROMETRY: Spirometry reveals the FVC to be adequate.
FEV1 is also adequate 93% predicted. FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.
After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.
MVV is also normal.
LUNG VOLUMES: Reveal a TLC to be 80% predicted. FRC is mildly decreased and RV is also mildly decreased. RV/TLC ratio is also normal 97% predicted.
DIFFUSION CAPACITY: After correction for alveolar ventilation, is 112% predicted which is normal.
OXYGEN SATURATION ON ROOM AIR: 98%.
FINAL INTERPRETATION: Pulmonary function test shows mild restrictive pulmonary disease. There is no significant obstructive disease present. There is no improvement after the use of bronchodilator and diffusion capacity is normal. Oxygen saturation on room air is also adequate. Clinical correlation will be necessary in this case.
FEV1 is also adequate 93% predicted. FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.
After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.
MVV is also normal.
LUNG VOLUMES: Reveal a TLC to be 80% predicted. FRC is mildly decreased and RV is also mildly decreased. RV/TLC ratio is also normal 97% predicted.
DIFFUSION CAPACITY: After correction for alveolar ventilation, is 112% predicted which is normal.
OXYGEN SATURATION ON ROOM AIR: 98%.
FINAL INTERPRETATION: Pulmonary function test shows mild restrictive pulmonary disease. There is no significant obstructive disease present. There is no improvement after the use of bronchodilator and diffusion capacity is normal. Oxygen saturation on room air is also adequate. Clinical correlation will be necessary in this case.
Sample Name: Radionuclide Stress Test
Description: Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INDICATION FOR STUDY: Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.
MEDICATIONS: Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.
BASELINE EKG: Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.
EXERCISE RESULTS:
1. The patient exercised for 3 minutes stopping due to fatigue. No chest pain.
2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern.
NUCLEAR PROTOCOL: Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.
NUCLEAR RESULTS:
1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0.
2. The Gated SPECT shows moderate LVH with slightly low EF of 48%.
IMPRESSION:
1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.
2. Mild hypertensive cardiomyopathy with an EF of 48%.
3. Poor exercise capacity due to cardiovascular deconditioning.
4. Suboptimally controlled blood pressure on today's exam.
MEDICATIONS: Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.
BASELINE EKG: Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.
EXERCISE RESULTS:
1. The patient exercised for 3 minutes stopping due to fatigue. No chest pain.
2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern.
NUCLEAR PROTOCOL: Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.
NUCLEAR RESULTS:
1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0.
2. The Gated SPECT shows moderate LVH with slightly low EF of 48%.
IMPRESSION:
1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.
2. Mild hypertensive cardiomyopathy with an EF of 48%.
3. Poor exercise capacity due to cardiovascular deconditioning.
4. Suboptimally controlled blood pressure on today's exam.
Sample Name: Saphenous Vein - Ligation & Stripping
Description: Ligation and stripping of left greater saphenous vein to the level of the knee. Stripping of multiple left lower extremity varicose veins. Varicose veins.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Varicose veins.
POSTOPERATIVE DIAGNOSIS: Varicose veins.
PROCEDURE PERFORMED:
1. Ligation and stripping of left greater saphenous vein to the level of the knee.
2. Stripping of multiple left lower extremity varicose veins.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Approximately 150 mL.
SPECIMENS: Multiple veins.
COMPLICATIONS: None.
BRIEF HISTORY: This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity. The patient has had painful varicose veins for number of years. He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins. It was recommended that the patient undergo a saphenous vein ligation and stripping. He was explained the risks, benefits, and complications of the procedure including intractable pain. He gave informed consent to proceed.
OPERATIVE FINDINGS: The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.
The vein was stripped from the saphenofemoral junction to the level of the knee. Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly. Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.
OPERATIVE PROCEDURE: The patient was marked preoperatively in the Preanesthesia Care Unit. The patient was brought to the operating suite, placed in the supine position. The patient underwent general endotracheal intubation. After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline. A diagonal incision was created in the direction of the inguinal crease on the left. A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified. The vein was isolated with a right angle. The vein was followed proximally until a multiple tributary branches were identified. These were ligated with #3-0 silk suture. The dissection was then carried to the femorosaphenous vein junction. This was identified and #0 silk suture was placed proximally and distally and ligated in between. The proximal suture was tied down. Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein. An incision was created at the level of the knee. The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated. The distal end of the vein stripping device was then passed through at its most proximal location. The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity. Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg. Multiple incisions were created with a #15 blade scalpel. The incisions were carried down with electrocautery. Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified. The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed. Additionally, some segments were removed. The stripping approach would be vein stripping device. Multiple branches of the saphenous vein were then ligated and/or removed. Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat. Bleeding was controlled with direct pressure. All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.
The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture. The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions. The leg was then wrapped with a sterile Kerlix. Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression. The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition. He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.
POSTOPERATIVE DIAGNOSIS: Varicose veins.
PROCEDURE PERFORMED:
1. Ligation and stripping of left greater saphenous vein to the level of the knee.
2. Stripping of multiple left lower extremity varicose veins.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Approximately 150 mL.
SPECIMENS: Multiple veins.
COMPLICATIONS: None.
BRIEF HISTORY: This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity. The patient has had painful varicose veins for number of years. He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins. It was recommended that the patient undergo a saphenous vein ligation and stripping. He was explained the risks, benefits, and complications of the procedure including intractable pain. He gave informed consent to proceed.
OPERATIVE FINDINGS: The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.
The vein was stripped from the saphenofemoral junction to the level of the knee. Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly. Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.
OPERATIVE PROCEDURE: The patient was marked preoperatively in the Preanesthesia Care Unit. The patient was brought to the operating suite, placed in the supine position. The patient underwent general endotracheal intubation. After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline. A diagonal incision was created in the direction of the inguinal crease on the left. A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified. The vein was isolated with a right angle. The vein was followed proximally until a multiple tributary branches were identified. These were ligated with #3-0 silk suture. The dissection was then carried to the femorosaphenous vein junction. This was identified and #0 silk suture was placed proximally and distally and ligated in between. The proximal suture was tied down. Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein. An incision was created at the level of the knee. The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated. The distal end of the vein stripping device was then passed through at its most proximal location. The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity. Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg. Multiple incisions were created with a #15 blade scalpel. The incisions were carried down with electrocautery. Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified. The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed. Additionally, some segments were removed. The stripping approach would be vein stripping device. Multiple branches of the saphenous vein were then ligated and/or removed. Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat. Bleeding was controlled with direct pressure. All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.
The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture. The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions. The leg was then wrapped with a sterile Kerlix. Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression. The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition. He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.
Sample Name: Selective Coronary Angiography & Angioplasty
Description: Selective coronary angiography, coronary angioplasty. Acute non-ST-elevation MI.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS AND INDICATIONS: Acute non-ST-elevation MI.
POSTOPERATIVE DIAGNOSIS AND SUMMARY: The patient presented with an acute non-ST-elevation MI. Despite medical therapy, she continued to have intermittent angina. Angiography demonstrated the severe LAD as the culprit lesion. This was treated as noted above with angioplasty alone as the stent could not be safely advanced. She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above. She will be continued on her medical therapy. At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.
PROCEDURE PERFORMED: Selective coronary angiography, coronary angioplasty.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position. The area of the right femoral artery was prepped and draped in a sterile fashion. Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance. With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system. The catheter was removed. The sheath flushed. The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery. The cath removed, the sheath flushed.
It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI. The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower. We repeated the level and it was slightly higher. We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV. Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.
A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal. An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated. Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent. The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium. The balloon was inflated and removed, repeat angiography performed. We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification. The stent was removed. Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful. It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed. Repeat angiography demonstrated no evidence of dissection. One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal. I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed. The guidewires and guide cath were removed. The sheath flushed and sutured into position. The patient moved to ICU in stable condition with no chest discomfort at all.
CONTRAST: Isovue-370, 120 mL.
FLUORO TIME: 9.4 minutes.
ESTIMATED BLOOD LOSS: 30 mL.
HEMODYNAMICS: Aorta 185/54.
Left ventriculography was not performed. I did not make an attempt to cross this severely stenotic aortic valve.
The left main is a large vessel, giving rise to LAD and circumflex vessels. The left main has no significant disease other than calcification in the walls.
The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal. The LAD has significant calcification proximally. There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent. This resulted in a 30% residual, mostly eccentric calcified plaque. Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal. This was not ballooned. Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal. These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal. As noted above, this area was not stented because I could not safely advance the stent. Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.
The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches. The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal. The remainder of the vessel was without significant disease.
The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch. The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch. The remainder of the right coronary and its branches were without significant disease.
POSTOPERATIVE DIAGNOSIS AND SUMMARY: The patient presented with an acute non-ST-elevation MI. Despite medical therapy, she continued to have intermittent angina. Angiography demonstrated the severe LAD as the culprit lesion. This was treated as noted above with angioplasty alone as the stent could not be safely advanced. She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above. She will be continued on her medical therapy. At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.
PROCEDURE PERFORMED: Selective coronary angiography, coronary angioplasty.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position. The area of the right femoral artery was prepped and draped in a sterile fashion. Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance. With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system. The catheter was removed. The sheath flushed. The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery. The cath removed, the sheath flushed.
It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI. The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower. We repeated the level and it was slightly higher. We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV. Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.
A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal. An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated. Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent. The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium. The balloon was inflated and removed, repeat angiography performed. We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification. The stent was removed. Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful. It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed. Repeat angiography demonstrated no evidence of dissection. One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal. I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed. The guidewires and guide cath were removed. The sheath flushed and sutured into position. The patient moved to ICU in stable condition with no chest discomfort at all.
CONTRAST: Isovue-370, 120 mL.
FLUORO TIME: 9.4 minutes.
ESTIMATED BLOOD LOSS: 30 mL.
HEMODYNAMICS: Aorta 185/54.
Left ventriculography was not performed. I did not make an attempt to cross this severely stenotic aortic valve.
The left main is a large vessel, giving rise to LAD and circumflex vessels. The left main has no significant disease other than calcification in the walls.
The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal. The LAD has significant calcification proximally. There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent. This resulted in a 30% residual, mostly eccentric calcified plaque. Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal. This was not ballooned. Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal. These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal. As noted above, this area was not stented because I could not safely advance the stent. Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.
The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches. The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal. The remainder of the vessel was without significant disease.
The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch. The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch. The remainder of the right coronary and its branches were without significant disease.
Sample Name: Septal Defect Repair
Description: Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
TITLE OF OPERATION:
1. Repair of total anomalous pulmonary venous connection.
2. Ligation of patent ductus arteriosus.
3. Repair secundum type atrial septal defect (autologous pericardial patch).
4. Subtotal thymectomy.
5. Insertion of peritoneal dialysis catheter.
INDICATION FOR SURGERY: This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection. Following initial stabilization, she was transferred to the Hospital for complete correction.
PREOP DIAGNOSIS:
1. Total anomalous pulmonary venous connection.
2. Atrial septal defect.
3. Patent ductus arteriosus.
4. Operative weight less than 4 kilograms (3.2 kilograms).
COMPLICATIONS: None.
CROSS-CLAMP TIME: 63 minutes.
CARDIOPULMONARY BYPASS TIME MONITOR: 35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes. Low flow perfusion 32 minutes.
FINDINGS: Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins. Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence. Nonobstructed ascending vein ligated. Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin. At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.
PROCEDURE: After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position. Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines. The patient was prepped and draped in the usual sterile fashion from chin to groins. A median sternotomy incision was performed. Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw. A subtotal thymectomy was performed. Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle. A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure. Pursestrings were deployed on the ascending aorta on the right. Atrial appendage. The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula. With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie. Systemic cooling was started and the head was packed and iced and systemic steroids were administered. During cooling, traction suture was placed in the apex of the left ventricle. After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping. Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula. The heart was then rotated to the right side and the venous confluence was exposed. It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed. The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture. Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir. A right atriotomy was then performed during the period of circulatory arrest. The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture. The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures. The venous cannula was reinserted. Cardiopulmonary bypass restarted and the aorta cross-clamp was released. The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm. Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains. Venous decannulation was followed by aortic decannulation and administration of protamine sulfate. All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic. With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires. The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred in very stable condition to the pediatric intensive care unit .
I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case. Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.
1. Repair of total anomalous pulmonary venous connection.
2. Ligation of patent ductus arteriosus.
3. Repair secundum type atrial septal defect (autologous pericardial patch).
4. Subtotal thymectomy.
5. Insertion of peritoneal dialysis catheter.
INDICATION FOR SURGERY: This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection. Following initial stabilization, she was transferred to the Hospital for complete correction.
PREOP DIAGNOSIS:
1. Total anomalous pulmonary venous connection.
2. Atrial septal defect.
3. Patent ductus arteriosus.
4. Operative weight less than 4 kilograms (3.2 kilograms).
COMPLICATIONS: None.
CROSS-CLAMP TIME: 63 minutes.
CARDIOPULMONARY BYPASS TIME MONITOR: 35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes. Low flow perfusion 32 minutes.
FINDINGS: Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins. Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence. Nonobstructed ascending vein ligated. Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin. At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.
PROCEDURE: After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position. Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines. The patient was prepped and draped in the usual sterile fashion from chin to groins. A median sternotomy incision was performed. Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw. A subtotal thymectomy was performed. Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle. A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure. Pursestrings were deployed on the ascending aorta on the right. Atrial appendage. The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula. With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie. Systemic cooling was started and the head was packed and iced and systemic steroids were administered. During cooling, traction suture was placed in the apex of the left ventricle. After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping. Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula. The heart was then rotated to the right side and the venous confluence was exposed. It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed. The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture. Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir. A right atriotomy was then performed during the period of circulatory arrest. The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture. The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures. The venous cannula was reinserted. Cardiopulmonary bypass restarted and the aorta cross-clamp was released. The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm. Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains. Venous decannulation was followed by aortic decannulation and administration of protamine sulfate. All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic. With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires. The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred in very stable condition to the pediatric intensive care unit .
I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case. Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.
Sample Name: Shiley Tracheostomy Tube Insertion
Description: Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
OPERATION: Insertion of a #8 Shiley tracheostomy tube.
ANESTHESIA: General endotracheal anesthesia.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.
Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea. The 2nd tracheal ring was identified. Next, a #11-blade scalpel was used to make a trap door in the trachea. The endotracheal tube was backed out. A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit. We then secured it in place using 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well.
ANESTHESIA: General endotracheal anesthesia.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.
Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea. The 2nd tracheal ring was identified. Next, a #11-blade scalpel was used to make a trap door in the trachea. The endotracheal tube was backed out. A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit. We then secured it in place using 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well.
Sample Name: Stenting
Description: Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
NAME OF PROCEDURE: Successful stenting of the left anterior descending.
DESCRIPTION OF PROCEDURE: Angina pectoris, tight lesion in left anterior descending.
TECHNIQUE OF PROCEDURE: Standard Judkins, right groin.
CATHETERS USED: 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.
ANTICOAGULATION: The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.
COMPLICATIONS: None.
INFORMED CONSENT: I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.
HEMODYNAMIC DATA: The aortic pressure was in the physiologic range.
ANGIOGRAPHIC DATA: Left coronary artery: The left main coronary artery showed insignificant disease. The left anterior descending showed fairly extensive calcification. There was 90% stenosis in the proximal to midportion of the vessel. Insignificant disease in the circumflex.
SUCCESSFUL STENTING: A wire crossed the lesion. We first predilated with a balloon, then advanced, deployed and post dilated the stent. Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.
PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30. He is saturating at 96% on 4 L nonrebreather.
GENERAL: The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3. The patient cannot speak and communicates through writing.
HEENT: Very small moles on face. However, pupils equal, round and regular and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is moist.
NECK: Supple. Tracheostomy site is clean without blood or discharge.
HEART: Regular rate and rhythm. No gallop, murmur or rub.
CHEST: Respirations congested. Mild crackles in the left lower quadrant and left lower base.
ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves II-XII grossly intact. No focal deficit.
GENITALIA: The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.
CONCLUSIONS
1. Successful stenting of the left anterior descending. Initially, there was 90% stenosis. After stenting with a drug-eluting stent, there was 0% residual.
2. Insignificant disease in the other coronaries.
PLAN: The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins. I have discussed this with him, and I have answered his questions.
DESCRIPTION OF PROCEDURE: Angina pectoris, tight lesion in left anterior descending.
TECHNIQUE OF PROCEDURE: Standard Judkins, right groin.
CATHETERS USED: 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.
ANTICOAGULATION: The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.
COMPLICATIONS: None.
INFORMED CONSENT: I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.
HEMODYNAMIC DATA: The aortic pressure was in the physiologic range.
ANGIOGRAPHIC DATA: Left coronary artery: The left main coronary artery showed insignificant disease. The left anterior descending showed fairly extensive calcification. There was 90% stenosis in the proximal to midportion of the vessel. Insignificant disease in the circumflex.
SUCCESSFUL STENTING: A wire crossed the lesion. We first predilated with a balloon, then advanced, deployed and post dilated the stent. Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.
PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30. He is saturating at 96% on 4 L nonrebreather.
GENERAL: The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3. The patient cannot speak and communicates through writing.
HEENT: Very small moles on face. However, pupils equal, round and regular and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is moist.
NECK: Supple. Tracheostomy site is clean without blood or discharge.
HEART: Regular rate and rhythm. No gallop, murmur or rub.
CHEST: Respirations congested. Mild crackles in the left lower quadrant and left lower base.
ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves II-XII grossly intact. No focal deficit.
GENITALIA: The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.
CONCLUSIONS
1. Successful stenting of the left anterior descending. Initially, there was 90% stenosis. After stenting with a drug-eluting stent, there was 0% residual.
2. Insignificant disease in the other coronaries.
PLAN: The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins. I have discussed this with him, and I have answered his questions.
Sample Name: Stress Test Adenosine Myoview
Description: Stress test - Adenosine Myoview. Ischemic cardiomyopathy. Inferoseptal and apical transmural scar.
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INDICATIONS: Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.
PROCEDURE DONE: Adenosine Myoview stress test.
STRESS ECG RESULTS: The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes. The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute. Underlying atrial fibrillation noted, very wide QRS complexes. The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.
MYOCARDIAL PERFUSION IMAGING: Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview. Adenosine infusion myocardial perfusion imaging and gated scan were carried out with 30 mCi of Tc-99m Myoview. The lung heart ratio is 0.34. A large transmural inferoseptal and apical perfusion defect of severe degree noted. No evidence of perfusion abnormality along the left anterior descending territory, which was the site of a PTCA and stenting a year ago. The gated scan revealed paradoxical septal motion, dyskinetic apical segment, severe inferior hypokinesis, mild to moderate anterolateral and basilar hypokinesis. Ejection fraction is 27%.
CONCLUSIONS:
1. Findings consistent with ischemic cardiomyopathy. Paradoxical septal motion consistent with abnormal ventricular depolarization related to right ventricular apical position of VVI pacemaker. Apical dyskinesis, severe inferior hypokinesis, mild to moderate anterolateral and basilar hypokinesis. Ejection fraction of 27%.
2. Large inferoseptal and apical transmural scar.
3. No evidence of adenosine-induced myocardial ischemia. Specifically no reversible perfusion abnormalities seen in the territory of the left anterior descending, which underwent stenting a year ago.
PROCEDURE DONE: Adenosine Myoview stress test.
STRESS ECG RESULTS: The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes. The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute. Underlying atrial fibrillation noted, very wide QRS complexes. The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.
MYOCARDIAL PERFUSION IMAGING: Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview. Adenosine infusion myocardial perfusion imaging and gated scan were carried out with 30 mCi of Tc-99m Myoview. The lung heart ratio is 0.34. A large transmural inferoseptal and apical perfusion defect of severe degree noted. No evidence of perfusion abnormality along the left anterior descending territory, which was the site of a PTCA and stenting a year ago. The gated scan revealed paradoxical septal motion, dyskinetic apical segment, severe inferior hypokinesis, mild to moderate anterolateral and basilar hypokinesis. Ejection fraction is 27%.
CONCLUSIONS:
1. Findings consistent with ischemic cardiomyopathy. Paradoxical septal motion consistent with abnormal ventricular depolarization related to right ventricular apical position of VVI pacemaker. Apical dyskinesis, severe inferior hypokinesis, mild to moderate anterolateral and basilar hypokinesis. Ejection fraction of 27%.
2. Large inferoseptal and apical transmural scar.
3. No evidence of adenosine-induced myocardial ischemia. Specifically no reversible perfusion abnormalities seen in the territory of the left anterior descending, which underwent stenting a year ago.
Sample Name: Stress Test Bruce Protocol
Description: Stress test with Bruce protocol due to chest pain.
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PROTOCOL: Bruce.
PERTINENT MEDICATION: None.
REASON FOR TEST: Chest pain.
PROCEDURE AND INTERPRETATION:
1. Baseline heart rate: 67.
2. Baseline blood pressure: 150/86.
3. Total time: 6 minute 51 seconds.
4. METs: 10.1.
5. Peak heart rate: 140.
6. Percent of maximum-predicted heart rate: 90.
7. Peak blood pressure: 200/92.
8. Reason test terminated: Shortness of breath and fatigue.
9. Estimated aerobic capacity: Average.
10. Heart rate response: Normal.
11. Blood pressure response: Hypertensive.
12. ST segment response: Normal.
13. Chest pain: None.
14. Symptoms: None.
15. Arrhythmia: None.
CONCLUSION:
1. Average aerobic capacity.
2. Normal heart rate and blood pressure response to exercise.
3. No symptomatic electrocardiographic evidence of ischemia.
CONDITION: Stable with normal vital signs.
DISPOSITION: The patient was discharged home and was asymptomatic.
PERTINENT MEDICATION: None.
REASON FOR TEST: Chest pain.
PROCEDURE AND INTERPRETATION:
1. Baseline heart rate: 67.
2. Baseline blood pressure: 150/86.
3. Total time: 6 minute 51 seconds.
4. METs: 10.1.
5. Peak heart rate: 140.
6. Percent of maximum-predicted heart rate: 90.
7. Peak blood pressure: 200/92.
8. Reason test terminated: Shortness of breath and fatigue.
9. Estimated aerobic capacity: Average.
10. Heart rate response: Normal.
11. Blood pressure response: Hypertensive.
12. ST segment response: Normal.
13. Chest pain: None.
14. Symptoms: None.
15. Arrhythmia: None.
CONCLUSION:
1. Average aerobic capacity.
2. Normal heart rate and blood pressure response to exercise.
3. No symptomatic electrocardiographic evidence of ischemia.
CONDITION: Stable with normal vital signs.
DISPOSITION: The patient was discharged home and was asymptomatic.
Sample Name: Stress Test Dobutamine
Description: Dobutamine stress test for atrial fibrillation.
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INDICATIONS: Atrial fibrillation, coronary disease.
STRESS TECHNIQUE: The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation.
IMAGE TECHNIQUE: The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.
IMAGE ANALYSIS: It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds. There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 65%. There is normal global and regional wall motion.
CONCLUSIONS:
1. Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.
2. Normal LV myocardial perfusion.
3. Normal LV systolic ejection fraction of 65%.
4. Normal global and regional wall motion.
STRESS TECHNIQUE: The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation.
IMAGE TECHNIQUE: The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.
IMAGE ANALYSIS: It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds. There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 65%. There is normal global and regional wall motion.
CONCLUSIONS:
1. Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.
2. Normal LV myocardial perfusion.
3. Normal LV systolic ejection fraction of 65%.
4. Normal global and regional wall motion.
Sample Name: Stress Test Dobutamine Myoview
Description: Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction.
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INDICATIONS: Chest pain, hypertension, type II diabetes mellitus.
PROCEDURE DONE: Dobutamine Myoview stress test.
STRESS ECG RESULTS: The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes. Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion. The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality. The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate. The blood pressure increased from 130/80 to 160/70. A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion. No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.
MYOCARDIAL PERFUSION IMAGING: Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview. Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview. The lung heart ratio is 0.36. Myocardial perfusion images were normal both at rest and with stress. Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.
CONCLUSIONS:
1. Stress test is negative for dobutamine-induced myocardial ischemia.
2. Normal left ventricular size, regional wall motion, and ejection fraction.
PROCEDURE DONE: Dobutamine Myoview stress test.
STRESS ECG RESULTS: The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes. Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion. The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality. The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate. The blood pressure increased from 130/80 to 160/70. A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion. No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.
MYOCARDIAL PERFUSION IMAGING: Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview. Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview. The lung heart ratio is 0.36. Myocardial perfusion images were normal both at rest and with stress. Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.
CONCLUSIONS:
1. Stress test is negative for dobutamine-induced myocardial ischemia.
2. Normal left ventricular size, regional wall motion, and ejection fraction.
Sample Name: Stress Test Dobutrex
Description: Dobutrex stress test for abnormal EKG
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INDICATIONS: Abnormal EKG.
STRESS TECHNIQUE: Dobutrex was infused at 10 µg/kg/minute increasing in three-minute intervals. Maximum heart rate was 113. No significant EKG changes noted.
NARRATIVE: Uptake of radioisotope was adequate in all views. There was an inferior abnormality noted in the short axis view from 4:00-6:30. In the vertical long axis view, there was an inferior abnormality with minimal improvement. The horizontal long axis view had a lateral apical abnormality with no change.
WALL MOTION: The left ventricle was of normal size and motion. All wall segments moved normally.
EJECTION FRACTION: 72%.
CONCLUSIONS:
1. Negative Dobutrex stress test.
2. Normal wall motion and ejection fraction.
3. Abnormal nuclear scan consistent with possible underlying ischemic heart disease. Clinical correlation suggested.
STRESS TECHNIQUE: Dobutrex was infused at 10 µg/kg/minute increasing in three-minute intervals. Maximum heart rate was 113. No significant EKG changes noted.
NARRATIVE: Uptake of radioisotope was adequate in all views. There was an inferior abnormality noted in the short axis view from 4:00-6:30. In the vertical long axis view, there was an inferior abnormality with minimal improvement. The horizontal long axis view had a lateral apical abnormality with no change.
WALL MOTION: The left ventricle was of normal size and motion. All wall segments moved normally.
EJECTION FRACTION: 72%.
CONCLUSIONS:
1. Negative Dobutrex stress test.
2. Normal wall motion and ejection fraction.
3. Abnormal nuclear scan consistent with possible underlying ischemic heart disease. Clinical correlation suggested.
Sample Name: Stress Test Graded Exercise Treadmill
Description: Chest pain, Chest wall tenderness occurred with exercise.
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INDICATIONS: Chest pain.
PROCEDURE DONE: Graded exercise treadmill stress test.
STRESS ECG RESULTS: The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol. The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate. The blood pressure increased from 120/70 to 130/80. The baseline resting electrocardiogram reveals a regular sinus rhythm. The tracing is within normal limits. Symptoms of chest pain occurred with exercise. The pain persisted during the recovery process and was aggravated by deep inspiration. Marked chest wall tenderness noted. There were no ischemic ST segment changes seen during exercise or during the recovery process.
CONCLUSIONS:
1. Stress test is negative for ischemia.
2. Chest wall tenderness occurred with exercise.
3. Blood pressure response to exercise is normal.
PROCEDURE DONE: Graded exercise treadmill stress test.
STRESS ECG RESULTS: The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol. The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate. The blood pressure increased from 120/70 to 130/80. The baseline resting electrocardiogram reveals a regular sinus rhythm. The tracing is within normal limits. Symptoms of chest pain occurred with exercise. The pain persisted during the recovery process and was aggravated by deep inspiration. Marked chest wall tenderness noted. There were no ischemic ST segment changes seen during exercise or during the recovery process.
CONCLUSIONS:
1. Stress test is negative for ischemia.
2. Chest wall tenderness occurred with exercise.
3. Blood pressure response to exercise is normal.
Sample Name: Stress Test Thallium
Description: Thallium stress test for chest pain.
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INDICATIONS: Chest pain.
STRESS TECHNIQUE: The patient exercised for 5.0 minutes to a heart rate of 133. ECG was normal. Patient achieved 7.0 METS.
IMAGE TECHNIQUE: The patient was injected with 4.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.
IMAGE ANALYSIS: There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 79%. There is normal global and regional wall motion of the left ventricle.
CONCLUSIONS:
1. Normal ECG stress.
2. Reduced aerobic capacity of 7 METS.
3. Normal LV myocardial perfusion.
4. Normal LV systolic ejection fraction of 79%.
5. Normal global and regional wall motion of the left ventricle.
STRESS TECHNIQUE: The patient exercised for 5.0 minutes to a heart rate of 133. ECG was normal. Patient achieved 7.0 METS.
IMAGE TECHNIQUE: The patient was injected with 4.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.
IMAGE ANALYSIS: There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 79%. There is normal global and regional wall motion of the left ventricle.
CONCLUSIONS:
1. Normal ECG stress.
2. Reduced aerobic capacity of 7 METS.
3. Normal LV myocardial perfusion.
4. Normal LV systolic ejection fraction of 79%.
5. Normal global and regional wall motion of the left ventricle.
Sample Name: Subclavian Central Venous Catheter Insertion
Description: Insertion of right subclavian central venous catheter. Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.
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PREOPERATIVE DIAGNOSES:
1. Need for intravenous access.
2. Status post fall.
3. Status post incision and drainage of left lower extremity.
POSTOPERATIVE DIAGNOSES:
1. Need for intravenous access.
2. Status post fall.
3. Status post incision and drainage of left lower extremity.
PROCEDURE PERFORMED: Insertion of right subclavian central venous catheter.
SECOND ANESTHESIA: Approximately 10 cc of 1% lidocaine.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR PROCEDURE: The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries. The patient went to OR today for an I&D of left lower extremity degloving injury. Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.
PROCEDURE: Informed consent was obtained by the patient and her daughter. All risks and benefits of the procedure were explained and all questions were answered. The patient was prepped and draped in the normal sterile fashion. After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid. Locator needle was used to correctly cannulate the right internal jugular vein. Multiple attempts were made and the right internal jugular vein was unable to be cannulized.
Therefore, we prepared for a right subclavian approach. The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle. A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch. The right subclavian vein was then accessed. A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin. A dilator sheath was placed over the guidewire and subsequently removed. The triple lumen catheter was then placed over the guidewire and advanced to 14 cm. All ports aspirated and flushed. Good blood return was noted and all ports were flushed well. The triple lumen catheter was then secured at 14 cm using #0 silk suture. A sterile dressing was then applied. A stat portable chest x-ray was ordered to check line placement. The patient tolerated the procedure well and there were no complications.
1. Need for intravenous access.
2. Status post fall.
3. Status post incision and drainage of left lower extremity.
POSTOPERATIVE DIAGNOSES:
1. Need for intravenous access.
2. Status post fall.
3. Status post incision and drainage of left lower extremity.
PROCEDURE PERFORMED: Insertion of right subclavian central venous catheter.
SECOND ANESTHESIA: Approximately 10 cc of 1% lidocaine.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR PROCEDURE: The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries. The patient went to OR today for an I&D of left lower extremity degloving injury. Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.
PROCEDURE: Informed consent was obtained by the patient and her daughter. All risks and benefits of the procedure were explained and all questions were answered. The patient was prepped and draped in the normal sterile fashion. After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid. Locator needle was used to correctly cannulate the right internal jugular vein. Multiple attempts were made and the right internal jugular vein was unable to be cannulized.
Therefore, we prepared for a right subclavian approach. The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle. A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch. The right subclavian vein was then accessed. A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin. A dilator sheath was placed over the guidewire and subsequently removed. The triple lumen catheter was then placed over the guidewire and advanced to 14 cm. All ports aspirated and flushed. Good blood return was noted and all ports were flushed well. The triple lumen catheter was then secured at 14 cm using #0 silk suture. A sterile dressing was then applied. A stat portable chest x-ray was ordered to check line placement. The patient tolerated the procedure well and there were no complications.
Sample Name: Subxiphoid Pericardial Window
Description: Emergent subxiphoid pericardial window, transesophageal echocardiogram.
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PREOPERATIVE DIAGNOSIS (ES):
1. Endocarditis.
2. Status post aortic valve replacement with St. Jude mechanical valve.
3. Pericardial tamponade.
POSTOPERATIVE DIAGNOSIS (ES):
1. Endocarditis.
2. Status post aortic valve replacement with St. Jude mechanical valve.
3. Pericardial tamponade.
PROCEDURE:
1. Emergent subxiphoid pericardial window.
2. Transesophageal echocardiogram.
ANESTHESIA: General endotracheal.
FINDINGS: The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.
DESCRIPTION OF THE OPERATION: The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.
1. Endocarditis.
2. Status post aortic valve replacement with St. Jude mechanical valve.
3. Pericardial tamponade.
POSTOPERATIVE DIAGNOSIS (ES):
1. Endocarditis.
2. Status post aortic valve replacement with St. Jude mechanical valve.
3. Pericardial tamponade.
PROCEDURE:
1. Emergent subxiphoid pericardial window.
2. Transesophageal echocardiogram.
ANESTHESIA: General endotracheal.
FINDINGS: The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.
DESCRIPTION OF THE OPERATION: The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.
Sample Name: Subxiphoid Pericardial Window - 1
Description: Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery.
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OPERATION: Subxiphoid pericardial window.
ANESTHESIA: General endotracheal anesthesia.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.
The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied.
ANESTHESIA: General endotracheal anesthesia.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.
The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied.
Sample Name: Subxiphoid Pericardiotomy
Description: Subxiphoid pericardiotomy. Symptomatic pericardial effusion. The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.
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PREOPERATIVE DIAGNOSIS: Symptomatic pericardial effusion.
POSTOPERATIVE DIAGNOSIS: Symptomatic pericardial effusion.
PROCEDURE PERFORMED: Subxiphoid pericardiotomy.
ANESTHESIA: General via ET tube.
ESTIMATED BLOOD LOSS: 50 cc.
FINDINGS: This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003. She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion. She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. Also, during that time, she had become significantly more short of breath. A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions. She had no tamponade physiology.
INDICATION FOR THE PROCEDURE: For therapeutic and diagnostic management of this symptomatic pericardial effusion. Risks, benefits, and alternative measures were discussed with the patient. Consent was obtained for the above procedure.
PROCEDURE: The patient was prepped and draped in the usual sterile fashion. A 4 cm incision was created in the midline above the xiphoid. Dissection was carried down through the fascia and the xiphoid was resected. The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium. An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.
This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization. Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc. A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed. The heart was visualized and appeared to be contracting well with no evidence of injury to the heart. The pericardium was then palpated. There was no evidence of studding. A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium. It was sewn into place with #0 silk suture. There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium. It was sewn in the similar way to the other chest tube. Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion. The patient tolerated the procedure well. Chest tubes were placed on 20 cm of water suction. The patient was taken to PACU in stable condition.
POSTOPERATIVE DIAGNOSIS: Symptomatic pericardial effusion.
PROCEDURE PERFORMED: Subxiphoid pericardiotomy.
ANESTHESIA: General via ET tube.
ESTIMATED BLOOD LOSS: 50 cc.
FINDINGS: This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003. She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion. She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. Also, during that time, she had become significantly more short of breath. A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions. She had no tamponade physiology.
INDICATION FOR THE PROCEDURE: For therapeutic and diagnostic management of this symptomatic pericardial effusion. Risks, benefits, and alternative measures were discussed with the patient. Consent was obtained for the above procedure.
PROCEDURE: The patient was prepped and draped in the usual sterile fashion. A 4 cm incision was created in the midline above the xiphoid. Dissection was carried down through the fascia and the xiphoid was resected. The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium. An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.
This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization. Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc. A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed. The heart was visualized and appeared to be contracting well with no evidence of injury to the heart. The pericardium was then palpated. There was no evidence of studding. A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium. It was sewn into place with #0 silk suture. There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium. It was sewn in the similar way to the other chest tube. Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion. The patient tolerated the procedure well. Chest tubes were placed on 20 cm of water suction. The patient was taken to PACU in stable condition.
Sample Name: Tesio Hemodialysis Catheter Insertion
Description: Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.
(Medical Transcription Sample Report)
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OPERATION
1. Insertion of a left subclavian Tesio hemodialysis catheter.
2. Surgeon-interpreted fluoroscopy.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered. Next, the patient's chest and neck were prepped and draped in the standard surgical fashion. Lidocaine 1% was used to infiltrate the skin in the region of the procedure. Next a #18-gauge finder needle was used to locate the left subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle. This process was repeated. The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, the subcutaneous tunnel was created. The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff. A dilator and sheath were passed over the individual J wires. The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn. The process was repeated. Both distal tips were noted to be in good position. The Tesio hemodialysis catheters were flushed and aspirated without difficulty. The catheters were secured at the cuff level with a 2-0 nylon. The skin was closed with 4-0 Monocryl. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition.
1. Insertion of a left subclavian Tesio hemodialysis catheter.
2. Surgeon-interpreted fluoroscopy.
OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered. Next, the patient's chest and neck were prepped and draped in the standard surgical fashion. Lidocaine 1% was used to infiltrate the skin in the region of the procedure. Next a #18-gauge finder needle was used to locate the left subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle. This process was repeated. The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, the subcutaneous tunnel was created. The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff. A dilator and sheath were passed over the individual J wires. The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn. The process was repeated. Both distal tips were noted to be in good position. The Tesio hemodialysis catheters were flushed and aspirated without difficulty. The catheters were secured at the cuff level with a 2-0 nylon. The skin was closed with 4-0 Monocryl. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition.
Sample Name: Tessio Catheter Insertion
Description: Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.
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OPERATIONS/PROCEDURES
1. Insertion of right internal jugular Tessio catheter.
2. Placement of left wrist primary submental arteriovenous fistula.
PROCEDURE IN DETAIL: The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The right neck, chest and left arm were prepped and draped in a sterile fashion. A small incision was made at the top of the anterior jugular triangle in the right neck. Through this small incision, the right internal jugular vein was punctured and a guidewire was placed. It was punctured a 2nd time, and a 2nd guidewire was placed. The Tessio catheters were assembled. They were measured for length. Counter-incisions were made on the right chest. They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs. They were flushed with saline. A suture was placed through the guidewire, and the guidewire and dilator were removed. The arterial catheter was then placed through this, and the tear-away introducer was removed. The catheter aspirated and bled easily. It was flushed with saline and capped. This was repeated with the venous line. It also aspirated easily and was flushed with saline and capped. The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon. Dressings were applied. An incision was then made at the left wrist. The basilic vein was dissected free, as was the radial artery. Heparin was given, 50 mg. The radial artery was clamped proximally and distally with a bulldog. It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed. The vein was clipped distally, divided and spatulated for anastomosis. It was sutured to the radial artery with a running 7-0 Prolene suture. The clamps were removed. Good flow was noted through the artery. Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin. The patient tolerated the procedure well.
1. Insertion of right internal jugular Tessio catheter.
2. Placement of left wrist primary submental arteriovenous fistula.
PROCEDURE IN DETAIL: The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The right neck, chest and left arm were prepped and draped in a sterile fashion. A small incision was made at the top of the anterior jugular triangle in the right neck. Through this small incision, the right internal jugular vein was punctured and a guidewire was placed. It was punctured a 2nd time, and a 2nd guidewire was placed. The Tessio catheters were assembled. They were measured for length. Counter-incisions were made on the right chest. They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs. They were flushed with saline. A suture was placed through the guidewire, and the guidewire and dilator were removed. The arterial catheter was then placed through this, and the tear-away introducer was removed. The catheter aspirated and bled easily. It was flushed with saline and capped. This was repeated with the venous line. It also aspirated easily and was flushed with saline and capped. The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon. Dressings were applied. An incision was then made at the left wrist. The basilic vein was dissected free, as was the radial artery. Heparin was given, 50 mg. The radial artery was clamped proximally and distally with a bulldog. It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed. The vein was clipped distally, divided and spatulated for anastomosis. It was sutured to the radial artery with a running 7-0 Prolene suture. The clamps were removed. Good flow was noted through the artery. Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin. The patient tolerated the procedure well.
Sample Name: Thoracentesis
Description: Thoracentesis. Left pleural effusion. Left hemothorax.
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PREOPERATIVE DIAGNOSIS: Left pleural effusion.
POSTOPERATIVE DIAGNOSIS: Left hemothorax.
PROCEDURE: Thoracentesis.
PROCEDURE IN DETAIL: After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. His left back was prepped and draped in the usual fashion. Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood. This blood was nonclotting and it was tested twice. Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s. Therefore, we laid him off his right side while keeping the chest catheter in place. At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.
Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.
POSTOPERATIVE DIAGNOSIS: Left hemothorax.
PROCEDURE: Thoracentesis.
PROCEDURE IN DETAIL: After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. His left back was prepped and draped in the usual fashion. Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood. This blood was nonclotting and it was tested twice. Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s. Therefore, we laid him off his right side while keeping the chest catheter in place. At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.
Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.
Sample Name: Thoracentesis - 1
Description: Thoracentesis, left. Malignant pleural effusion, left, with dyspnea.
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PREOPERATIVE DIAGNOSIS: Malignant pleural effusion, left, with dyspnea.
POSTOPERATIVE DIAGNOSIS: Malignant pleural effusion, left, with dyspnea.
PROCEDURE: Thoracentesis, left.
DESCRIPTION OF PROCEDURE: The patient was brought to the recovery area of the operating room. After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion. Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line. Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall. Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid. From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.
The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle. At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine. At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation. We then thought that if she was doing fine, then we will send her home.
A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.
POSTOPERATIVE DIAGNOSIS: Malignant pleural effusion, left, with dyspnea.
PROCEDURE: Thoracentesis, left.
DESCRIPTION OF PROCEDURE: The patient was brought to the recovery area of the operating room. After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion. Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line. Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall. Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid. From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.
The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle. At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine. At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation. We then thought that if she was doing fine, then we will send her home.
A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.
Sample Name: Thoracoabdominal Aneurysm
Description: A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
POSTOPERATIVE DIAGNOSIS: Type 4 thoracoabdominal aneurysm.
OPERATION/PROCEDURE: A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.
DESCRIPTION OF PROCEDURE IN DETAIL: Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube. Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle. The left groin, abdominal and chest were prepped and draped in a sterile fashion. A thoracoabdominal incision was made. The 8th interspace was entered. The costal margin was divided. The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta. The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm. It was dissected free circumferentially. The aortic bifurcation was dissected free, dissecting free both iliac arteries. The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this. The patient was heparinized. Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet. This was hooked to a venous inflow of left heart bypass machine. A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow. Bypass was instituted. The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm. The area was divided at this point. A 26-mm graft was then sutured in place with running 3-0 Prolene suture. The graft was brought into the diaphragm. Clamps were then placed on the iliacs, and the pump was shut off. The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation. The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch. The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference. The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels. The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture. All clamps were removed, and flow was re-established. An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal. A partial-occlusion clamp was placed. An area of graft was removed. The end of the graft was cut to fit this and sutured in place with running Prolene suture. The partial-occlusion clamp was removed. Protamine was given. Good hemostasis was noted. The arterial cannula, of course, had been removed when that part of the aneurysm was removed. The venous cannula was removed and oversewn with a 4-0 Prolene suture. Good hemostasis was noted. A 36 French posterior and a 32 French anterior chest tube were placed. The ribs were closed with figure-of-eight #2 Vicryl. The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch. Patient tolerated the procedure well.
OPERATION/PROCEDURE: A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.
DESCRIPTION OF PROCEDURE IN DETAIL: Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube. Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle. The left groin, abdominal and chest were prepped and draped in a sterile fashion. A thoracoabdominal incision was made. The 8th interspace was entered. The costal margin was divided. The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta. The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm. It was dissected free circumferentially. The aortic bifurcation was dissected free, dissecting free both iliac arteries. The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this. The patient was heparinized. Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet. This was hooked to a venous inflow of left heart bypass machine. A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow. Bypass was instituted. The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm. The area was divided at this point. A 26-mm graft was then sutured in place with running 3-0 Prolene suture. The graft was brought into the diaphragm. Clamps were then placed on the iliacs, and the pump was shut off. The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation. The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch. The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference. The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels. The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture. All clamps were removed, and flow was re-established. An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal. A partial-occlusion clamp was placed. An area of graft was removed. The end of the graft was cut to fit this and sutured in place with running Prolene suture. The partial-occlusion clamp was removed. Protamine was given. Good hemostasis was noted. The arterial cannula, of course, had been removed when that part of the aneurysm was removed. The venous cannula was removed and oversewn with a 4-0 Prolene suture. Good hemostasis was noted. A 36 French posterior and a 32 French anterior chest tube were placed. The ribs were closed with figure-of-eight #2 Vicryl. The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch. Patient tolerated the procedure well.
Sample Name: Thoracoscopy & Thoracotomy - Mesothelioma
Description: Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.
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(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Left mesothelioma, focal.
POSTOPERATIVE DIAGNOSIS: Left pleural-based nodule.
PROCEDURES PERFORMED:
1. Left thoracoscopy.
2. Left mini thoracotomy with resection of left pleural-based mass.
FINDINGS: Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.
FLUIDS: 800 mL of crystalloid.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS, TUBES, CATHETERS: 24-French chest tube in the left thorax plus Foley catheter.
SPECIMENS: Left pleural-based nodule.
INDICATION FOR OPERATION: The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray. Preoperative evaluation included a CT scan, which showed focal mass. CT and PET confirmed anterior lesion. Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction. In the outpatient setting, the patient was willing to proceed.
PROCEDURE PERFORMED IN DETAIL: After informed consent was obtained, the patient identified correctly. She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty. She was sedated and intubated with double-lumen endotracheal tube without difficulty. She was positioned with left side up. Appropriate pressure points were padded. The left chest was prepped and draped in the standard surgical fashion. The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.
Pleura was entered. There was good deflation of the left lung. __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning. Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall. There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified. The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm. It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.
Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion. Camera was placed through this port. Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity. Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site. This was taken down to the subcutaneous tissue with Bovie electrocautery. Periosteal elevator was used to lift the intercostal muscle off. The ribs were not spread. Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed. Prestige graspers were used to pull the specimen from the chest wall. Care was taken not to injure the capsule. The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall. Care was taken not to transect the stalk. Specimen came off the chest wall very easily. There was good hemostasis.
At this point, the EndoCatch bag was placed through the incision. Specimen was placed in the bag and then removed from the field. There was good hemostasis. Camera was removed. A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture. The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes. The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.
POSTOPERATIVE DIAGNOSIS: Left pleural-based nodule.
PROCEDURES PERFORMED:
1. Left thoracoscopy.
2. Left mini thoracotomy with resection of left pleural-based mass.
FINDINGS: Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.
FLUIDS: 800 mL of crystalloid.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS, TUBES, CATHETERS: 24-French chest tube in the left thorax plus Foley catheter.
SPECIMENS: Left pleural-based nodule.
INDICATION FOR OPERATION: The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray. Preoperative evaluation included a CT scan, which showed focal mass. CT and PET confirmed anterior lesion. Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction. In the outpatient setting, the patient was willing to proceed.
PROCEDURE PERFORMED IN DETAIL: After informed consent was obtained, the patient identified correctly. She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty. She was sedated and intubated with double-lumen endotracheal tube without difficulty. She was positioned with left side up. Appropriate pressure points were padded. The left chest was prepped and draped in the standard surgical fashion. The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.
Pleura was entered. There was good deflation of the left lung. __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning. Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall. There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified. The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm. It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.
Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion. Camera was placed through this port. Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity. Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site. This was taken down to the subcutaneous tissue with Bovie electrocautery. Periosteal elevator was used to lift the intercostal muscle off. The ribs were not spread. Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed. Prestige graspers were used to pull the specimen from the chest wall. Care was taken not to injure the capsule. The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall. Care was taken not to transect the stalk. Specimen came off the chest wall very easily. There was good hemostasis.
At this point, the EndoCatch bag was placed through the incision. Specimen was placed in the bag and then removed from the field. There was good hemostasis. Camera was removed. A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture. The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes. The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.
Sample Name: Thoracoscopy/Thoracotomy
Description: Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES: Empyema of the left chest and consolidation of the left lung.
POSTOPERATIVE DIAGNOSES: Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.
OPERATIVE PROCEDURE: Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.
ANESTHESIA: General.
FINDINGS: The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax. There was also noted to be some mild infiltrates of the right lung. The patient had a 30-year history of cigarette smoking. A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor. Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT. The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed. The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out. This was suctioned out with the addition of the use of saline ***** in the bronchus. Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.
The patient was transferred for continued evaluation and treatment. Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted. These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus. Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that. The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract. A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity. Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout. Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe. There were many pockets of purulent material, which had a gray-white appearance to it. There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe. The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time. There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed. Many cultures were taken from several areas. The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.
The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.
PROCEDURE AND TECHNIQUE: With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner. The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this. Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy. Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space. Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity. Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense. Suture ligatures of Prolene were required. When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a "tissue pledget" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.
Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed. The patch was sutured onto the pulmonary artery tear. A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity. Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel. After reasonably good hemostasis was established pleural cavity was irrigated with saline. As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung. Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk. One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex. These were later connected to water-seal suction at 40 cm of water with negative pressure.
Good hemostasis was observed. Sponge count was reported as being correct. Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out. Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib. Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl. The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin. The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure. Sterile dressings were applied. The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen. The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.
POSTOPERATIVE DIAGNOSES: Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.
OPERATIVE PROCEDURE: Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.
ANESTHESIA: General.
FINDINGS: The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax. There was also noted to be some mild infiltrates of the right lung. The patient had a 30-year history of cigarette smoking. A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor. Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT. The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed. The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out. This was suctioned out with the addition of the use of saline ***** in the bronchus. Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.
The patient was transferred for continued evaluation and treatment. Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted. These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus. Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that. The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract. A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity. Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout. Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe. There were many pockets of purulent material, which had a gray-white appearance to it. There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe. The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time. There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed. Many cultures were taken from several areas. The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.
The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.
PROCEDURE AND TECHNIQUE: With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner. The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this. Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy. Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space. Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity. Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense. Suture ligatures of Prolene were required. When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a "tissue pledget" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.
Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed. The patch was sutured onto the pulmonary artery tear. A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity. Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel. After reasonably good hemostasis was established pleural cavity was irrigated with saline. As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung. Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk. One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex. These were later connected to water-seal suction at 40 cm of water with negative pressure.
Good hemostasis was observed. Sponge count was reported as being correct. Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out. Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib. Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl. The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin. The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure. Sterile dressings were applied. The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen. The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.
Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracotomy & Bronchoscopy
Description: Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Empyema.
POSTOPERATIVE DIAGNOSIS: Empyema.
PROCEDURE PERFORMED:
1. Right thoracotomy, total decortication.
2. Intraoperative bronchoscopy.
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 300 cc.
FLUIDS: 2600 cc IV crystalloid.
URINE: 300 cc intraoperatively.
INDICATIONS FOR PROCEDURE: The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations. Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.
OPERATIVE PROCEDURE: The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department. Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage. Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation. The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi. At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear. Bronchoscope was then removed. Vital signs remained stable throughout this portion of the procedure. The patient was re-intubated by Anesthesia with a double lumen endotracheal tube. At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion. At this point, the right chest was prepped and draped in the usual sterile fashion. The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine. The first port was placed through this incision intrathoracically. A bronchoscope was placed for inspection of the intrathoracic cavity. Pictures were taken. There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax. At this point, a second port site anteriorly was placed under direct visualization. With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid. Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped. Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion. Incision was made. The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space. The chest cavity was entered with the right lung deflated per Anesthesia at our request. Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe. With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand. There was no evidence of gross leakage or bleeding at the conclusion of surgery.
Full lung re-expansion was noted upon re-inflation of the lung. Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus. The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction. Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture. Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure. Steri-Strips were applied along with sterile occlusive dressings. The patient was awakened from anesthesia without difficulty and extubated in the operating room. The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung. The patient was transported to the recovery with vital signs stable. Stat portable chest x-ray is pending. The patient will be admitted to the Intensive Care Unit for close monitoring overnight.
POSTOPERATIVE DIAGNOSIS: Empyema.
PROCEDURE PERFORMED:
1. Right thoracotomy, total decortication.
2. Intraoperative bronchoscopy.
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 300 cc.
FLUIDS: 2600 cc IV crystalloid.
URINE: 300 cc intraoperatively.
INDICATIONS FOR PROCEDURE: The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations. Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.
OPERATIVE PROCEDURE: The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department. Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage. Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation. The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi. At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear. Bronchoscope was then removed. Vital signs remained stable throughout this portion of the procedure. The patient was re-intubated by Anesthesia with a double lumen endotracheal tube. At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion. At this point, the right chest was prepped and draped in the usual sterile fashion. The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine. The first port was placed through this incision intrathoracically. A bronchoscope was placed for inspection of the intrathoracic cavity. Pictures were taken. There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax. At this point, a second port site anteriorly was placed under direct visualization. With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid. Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped. Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion. Incision was made. The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space. The chest cavity was entered with the right lung deflated per Anesthesia at our request. Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe. With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand. There was no evidence of gross leakage or bleeding at the conclusion of surgery.
Full lung re-expansion was noted upon re-inflation of the lung. Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus. The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction. Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture. Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure. Steri-Strips were applied along with sterile occlusive dressings. The patient was awakened from anesthesia without difficulty and extubated in the operating room. The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung. The patient was transported to the recovery with vital signs stable. Stat portable chest x-ray is pending. The patient will be admitted to the Intensive Care Unit for close monitoring overnight.
Sample Name: Thoracotomy & Esophageal Exploration
Description: Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Esophageal rupture.
POSTOPERATIVE DIAGNOSIS: Esophageal rupture.
OPERATION PERFORMED
1. Left thoracotomy with drainage of pleural fluid collection.
2. Esophageal exploration and repair of esophageal perforation.
3. Diagnostic laparoscopy and gastrostomy.
4. Radiographic gastrostomy tube study with gastric contrast, interpretation.
ANESTHESIA: General anesthesia.
INDICATIONS OF THE PROCEDURE: The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching. He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.
DETAILS OF THE PROCEDURE: After an extensive informed consent discussion process, the patient was brought to the operating room. He was placed in a supine position on the operating table. After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll. Left chest was prepped and draped in a usual sterile fashion. After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace. The left lung was deflated and the pleural cavity entered. The Finochietto retractor was used to help provide exposure. The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.
Immediately encountered was left pleural fluid including some purulent fluid. Cultures of this were sampled and sent for microbiology analysis. The left pleural space was then copiously irrigated. A careful expiration demonstrated that the rupture appeared to be sealed. There was crepitus within the mediastinal cavity. The mediastinum was opened and explored and the esophagus was explored. The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus. It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area. The area was copiously irrigated, this provided nice coverage and repair. After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French. These were secured at the left axillary line region at the skin level with #0-silk.
The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures. Muscle layers were closed with running #1 Vicryl sutures. The wound was irrigated and the skin was closed with skin staples.
The patient was then turned and placed in a supine position. A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed. A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced. The laparoscope was introduced. A single additional left-sided separator trocar was introduced. It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance. The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely. The skin incision was made and the gastric lumen was then accessed with the Seldinger technique. Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire. #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated. We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall. The T-fasteners were all crimped and secured into position. As was in the plan, the gastrostomy was secured to the skin and into the tube. Sterile dressing was applied. Aspiration demonstrated gastric content.
Gastrostomy tube study, with interpretation. Radiographic gastrostomy tube study with gastric contrast, with interpretation:
A gastric contrast study was then performed.
Approximately 25 mL Gastrografin was introduced into the gastric lumen. The abdominal films then demonstrated intragastric content with no extravasation. After final inspection, the trocars were removed, the trocar sites were irrigated and closed with 4-0 Vicryl sutures. Steri-strips and sterile dressings were applied. Needle, sponge and instrument counts correct.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
POSTOPERATIVE DIAGNOSIS: Esophageal rupture.
OPERATION PERFORMED
1. Left thoracotomy with drainage of pleural fluid collection.
2. Esophageal exploration and repair of esophageal perforation.
3. Diagnostic laparoscopy and gastrostomy.
4. Radiographic gastrostomy tube study with gastric contrast, interpretation.
ANESTHESIA: General anesthesia.
INDICATIONS OF THE PROCEDURE: The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching. He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.
DETAILS OF THE PROCEDURE: After an extensive informed consent discussion process, the patient was brought to the operating room. He was placed in a supine position on the operating table. After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll. Left chest was prepped and draped in a usual sterile fashion. After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace. The left lung was deflated and the pleural cavity entered. The Finochietto retractor was used to help provide exposure. The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.
Immediately encountered was left pleural fluid including some purulent fluid. Cultures of this were sampled and sent for microbiology analysis. The left pleural space was then copiously irrigated. A careful expiration demonstrated that the rupture appeared to be sealed. There was crepitus within the mediastinal cavity. The mediastinum was opened and explored and the esophagus was explored. The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus. It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area. The area was copiously irrigated, this provided nice coverage and repair. After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French. These were secured at the left axillary line region at the skin level with #0-silk.
The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures. Muscle layers were closed with running #1 Vicryl sutures. The wound was irrigated and the skin was closed with skin staples.
The patient was then turned and placed in a supine position. A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed. A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced. The laparoscope was introduced. A single additional left-sided separator trocar was introduced. It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance. The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely. The skin incision was made and the gastric lumen was then accessed with the Seldinger technique. Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire. #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated. We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall. The T-fasteners were all crimped and secured into position. As was in the plan, the gastrostomy was secured to the skin and into the tube. Sterile dressing was applied. Aspiration demonstrated gastric content.
Gastrostomy tube study, with interpretation. Radiographic gastrostomy tube study with gastric contrast, with interpretation:
A gastric contrast study was then performed.
Approximately 25 mL Gastrografin was introduced into the gastric lumen. The abdominal films then demonstrated intragastric content with no extravasation. After final inspection, the trocars were removed, the trocar sites were irrigated and closed with 4-0 Vicryl sutures. Steri-strips and sterile dressings were applied. Needle, sponge and instrument counts correct.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
Sample Name: Thoracotomy & Lobectomy
Description: Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.
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PREOPERATIVE DIAGNOSES:
1. Non-small-cell carcinoma of the left upper lobe.
2. History of lymphoma in remission.
POSTOPERATIVE DIAGNOSES:
1. Non-small-cell carcinoma of the left upper lobe.
2. History of lymphoma in remission.
PROCEDURE: Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.
INDICATIONS FOR THE PROCEDURE: This is an 84-year-old lady who was referred by Dr. A for treatment of her left upper lobe carcinoma. The patient has a history of lymphoma and is in remission. An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma. A mass in the left upper lobe was biopsied with fine-needle aspiration and shown to be a primary non-small-cell carcinoma of the lung. PET scan was, otherwise, negative for spread and resection was advised. All the risk and benefits were fully explained to the patient and she elected to proceed as planned. She was transferred to rehab for couple of weeks to buildup strength before the surgery.
PROCEDURE IN DETAIL: In the operating room under anesthesia, she was prepped and draped suitably. Dr. B was the staff anesthesiologist. Left muscle sparing mini thoracotomy was made. The serratus and latissimus muscles were not cut but moved out to the way. Access to the chest was obtained through the fifth intercostal space. Two Tuffier retractors of right angles provided adequate exposure.
The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology. The parietal pleural reflexion around the hilum was now circumcised, and lymph nodes were taken from station 8 and station 5.
The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30/2.5 staple gun or/and the smaller one were ligated with 2-0 silk. The left superior pulmonary vein was transected using a TA30/2.5 staple gun, and the fissure was completed using firings of an endo-GIA 60/4.8 staple gun. Finally, the left upper lobe bronchus was transected using a TA30/4.8 staple gun. Please note, that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe.
The specimen was delivered and sent to pathology. The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe. Frozen section showed that the margin was negative.
The chest was irrigated with warm sterile water and when the left lower lobe inflated, there was no air leak. A single 32-French chest tube was inserted, and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together. A #2 Vicryl pericostal sutures were now applied. The serratus and latissimus muscles retracted back in place. A #19 French Blake drain placed in the subcutaneous tissues and 2-0 Vicryl used for the fat followed by 4-0 Monocryl for the skin. The patient was transferred to the ICU in a stable condition.
1. Non-small-cell carcinoma of the left upper lobe.
2. History of lymphoma in remission.
POSTOPERATIVE DIAGNOSES:
1. Non-small-cell carcinoma of the left upper lobe.
2. History of lymphoma in remission.
PROCEDURE: Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.
INDICATIONS FOR THE PROCEDURE: This is an 84-year-old lady who was referred by Dr. A for treatment of her left upper lobe carcinoma. The patient has a history of lymphoma and is in remission. An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma. A mass in the left upper lobe was biopsied with fine-needle aspiration and shown to be a primary non-small-cell carcinoma of the lung. PET scan was, otherwise, negative for spread and resection was advised. All the risk and benefits were fully explained to the patient and she elected to proceed as planned. She was transferred to rehab for couple of weeks to buildup strength before the surgery.
PROCEDURE IN DETAIL: In the operating room under anesthesia, she was prepped and draped suitably. Dr. B was the staff anesthesiologist. Left muscle sparing mini thoracotomy was made. The serratus and latissimus muscles were not cut but moved out to the way. Access to the chest was obtained through the fifth intercostal space. Two Tuffier retractors of right angles provided adequate exposure.
The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology. The parietal pleural reflexion around the hilum was now circumcised, and lymph nodes were taken from station 8 and station 5.
The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30/2.5 staple gun or/and the smaller one were ligated with 2-0 silk. The left superior pulmonary vein was transected using a TA30/2.5 staple gun, and the fissure was completed using firings of an endo-GIA 60/4.8 staple gun. Finally, the left upper lobe bronchus was transected using a TA30/4.8 staple gun. Please note, that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe.
The specimen was delivered and sent to pathology. The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe. Frozen section showed that the margin was negative.
The chest was irrigated with warm sterile water and when the left lower lobe inflated, there was no air leak. A single 32-French chest tube was inserted, and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together. A #2 Vicryl pericostal sutures were now applied. The serratus and latissimus muscles retracted back in place. A #19 French Blake drain placed in the subcutaneous tissues and 2-0 Vicryl used for the fat followed by 4-0 Monocryl for the skin. The patient was transferred to the ICU in a stable condition.
Sample Name: Thoracotomy & Pleurectomy
Description: Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left.
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PREOPERATIVE DIAGNOSIS: Empyema of the chest, left.
POSTOPERATIVE DIAGNOSIS: Empyema of the chest, left.
PROCEDURE: Left thoracotomy with total pulmonary decortication and parietal pleurectomy.
PROCEDURE DETAIL: After obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube. A time-out process had been followed and preoperative antibiotics were given.
The patient was positioned with the left side up for a left thoracotomy. The patient was prepped and draped in the usual fashion. A posterolateral thoracotomy was performed. It included the previous incision. The chest was entered through the fifth intercostal space. Actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke. Thanks to Dr. X's ingenuity, we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura. We aspirated an abundant amount of pus from this cavity. The sample was taken for culture and sensitivity.
Then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm. Once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung. Further samples for culture and sensitivity were sent.
Then, we were left with the trapped lung. It was trapped by thickened visceral pleura. This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively. Finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily. There was only one area towards the mediastinum that apparently I was not able to fill. This area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so I restrained from doing that. Two large chest tubes were placed. The cavity had been abundantly irrigated with warm saline. Then, the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.
The chest tubes were affixed to the skin with heavy sutures of silk. Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.
Estimated blood loss was about 500 mL. The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition.
POSTOPERATIVE DIAGNOSIS: Empyema of the chest, left.
PROCEDURE: Left thoracotomy with total pulmonary decortication and parietal pleurectomy.
PROCEDURE DETAIL: After obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube. A time-out process had been followed and preoperative antibiotics were given.
The patient was positioned with the left side up for a left thoracotomy. The patient was prepped and draped in the usual fashion. A posterolateral thoracotomy was performed. It included the previous incision. The chest was entered through the fifth intercostal space. Actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke. Thanks to Dr. X's ingenuity, we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura. We aspirated an abundant amount of pus from this cavity. The sample was taken for culture and sensitivity.
Then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm. Once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung. Further samples for culture and sensitivity were sent.
Then, we were left with the trapped lung. It was trapped by thickened visceral pleura. This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively. Finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily. There was only one area towards the mediastinum that apparently I was not able to fill. This area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so I restrained from doing that. Two large chest tubes were placed. The cavity had been abundantly irrigated with warm saline. Then, the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.
The chest tubes were affixed to the skin with heavy sutures of silk. Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.
Estimated blood loss was about 500 mL. The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition.
Sample Name: Thrombectomy
Description: Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Thrombosed left forearm loop fistula graft.
2. Chronic renal failure.
3. Hyperkalemia.
POSTOPERATIVE DIAGNOSES:
1. Thrombosed left forearm loop fistula graft.
2. Chronic renal failure.
3. Hyperkalemia.
PROCEDURE PERFORMED: Thrombectomy of the left forearm loop graft.
ANESTHESIA: Local with sedation.
ESTIMATED BLOOD LOSS: Less than 5 cc.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The venous outflow was good. There was stenosis in the mid-venous limb of the graft.
INDICATIONS: The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft. She was not able to have her dialysis as routine. Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery. Both Surgery and Anesthesia thought this would be too risky to do. Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning. This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.
PROCEDURE: The patient was taken to the operative suite and prepped and draped in the usual sterile fashion. A transverse incision was made at the region of the venous anastomosis of the graft. Further dissection was carried down to the catheter. The vein appeared to be soft and without thrombus. This outflow did not appear to be significantly impaired. A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis. Next, a thrombectomy was done using a #4 Fogarty catheter. Some of the clot and thrombus was removed from the venous limb. The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis. Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis. At this point, we felt the patient would benefit from a curettage of the venous limb of the graft. This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage. The Fogarty balloon was then passed beyond the clot and the plug. The plug was visualized and inspected. This also gave a good brisk bleeding from the graft. The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb. Attention was directed up to its anastomosis and the vein. Fogarty balloon and thrombectomy was also performed well enough into this way. There was good venous back bleeding following this. The area was checked for any stenosis with the dilators and none was present. Next, a #6-0 Prolene suture was used in a running fashion to close the graft. Just prior to tying the suture, the graft was allowed to flush to move any debris or air. The suture was also checked at that point for augmentation, which was good. The suture was tied down and the wound was irrigated with antibiotic solution. Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges. Steri-Strips were applied and the patient was taken to recovery in stable condition. She tolerated the procedure well. She will be discharged from recovery when stable. She is to resume her regular dialysis schedule and present for dialysis tomorrow.
1. Thrombosed left forearm loop fistula graft.
2. Chronic renal failure.
3. Hyperkalemia.
POSTOPERATIVE DIAGNOSES:
1. Thrombosed left forearm loop fistula graft.
2. Chronic renal failure.
3. Hyperkalemia.
PROCEDURE PERFORMED: Thrombectomy of the left forearm loop graft.
ANESTHESIA: Local with sedation.
ESTIMATED BLOOD LOSS: Less than 5 cc.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The venous outflow was good. There was stenosis in the mid-venous limb of the graft.
INDICATIONS: The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft. She was not able to have her dialysis as routine. Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery. Both Surgery and Anesthesia thought this would be too risky to do. Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning. This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.
PROCEDURE: The patient was taken to the operative suite and prepped and draped in the usual sterile fashion. A transverse incision was made at the region of the venous anastomosis of the graft. Further dissection was carried down to the catheter. The vein appeared to be soft and without thrombus. This outflow did not appear to be significantly impaired. A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis. Next, a thrombectomy was done using a #4 Fogarty catheter. Some of the clot and thrombus was removed from the venous limb. The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis. Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis. At this point, we felt the patient would benefit from a curettage of the venous limb of the graft. This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage. The Fogarty balloon was then passed beyond the clot and the plug. The plug was visualized and inspected. This also gave a good brisk bleeding from the graft. The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb. Attention was directed up to its anastomosis and the vein. Fogarty balloon and thrombectomy was also performed well enough into this way. There was good venous back bleeding following this. The area was checked for any stenosis with the dilators and none was present. Next, a #6-0 Prolene suture was used in a running fashion to close the graft. Just prior to tying the suture, the graft was allowed to flush to move any debris or air. The suture was also checked at that point for augmentation, which was good. The suture was tied down and the wound was irrigated with antibiotic solution. Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges. Steri-Strips were applied and the patient was taken to recovery in stable condition. She tolerated the procedure well. She will be discharged from recovery when stable. She is to resume her regular dialysis schedule and present for dialysis tomorrow.
Sample Name: Thrombectomy AV Shunt
Description: Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Thrombosed arteriovenous shunt left forearm.
POSTOPERATIVE DIAGNOSIS: Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.
PROCEDURE: Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.
ANESTHESIA: Local.
SKIN PREP: Betadine.
DRAINS: None.
PROCEDURE TECHNIQUE: The left arm was prepped and draped. Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop. The runoff vein was dissected out and encircled with the vessel loop as well. A longitudinal incision was made over the venous anastomosis. There was a narrowing in the area and slightly the incision was extended more proximally. There was good back bleeding from the vein as well as bleeding from the more distal vein. These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously. A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established. There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator. The Fogarty catheter was then passed up the vein, but no clot was obtained. A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture. Clamps were removed and flow established. A thrill was easily palpable. Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin. A sterile dressing was applied. The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct.
POSTOPERATIVE DIAGNOSIS: Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.
PROCEDURE: Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.
ANESTHESIA: Local.
SKIN PREP: Betadine.
DRAINS: None.
PROCEDURE TECHNIQUE: The left arm was prepped and draped. Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop. The runoff vein was dissected out and encircled with the vessel loop as well. A longitudinal incision was made over the venous anastomosis. There was a narrowing in the area and slightly the incision was extended more proximally. There was good back bleeding from the vein as well as bleeding from the more distal vein. These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously. A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established. There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator. The Fogarty catheter was then passed up the vein, but no clot was obtained. A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture. Clamps were removed and flow established. A thrill was easily palpable. Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin. A sterile dressing was applied. The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct.
Sample Name: Thromboendarterectomy
Description: Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
OPERATIVE PROCEDURE
1. Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.
2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.
DESCRIPTION: The patient was brought to the operating room, placed in supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The chest, abdomen and legs were prepped and draped in a sterile fashion. The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution. The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped. A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The sternum was closed. A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma. The deep fascia was divided. The facial vein was divided between clamps and tied with 2-0 silk. The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk. Shunts were prepared. A patch was prepared. Heparin 50 mg was given IV. Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery. Distal internal was held with a forceps. Internal carotid artery was opened with 11-blade. Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond. The shunt was placed and proximal and distal snares were tightened. Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external. All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line. Suture line was completed and the neck was packed.
The pericardium was opened. A pericardial cradle was created. The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula. A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet. An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted. The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg. This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus. The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture. The vein was cut to length. Antegrade and retrograde cold blood potassium cardioplegia was given. The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein. The vein was cut to length. The mammary was clipped distally, divided and spatulated for anastomosis. Antegrade and retrograde cold blood potassium cardioplegia was given. The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture. Warm blood potassium cardioplegia was given, and the cross-clamp was removed. A partial-occlusion clamp was placed. Two aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. The partial- occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. Ventilation was commenced. The patient was fully warmed. The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.
1. Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.
2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.
DESCRIPTION: The patient was brought to the operating room, placed in supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The chest, abdomen and legs were prepped and draped in a sterile fashion. The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution. The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped. A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The sternum was closed. A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma. The deep fascia was divided. The facial vein was divided between clamps and tied with 2-0 silk. The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk. Shunts were prepared. A patch was prepared. Heparin 50 mg was given IV. Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery. Distal internal was held with a forceps. Internal carotid artery was opened with 11-blade. Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond. The shunt was placed and proximal and distal snares were tightened. Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external. All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line. Suture line was completed and the neck was packed.
The pericardium was opened. A pericardial cradle was created. The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula. A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet. An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted. The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg. This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus. The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture. The vein was cut to length. Antegrade and retrograde cold blood potassium cardioplegia was given. The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein. The vein was cut to length. The mammary was clipped distally, divided and spatulated for anastomosis. Antegrade and retrograde cold blood potassium cardioplegia was given. The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture. Warm blood potassium cardioplegia was given, and the cross-clamp was removed. A partial-occlusion clamp was placed. Two aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. The partial- occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. Ventilation was commenced. The patient was fully warmed. The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.
Sample Name: Tilt Table Test
Description: Tilt table test. Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
FINDINGS:
1. The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.
2. There was no significant change in heart rate or blood pressure on 80-degree tilt.
3. No symptoms reported during the tilt study.
CONCLUSION: Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.
1. The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.
2. There was no significant change in heart rate or blood pressure on 80-degree tilt.
3. No symptoms reported during the tilt study.
CONCLUSION: Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.
Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Tilt Table Test - 1
Description: Tilt table test. A patient with past medical history of syncope. The patient is also complaining of dizziness.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INDICATIONS: The patient is a 22-year-old female with past medical history of syncope. The patient is also complaining of dizziness. She was referred here by Dr. X for tilt table.
TECHNIQUE: Risks and benefits explained to the patient. Consent obtained. She was lying down on her back for 20 minutes and her blood pressure was 111/75 and heart rate 89. She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120/80. Then, the patient received sublingual nitroglycerin 0.4 mg. The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110/50. The patient felt nauseous and felt hot at that time. She did not pass out.
COMPLICATIONS: None.
Tilt table was then terminated.
SUMMARY: Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure.
RECOMMENDATIONS: I recommend followup in the office in one week and she will need Toprol-XL 12.5 mg every day if symptoms persist.
TECHNIQUE: Risks and benefits explained to the patient. Consent obtained. She was lying down on her back for 20 minutes and her blood pressure was 111/75 and heart rate 89. She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120/80. Then, the patient received sublingual nitroglycerin 0.4 mg. The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110/50. The patient felt nauseous and felt hot at that time. She did not pass out.
COMPLICATIONS: None.
Tilt table was then terminated.
SUMMARY: Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure.
RECOMMENDATIONS: I recommend followup in the office in one week and she will need Toprol-XL 12.5 mg every day if symptoms persist.
Sample Name: Toronto Porcine Valve Insertion
Description: Aortic stenosis. Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Aortic stenosis.
POSTOPERATIVE DIAGNOSIS: Aortic stenosis.
PROCEDURES PERFORMED
1. Insertion of a **-mm Toronto stentless porcine valve.
2. Cardiopulmonary bypass.
3. Cold cardioplegia arrest of the heart.
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 300 cc.
INTRAVENOUS FLUIDS: 1200 cc of crystalloid.
URINE OUTPUT: 250 cc.
AORTIC CROSS-CLAMP TIME: **
CARDIOPULMONARY BYPASS TIME TOTAL: **
PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next the neck, chest and legs were prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make a midline median sternotomy incision. Dissection was carried down to the left of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw. The chest retractor was positioned. Next, full-dose heparin was given. The pericardium was opened. Pericardial stay sutures were positioned. After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass. A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta. Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine. Next a 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine. A 4-0 U-stitch was placed in the right atrium. A retrograde cardioplegia catheter was positioned at this site. Next, scissors were used to dissect out the right upper pulmonary vein. A 4-0 Prolene pursestring was placed in the right upper pulmonary vein. Next, a right-angle sump was placed at this position. We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit. Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery. The aorta was completely encircled. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. We then prepared to cross-clamp the aorta. We went down on our flows and cross-clamped the aorta. We backed up our flows. We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart. The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit. Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures. In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view. Next, scissors were used to excise the diseased aortic valve leaflets. Care was taken to remove all the calcium from the aortic annulus. We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve. We prepared the valve. Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus. We started with our individual commissural stitches. They were connected to our valve sewing ring. Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position. After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve. The valve was lowered into place and all of the sutures were tied. Next, we gave another round of cold blood antegrade and retrograde cardioplegia. Next, we sewed our distal suture line. We began with the left coronary cusp of the valve. We ran a 5-0 RB needle up both sides of the valve. Care was taken to avoid the left coronary ostia. This procedure was repeated on the right cusp of the stentless porcine valve. Again, care was taken to avoid any injury to the coronary ostia. Lastly, we sewed our non-coronary cusp. This was done without difficulty. At this point we inspected our aortic valve. There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open. We gave another round of cold blood antegrade and retrograde cardioplegia. The antegrade portion was given in a direct ostial fashion once again. We now turned our attention to closing the aorta. A 4-0 Prolene double row of suture was used to close the aorta in a running fashion. Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia. At this point, we removed our aortic cross-clamp. The heart gradually regained its electromechanical activity. We placed 2 atrial and 2 ventricular pacing wires. We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle. We removed our retrograde cardioplegia catheter. We oversewed that site with a 5-0 Prolene. By now, the heart was de-aired and resumed normal electromechanical activity. We began to wean the patient from cardiopulmonary bypass. We then removed our venous cannula and suture ligated that site with a #2 silk. We then gave full-dose protamine. After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula. We buttressed that site with a 4-0 Prolene on an SH needle. We placed a mediastinal chest tube and brought it out through the skin. We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions. They were brought out through the skin. The sternum was closed with #7 wires in an interrupted figure-of-eight fashion. The fascia was closed with #1 Vicryl. We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.
POSTOPERATIVE DIAGNOSIS: Aortic stenosis.
PROCEDURES PERFORMED
1. Insertion of a **-mm Toronto stentless porcine valve.
2. Cardiopulmonary bypass.
3. Cold cardioplegia arrest of the heart.
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 300 cc.
INTRAVENOUS FLUIDS: 1200 cc of crystalloid.
URINE OUTPUT: 250 cc.
AORTIC CROSS-CLAMP TIME: **
CARDIOPULMONARY BYPASS TIME TOTAL: **
PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next the neck, chest and legs were prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make a midline median sternotomy incision. Dissection was carried down to the left of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw. The chest retractor was positioned. Next, full-dose heparin was given. The pericardium was opened. Pericardial stay sutures were positioned. After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass. A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta. Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine. Next a 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine. A 4-0 U-stitch was placed in the right atrium. A retrograde cardioplegia catheter was positioned at this site. Next, scissors were used to dissect out the right upper pulmonary vein. A 4-0 Prolene pursestring was placed in the right upper pulmonary vein. Next, a right-angle sump was placed at this position. We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit. Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery. The aorta was completely encircled. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. We then prepared to cross-clamp the aorta. We went down on our flows and cross-clamped the aorta. We backed up our flows. We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart. The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit. Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures. In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view. Next, scissors were used to excise the diseased aortic valve leaflets. Care was taken to remove all the calcium from the aortic annulus. We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve. We prepared the valve. Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus. We started with our individual commissural stitches. They were connected to our valve sewing ring. Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position. After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve. The valve was lowered into place and all of the sutures were tied. Next, we gave another round of cold blood antegrade and retrograde cardioplegia. Next, we sewed our distal suture line. We began with the left coronary cusp of the valve. We ran a 5-0 RB needle up both sides of the valve. Care was taken to avoid the left coronary ostia. This procedure was repeated on the right cusp of the stentless porcine valve. Again, care was taken to avoid any injury to the coronary ostia. Lastly, we sewed our non-coronary cusp. This was done without difficulty. At this point we inspected our aortic valve. There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open. We gave another round of cold blood antegrade and retrograde cardioplegia. The antegrade portion was given in a direct ostial fashion once again. We now turned our attention to closing the aorta. A 4-0 Prolene double row of suture was used to close the aorta in a running fashion. Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia. At this point, we removed our aortic cross-clamp. The heart gradually regained its electromechanical activity. We placed 2 atrial and 2 ventricular pacing wires. We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle. We removed our retrograde cardioplegia catheter. We oversewed that site with a 5-0 Prolene. By now, the heart was de-aired and resumed normal electromechanical activity. We began to wean the patient from cardiopulmonary bypass. We then removed our venous cannula and suture ligated that site with a #2 silk. We then gave full-dose protamine. After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula. We buttressed that site with a 4-0 Prolene on an SH needle. We placed a mediastinal chest tube and brought it out through the skin. We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions. They were brought out through the skin. The sternum was closed with #7 wires in an interrupted figure-of-eight fashion. The fascia was closed with #1 Vicryl. We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.
Sample Name: Tracheostomy
Description: Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES
Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.
POSTOPERATIVE DIAGNOSES
Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.
OPERATION PERFORMED
Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.
INDICATIONS FOR SURGERY
The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement. However developed progressive problems and he had two additional stents placed with some initial improvement. Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY. He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes. The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management. Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient. Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length. The patient stated that he understood and wished to proceed.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room, placed in the supine position. Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion. The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine. A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out. The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly. Strap muscles were separated in the midline, dissection carried down to visceral fascia. Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks. There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable. There was a markedly enlarged thyroid isthmus. Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection. Trachea was exposed from the cricoid to the fourth ring which entered down into the chest. The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation. The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness. The trachea was entered and visualized with thickening of the mucosa and submucosa was noted. The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered. Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site. Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea. A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis. After removal of the stents and granulation tissue, the upper trachea was widely patent. The mid trachea had some marked narrowing secondary to granulation. Stent material was removed from this area as well. In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time. All visible stent material in the upper and mid trachea were removed. Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third. Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube. A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa. The distal trachea and mainstem bronchi were widely patent. This secured his airway and no further manipulation felt to be needed at this time. Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl. The skin laterally to the trach site was closed with running 2-0 Prolene. Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition. The patient tolerated the procedure well without complication.
Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.
POSTOPERATIVE DIAGNOSES
Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.
OPERATION PERFORMED
Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.
INDICATIONS FOR SURGERY
The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement. However developed progressive problems and he had two additional stents placed with some initial improvement. Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY. He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes. The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management. Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient. Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length. The patient stated that he understood and wished to proceed.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room, placed in the supine position. Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion. The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine. A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out. The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly. Strap muscles were separated in the midline, dissection carried down to visceral fascia. Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks. There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable. There was a markedly enlarged thyroid isthmus. Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection. Trachea was exposed from the cricoid to the fourth ring which entered down into the chest. The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation. The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness. The trachea was entered and visualized with thickening of the mucosa and submucosa was noted. The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered. Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site. Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea. A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis. After removal of the stents and granulation tissue, the upper trachea was widely patent. The mid trachea had some marked narrowing secondary to granulation. Stent material was removed from this area as well. In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time. All visible stent material in the upper and mid trachea were removed. Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third. Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube. A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa. The distal trachea and mainstem bronchi were widely patent. This secured his airway and no further manipulation felt to be needed at this time. Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl. The skin laterally to the trach site was closed with running 2-0 Prolene. Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition. The patient tolerated the procedure well without complication.
Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram
Description: Transesophageal echocardiogram and direct current cardioversion.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
EXAM: Transesophageal echocardiogram and direct current cardioversion.
REASON FOR EXAM:
1. Atrial fibrillation with rapid ventricular rate.
2. Shortness of breath.
PROCEDURE: After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl. Following this, transesophageal probe was placed in the esophagus. Transesophageal views of the heart were then obtained.
FINDINGS:
1. Left ventricle is of normal size. Overall LV systolic function is preserved. Estimated ejection fraction is 60% to 65%. No wall motion abnormalities are noted.
2. Left atrium is dilated.
3. Left atrial appendage is free of clots.
4. Right atrium is of normal size.
5. Right ventricle is of normal size.
6. Mitral valve shows evidence of mild MAC.
7. Aortic valve is sclerotic without significant restriction of leaflet motion.
8. Tricuspid valve appears normal.
9. Pulmonic valve appears normal.
10. Pacer wires are noted in the right atrium and in the right ventricle.
11. Doppler interrogation of moderate mitral regurgitation is present.
12. Mild-to-moderate AI is seen.
13. No significant TR is noted.
14. No significant TI is noted.
15. No pericardial disease seen.
IMPRESSION:
1. Preserved left ventricular systolic function.
2. Dilated left atrium.
3. Moderate mitral regurgitation.
4. Aortic valve sclerosis with mild-to-moderate aortic insufficiency.
5. Left atrial appendage is free of clots.
Following these, direct current cardioversion was performed. Three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm. The patient remained in atrial fibrillation.
PLAN: Plan will be to continue medical therapy. We will consider using beta-blocker, calcium channel blockers for better ventricular rate control.
REASON FOR EXAM:
1. Atrial fibrillation with rapid ventricular rate.
2. Shortness of breath.
PROCEDURE: After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl. Following this, transesophageal probe was placed in the esophagus. Transesophageal views of the heart were then obtained.
FINDINGS:
1. Left ventricle is of normal size. Overall LV systolic function is preserved. Estimated ejection fraction is 60% to 65%. No wall motion abnormalities are noted.
2. Left atrium is dilated.
3. Left atrial appendage is free of clots.
4. Right atrium is of normal size.
5. Right ventricle is of normal size.
6. Mitral valve shows evidence of mild MAC.
7. Aortic valve is sclerotic without significant restriction of leaflet motion.
8. Tricuspid valve appears normal.
9. Pulmonic valve appears normal.
10. Pacer wires are noted in the right atrium and in the right ventricle.
11. Doppler interrogation of moderate mitral regurgitation is present.
12. Mild-to-moderate AI is seen.
13. No significant TR is noted.
14. No significant TI is noted.
15. No pericardial disease seen.
IMPRESSION:
1. Preserved left ventricular systolic function.
2. Dilated left atrium.
3. Moderate mitral regurgitation.
4. Aortic valve sclerosis with mild-to-moderate aortic insufficiency.
5. Left atrial appendage is free of clots.
Following these, direct current cardioversion was performed. Three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm. The patient remained in atrial fibrillation.
PLAN: Plan will be to continue medical therapy. We will consider using beta-blocker, calcium channel blockers for better ventricular rate control.
Sample Name: Transesophageal Echocardiography Probe
Description: Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.
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(Medical Transcription Sample Report)
INDICATIONS FOR PROCEDURE: Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.
Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.
PROCEDURE #1: Insertion of transesophageal echocardiography probe.
DESCRIPTION OF PROCEDURE #1: The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance. The probe was placed so that the larger diameter was in the anterior-posterior position during insertion. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. At the end, it was removed without trauma and there was no blood tingeing. It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned. There was no overt bleeding.
PROCEDURE #2: Attempted and unsuccessful insertion of arterial venous lines.
DESCRIPTION OF PROCEDURE #2: Both groins were prepped and draped. The patient was placed at 10 degrees head-up position. A Cook 4-French double-lumen 8-cm catheter kit was opened. Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin. There were several successful punctures of these vessels, but I was unable to advance Seldinger wire. After removal of the needles, the area was compressed digitally for approximately 5 minutes. There was a small hematoma that was not growing. Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds. Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath. Further observation, the capillary refill and circulation of the left leg became more than adequate. The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end. At the end of the procedure, the circulation of the leg was intact.
Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.
PROCEDURE #1: Insertion of transesophageal echocardiography probe.
DESCRIPTION OF PROCEDURE #1: The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance. The probe was placed so that the larger diameter was in the anterior-posterior position during insertion. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. At the end, it was removed without trauma and there was no blood tingeing. It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned. There was no overt bleeding.
PROCEDURE #2: Attempted and unsuccessful insertion of arterial venous lines.
DESCRIPTION OF PROCEDURE #2: Both groins were prepped and draped. The patient was placed at 10 degrees head-up position. A Cook 4-French double-lumen 8-cm catheter kit was opened. Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin. There were several successful punctures of these vessels, but I was unable to advance Seldinger wire. After removal of the needles, the area was compressed digitally for approximately 5 minutes. There was a small hematoma that was not growing. Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds. Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath. Further observation, the capillary refill and circulation of the left leg became more than adequate. The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end. At the end of the procedure, the circulation of the leg was intact.
Sample Name: Transesophageal Echocardiogram - 1
Description: Transesophageal echocardiogram for aortic stenosis. Normal left ventricular size and function. Benign Doppler flow pattern. Doppler study essentially benign. Aorta essentially benign. Atrial septum intact. Study was negative.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INDICATION: Aortic stenosis.
PROCEDURE: Transesophageal echocardiogram.
INTERPRETATION: Procedure and complications explained to the patient in detail. Informed consent was obtained. The patient was anesthetized in the throat with lidocaine spray. Subsequently, 3 mg of IV Versed was given for sedation. The patient was positioned and transesophageal probe was introduced without any difficulty. Images were taken. The patient tolerated the procedure very well without any complications. Findings as mentioned below.
FINDINGS:
1. Left ventricle is in normal size and dimension. Normal function. Ejection fraction of 60%.
2. Left atrium and right-sided chambers are of normal size and dimension.
3. Mitral, tricuspid, and pulmonic valves are structurally normal.
4. Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.
5. Left atrial appendage is clean without any clot or smoke effect.
6. Atrial septum intact. Study was negative.
7. Doppler study essentially benign.
8. Aorta essentially benign.
9. Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.
SUMMARY:
1. Normal left ventricular size and function.
2. Benign Doppler flow pattern.
3. Aortic valve area of 1.3 cm2 planimetry.
PROCEDURE: Transesophageal echocardiogram.
INTERPRETATION: Procedure and complications explained to the patient in detail. Informed consent was obtained. The patient was anesthetized in the throat with lidocaine spray. Subsequently, 3 mg of IV Versed was given for sedation. The patient was positioned and transesophageal probe was introduced without any difficulty. Images were taken. The patient tolerated the procedure very well without any complications. Findings as mentioned below.
FINDINGS:
1. Left ventricle is in normal size and dimension. Normal function. Ejection fraction of 60%.
2. Left atrium and right-sided chambers are of normal size and dimension.
3. Mitral, tricuspid, and pulmonic valves are structurally normal.
4. Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.
5. Left atrial appendage is clean without any clot or smoke effect.
6. Atrial septum intact. Study was negative.
7. Doppler study essentially benign.
8. Aorta essentially benign.
9. Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.
SUMMARY:
1. Normal left ventricular size and function.
2. Benign Doppler flow pattern.
3. Aortic valve area of 1.3 cm2 planimetry.
Sample Name: Transesophageal Echocardiogram - 2
Description: Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function. Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.
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(Medical Transcription Sample Report)
REASON FOR EXAM: Vegetation and bacteremia.
PROCEDURE: Transesophageal echocardiogram.
INTERPRETATION: The procedure and its complications were explained to the patient in detail and formal consent was obtained. The patient was brought to special procedure unit. His throat was anesthetized with lidocaine spray. Subsequently, 2 mg of IV Versed was given for sedation. The patient was positioned. Probe was introduced without any difficulty. The patient tolerated the procedure very well. Probe was taken out. No complications were noted. Findings are as mentioned below.
FINDINGS:
1. Left ventricle has normal size and dimensions with normal function. Ejection fraction of 60%.
2. Left atrium and right-sided chambers were of normal size and dimensions.
3. Left atrial appendage is clean without any clot or smoke effect.
4. Atrial septum is intact. Bubble study was negative.
5. Mitral valve is structurally normal.
6. Aortic valve reveals echodensity suggestive of vegetation.
7. Tricuspid valve was structurally normal.
8. Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.
9. Aorta is benign.
IMPRESSION:
1. Normal left ventricular size and function.
2. Echodensity involving the aortic valve suggestive of endocarditis and vegetation.
3. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.
PROCEDURE: Transesophageal echocardiogram.
INTERPRETATION: The procedure and its complications were explained to the patient in detail and formal consent was obtained. The patient was brought to special procedure unit. His throat was anesthetized with lidocaine spray. Subsequently, 2 mg of IV Versed was given for sedation. The patient was positioned. Probe was introduced without any difficulty. The patient tolerated the procedure very well. Probe was taken out. No complications were noted. Findings are as mentioned below.
FINDINGS:
1. Left ventricle has normal size and dimensions with normal function. Ejection fraction of 60%.
2. Left atrium and right-sided chambers were of normal size and dimensions.
3. Left atrial appendage is clean without any clot or smoke effect.
4. Atrial septum is intact. Bubble study was negative.
5. Mitral valve is structurally normal.
6. Aortic valve reveals echodensity suggestive of vegetation.
7. Tricuspid valve was structurally normal.
8. Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.
9. Aorta is benign.
IMPRESSION:
1. Normal left ventricular size and function.
2. Echodensity involving the aortic valve suggestive of endocarditis and vegetation.
3. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.
Sample Name: Transesophageal Echocardiogram - 3
Description: Transesophageal echocardiographic examination report. Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.
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(Medical Transcription Sample Report)
REASON FOR EXAM: Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.
PREOPERATIVE DIAGNOSIS: Atrial valve replacement.
POSTOPERATIVE DIAGNOSES: Moderate stenosis of aortic valve replacement. Mild mitral regurgitation. Normal left ventricular function.
PROCEDURES IN DETAIL: The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control. The oropharynx anesthetized with benzocaine spray and lidocaine solution.
Esophageal intubation was done with no difficulty with the second attempt. In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm. Multiple pictures obtained. Assessment of the peak velocity was done later.
The probe was pulled to the mid esophageal level. Different pictures including short-axis views of the aortic valve was done. Extubation done with no problems and no blood on the probe. The patient tolerated the procedure well with no immediate postprocedure complications.
INTERPRETATION: The left atrium was mildly dilated. No masses or thrombi were seen. The left atrial appendage was free of thrombus. Pulse wave interrogation showed peak velocities of 60 cm per second.
The left ventricle was normal in size and contractility with mild LVH. EF is normal and preserved.
The right atrium and right ventricle were both normal in size.
Mitral valve showed no vegetations or prolapse. There was mild-to-moderate regurgitation on color flow interrogation. Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed. No perivalvular leak was noticed. There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.
No AIC.
Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve. Overall showed no abnormalities. The tricuspid valve was structurally normal.
Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.
The aorta and aortic arch were unremarkable. No dissection.
IMPRESSION:
1. Mildly dilated left atrium.
2. Mild-to-moderate regurgitation.
3. Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis. Reevaluation in two to three years with transthoracic echocardiogram will be recommended.
PREOPERATIVE DIAGNOSIS: Atrial valve replacement.
POSTOPERATIVE DIAGNOSES: Moderate stenosis of aortic valve replacement. Mild mitral regurgitation. Normal left ventricular function.
PROCEDURES IN DETAIL: The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control. The oropharynx anesthetized with benzocaine spray and lidocaine solution.
Esophageal intubation was done with no difficulty with the second attempt. In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm. Multiple pictures obtained. Assessment of the peak velocity was done later.
The probe was pulled to the mid esophageal level. Different pictures including short-axis views of the aortic valve was done. Extubation done with no problems and no blood on the probe. The patient tolerated the procedure well with no immediate postprocedure complications.
INTERPRETATION: The left atrium was mildly dilated. No masses or thrombi were seen. The left atrial appendage was free of thrombus. Pulse wave interrogation showed peak velocities of 60 cm per second.
The left ventricle was normal in size and contractility with mild LVH. EF is normal and preserved.
The right atrium and right ventricle were both normal in size.
Mitral valve showed no vegetations or prolapse. There was mild-to-moderate regurgitation on color flow interrogation. Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed. No perivalvular leak was noticed. There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.
No AIC.
Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve. Overall showed no abnormalities. The tricuspid valve was structurally normal.
Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.
The aorta and aortic arch were unremarkable. No dissection.
IMPRESSION:
1. Mildly dilated left atrium.
2. Mild-to-moderate regurgitation.
3. Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis. Reevaluation in two to three years with transthoracic echocardiogram will be recommended.
Sample Name: Transesophageal Echocardiogram - 4
Description: Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.
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PROCEDURE NOTE: The patient was brought to the transesophageal echo laboratory after informed consent was obtained. The patient was seen by Anesthesia for MAC anesthesia. The patient's posterior pharynx was anesthetized with local Cetacaine spray. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.
FINDINGS:
1. Left ventricle is normal in size and function; ejection fraction approximately 60%.
2. Right ventricle is normal in size and function.
3. Left atrium and right atrium are normal in size.
4. Mitral valve, aortic valve, tricuspid valve, and pulmonic valve with no evidence of vegetation. Aortic valve is only minimally thickened.
5. Mild mitral regurgitation and mild tricuspid regurgitation.
6. No left ventricular thrombus.
7. No pericardial effusion.
8. There is evidence of patent foramen ovale by contrast study.
The patient tolerated the procedure well and is sent to recovery in stable condition. He should be n.p.o. x4 hours, then liquid, then increase as tolerated. Once his infection is cleared, he should follow up with us with regard to followup of patent foramen ovale.
FINDINGS:
1. Left ventricle is normal in size and function; ejection fraction approximately 60%.
2. Right ventricle is normal in size and function.
3. Left atrium and right atrium are normal in size.
4. Mitral valve, aortic valve, tricuspid valve, and pulmonic valve with no evidence of vegetation. Aortic valve is only minimally thickened.
5. Mild mitral regurgitation and mild tricuspid regurgitation.
6. No left ventricular thrombus.
7. No pericardial effusion.
8. There is evidence of patent foramen ovale by contrast study.
The patient tolerated the procedure well and is sent to recovery in stable condition. He should be n.p.o. x4 hours, then liquid, then increase as tolerated. Once his infection is cleared, he should follow up with us with regard to followup of patent foramen ovale.
Sample Name: Transesophageal Echocardiogram - 5
Description: Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.
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(Medical Transcription Sample Report)
CLINICAL INDICATIONS: MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.
DESCRIPTION OF PROCEDURE: The transesophageal echocardiogram was performed after getting verbal and a written consent signed. Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained. There were no complications. The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.
FINDINGS:
1. Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp. The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.
2. Mitral valve is calcified and thick. No vegetation seen. There is mild-to-moderate MR present. There is mild AI present also.
3. Tricuspid valve and pulmonary valve are structurally normal.
4. There is a mild TR present.
5. There is no clot seen in the left atrial appendage. The velocity in the left atrial appendage was 0.6 m/sec.
6. Intraatrial septum was intact. There is no clot or mass seen.
7. Normal LV and RV systolic function.
8. There is thick raised calcified plaque seen in the thoracic aorta and arch.
SUMMARY:
1. There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis. Calculated aortic valve area was 0.6 sq. cm.
2. Normal LV systolic function.
DESCRIPTION OF PROCEDURE: The transesophageal echocardiogram was performed after getting verbal and a written consent signed. Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained. There were no complications. The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.
FINDINGS:
1. Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp. The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.
2. Mitral valve is calcified and thick. No vegetation seen. There is mild-to-moderate MR present. There is mild AI present also.
3. Tricuspid valve and pulmonary valve are structurally normal.
4. There is a mild TR present.
5. There is no clot seen in the left atrial appendage. The velocity in the left atrial appendage was 0.6 m/sec.
6. Intraatrial septum was intact. There is no clot or mass seen.
7. Normal LV and RV systolic function.
8. There is thick raised calcified plaque seen in the thoracic aorta and arch.
SUMMARY:
1. There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis. Calculated aortic valve area was 0.6 sq. cm.
2. Normal LV systolic function.
Sample Name: Transthoracic Echocardiography
Description: Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe.
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(Medical Transcription Sample Report)
REASON FOR EXAM: Coronary artery bypass surgery and aortic stenosis.
FINDINGS: Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50% to 55%. Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm. Left atrium is enlarged, measuring 4.42 cm. Right-sided chambers are normal in size and dimensions. Aortic root has normal diameter.
Mitral and tricuspid valve reveals annular calcification. Fibrocalcific valve leaflets noted with adequate excursion. Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.
Doppler study reveals mild-to-moderate mitral regurgitation. Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis. There is also mitral stenosis.
IMPRESSION:
1. Concentric hypertrophy of the left ventricle with left ventricular function.
2. Moderate mitral regurgitation.
3. Severe aortic stenosis, severe.
FINDINGS: Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50% to 55%. Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm. Left atrium is enlarged, measuring 4.42 cm. Right-sided chambers are normal in size and dimensions. Aortic root has normal diameter.
Mitral and tricuspid valve reveals annular calcification. Fibrocalcific valve leaflets noted with adequate excursion. Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.
Doppler study reveals mild-to-moderate mitral regurgitation. Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis. There is also mitral stenosis.
IMPRESSION:
1. Concentric hypertrophy of the left ventricle with left ventricular function.
2. Moderate mitral regurgitation.
3. Severe aortic stenosis, severe.
Sample Name: Treadmill Test
Description: The patient was exercised according to standard Bruce protocol for 9 minutes.
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REASON FOR EXAMINATION: Abnormal EKG.
FINDINGS: The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. Peak blood pressure was 132/60. The patient did not experience any chest discomfort during stress or recovery. The test was terminated due to leg fatigue and achieving target heart rate.
Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram. Technetium was injected at 5 minutes into stress.
IMPRESSION:
1. Good exercise tolerance.
2. Adequate heart rate and blood pressure response.
3. This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease.
FINDINGS: The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. Peak blood pressure was 132/60. The patient did not experience any chest discomfort during stress or recovery. The test was terminated due to leg fatigue and achieving target heart rate.
Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram. Technetium was injected at 5 minutes into stress.
IMPRESSION:
1. Good exercise tolerance.
2. Adequate heart rate and blood pressure response.
3. This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease.
Sample Name: Triple Lumen Catheter Insertion
Description: Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.
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PREOPERATIVE DIAGNOSES:
1. Hyperpyrexia/leukocytosis.
2. Ventilator-dependent respiratory failure.
3. Acute pancreatitis.
POSTOPERATIVE DIAGNOSES:
1. Hyperpyrexia/leukocytosis.
2. Ventilator-dependent respiratory failure.
3. Acute pancreatitis.
PROCEDURE PERFORMED:
1. Insertion of a right brachial artery arterial catheter.
2. Insertion of a right subclavian vein triple lumen catheter.
ANESTHESIA: Local, 1% lidocaine.
BLOOD LOSS: Less than 5 cc.
COMPLICATIONS: None.
INDICATIONS: The patient is a 46-year-old Caucasian female admitted with severe pancreatitis. She was severely dehydrated and necessitated some fluid boluses. The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic. She required intubation and has been ventilator-dependent in the Intensive Care since that time. The patient developed very high temperatures as well as leukocytosis. Her lines required being changed.
PROCEDURE:
1. RIGHT BRACHIAL ARTERIAL LINE: The patient's right arm was prepped and draped in the usual sterile fashion. There was a good brachial pulse palpated. The artery was cannulated with the provided needle and the kit. There was good arterial blood return noted immediately. On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty. The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery. The femoral catheter was used in this case secondary to the patient's severe edema and anasarca. We did not feel that the shorter catheter would provide enough length. The catheter was connected to the system and flushed without difficulty. A good waveform was noted. The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.
2. RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER: The patient was prepped and draped in the usual sterile fashion. 1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle. Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized. Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle. We roughed the needle down off the clavicle and directed it towards the sternal notch. There was good venous return noted immediately. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein. The needle was then removed. A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein. Next, the triple lumen catheter was inserted over the guidewire without difficulty. The guidewire was removed. All the ports aspirated and flushed without difficulty. The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied. The patient tolerated the above procedures well. A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.
1. Hyperpyrexia/leukocytosis.
2. Ventilator-dependent respiratory failure.
3. Acute pancreatitis.
POSTOPERATIVE DIAGNOSES:
1. Hyperpyrexia/leukocytosis.
2. Ventilator-dependent respiratory failure.
3. Acute pancreatitis.
PROCEDURE PERFORMED:
1. Insertion of a right brachial artery arterial catheter.
2. Insertion of a right subclavian vein triple lumen catheter.
ANESTHESIA: Local, 1% lidocaine.
BLOOD LOSS: Less than 5 cc.
COMPLICATIONS: None.
INDICATIONS: The patient is a 46-year-old Caucasian female admitted with severe pancreatitis. She was severely dehydrated and necessitated some fluid boluses. The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic. She required intubation and has been ventilator-dependent in the Intensive Care since that time. The patient developed very high temperatures as well as leukocytosis. Her lines required being changed.
PROCEDURE:
1. RIGHT BRACHIAL ARTERIAL LINE: The patient's right arm was prepped and draped in the usual sterile fashion. There was a good brachial pulse palpated. The artery was cannulated with the provided needle and the kit. There was good arterial blood return noted immediately. On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty. The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery. The femoral catheter was used in this case secondary to the patient's severe edema and anasarca. We did not feel that the shorter catheter would provide enough length. The catheter was connected to the system and flushed without difficulty. A good waveform was noted. The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.
2. RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER: The patient was prepped and draped in the usual sterile fashion. 1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle. Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized. Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle. We roughed the needle down off the clavicle and directed it towards the sternal notch. There was good venous return noted immediately. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein. The needle was then removed. A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein. Next, the triple lumen catheter was inserted over the guidewire without difficulty. The guidewire was removed. All the ports aspirated and flushed without difficulty. The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied. The patient tolerated the above procedures well. A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.
Sample Name: Triple Lumen Catheter Insertion - 1
Description: Need for intravenous access. Insertion of a right femoral triple lumen catheter. he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.
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PREOPERATIVE DIAGNOSIS: Need for intravenous access.
POSTOPERATIVE DIAGNOSIS: Need for intravenous access.
PROCEDURE PERFORMED: Insertion of a right femoral triple lumen catheter.
ANESTHESIA: Includes 4 cc of 1% lidocaine locally.
ESTIMATED BLOOD LOSS: Minimum.
INDICATIONS: The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site. The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.
PROCEDURE: The patient's legal guardian was talked to. All questions were answered and consent was obtained. The patient was sterilely prepped and draped. Approximately 4 cc of 1% lidocaine was injected into the inguinal site. A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated. A guidewire was then placed through the needle. The needle was then removed. The skin was ________ at the base of the wire and a dilator was placed over the wire. The triple lumen catheters were then flushed with bacteriostatic saline. The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.
The wire was then carefully removed. Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports. Each port was closed off and also kept off. Straight needle suture was then used to suture the triple lumen catheter down to the skin. Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site. The surgical site was then sterilely cleaned. The patient tolerated the full procedure well. There were no complications. The nurse was then contacted to allow for access of the triple lumen catheter.
POSTOPERATIVE DIAGNOSIS: Need for intravenous access.
PROCEDURE PERFORMED: Insertion of a right femoral triple lumen catheter.
ANESTHESIA: Includes 4 cc of 1% lidocaine locally.
ESTIMATED BLOOD LOSS: Minimum.
INDICATIONS: The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site. The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.
PROCEDURE: The patient's legal guardian was talked to. All questions were answered and consent was obtained. The patient was sterilely prepped and draped. Approximately 4 cc of 1% lidocaine was injected into the inguinal site. A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated. A guidewire was then placed through the needle. The needle was then removed. The skin was ________ at the base of the wire and a dilator was placed over the wire. The triple lumen catheters were then flushed with bacteriostatic saline. The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.
The wire was then carefully removed. Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports. Each port was closed off and also kept off. Straight needle suture was then used to suture the triple lumen catheter down to the skin. Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site. The surgical site was then sterilely cleaned. The patient tolerated the full procedure well. There were no complications. The nurse was then contacted to allow for access of the triple lumen catheter.
Sample Name: Ultrasound - Carotid - 1
Description: Right and Left carotid ultrasound
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RIGHT:
1. Mild heterogeneous plaque seen in common carotid artery.
2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery.
3. Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%.
4. Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.
5. Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.
LEFT:
1. Mild heterogeneous plaque seen in common carotid artery and external carotid artery.
2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.
3. Peak systolic velocity is normal in common carotid artery and in the bulb.
4. Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.
VERTEBRALS: Antegrade flow seen bilaterally.
1. Mild heterogeneous plaque seen in common carotid artery.
2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery.
3. Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%.
4. Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.
5. Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.
LEFT:
1. Mild heterogeneous plaque seen in common carotid artery and external carotid artery.
2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.
3. Peak systolic velocity is normal in common carotid artery and in the bulb.
4. Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.
VERTEBRALS: Antegrade flow seen bilaterally.
Sample Name: Ultrasound - Carotid - 2
Description: Bilateral carotid ultrasound to evaluate pain.
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EXAM: Ultrasound carotid, bilateral.
REASON FOR EXAMINATION: Pain.
COMPARISON: None.
FINDINGS: Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery. There are no different colors or spectral Doppler waveform abnormalities.
PARAMETRIC DATA: Right CCA PSV 0.72 m/s. Right ICA PSV is 0.595 m/s. Right ICA EDV 0.188 m/s. Right vertebral 0.517 m/s. Right IC/CC is 0.826. Left CCA PSV 0.571 m/s, left ICA PSV 0.598 m/s. Left ICA EDV 0.192 m/s. Left vertebral 0.551 m/s. Left IC/CC is 1.047.
IMPRESSION:
1. No evidence for clinically significant stenosis.
2. Minimal, predominantly soft plaquing.
REASON FOR EXAMINATION: Pain.
COMPARISON: None.
FINDINGS: Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery. There are no different colors or spectral Doppler waveform abnormalities.
PARAMETRIC DATA: Right CCA PSV 0.72 m/s. Right ICA PSV is 0.595 m/s. Right ICA EDV 0.188 m/s. Right vertebral 0.517 m/s. Right IC/CC is 0.826. Left CCA PSV 0.571 m/s, left ICA PSV 0.598 m/s. Left ICA EDV 0.192 m/s. Left vertebral 0.551 m/s. Left IC/CC is 1.047.
IMPRESSION:
1. No evidence for clinically significant stenosis.
2. Minimal, predominantly soft plaquing.
Sample Name: Urgent Cardiac Cath
Description: Urgent cardiac catheterization with coronary angiogram.
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PROCEDURE: Urgent cardiac catheterization with coronary angiogram.
PROCEDURE IN DETAIL: The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.
RESULTS
1. The left main was free of disease.
2. The left anterior descending and its branches were free of disease.
3. The circumflex was free of disease.
4. The right coronary artery was free of disease. There was no gradient across the aortic valve.
IMPRESSION: Normal coronary angiogram.
PROCEDURE IN DETAIL: The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.
RESULTS
1. The left main was free of disease.
2. The left anterior descending and its branches were free of disease.
3. The circumflex was free of disease.
4. The right coronary artery was free of disease. There was no gradient across the aortic valve.
IMPRESSION: Normal coronary angiogram.
Sample Name: VVIR Permanent Pacemaker Insertion
Description: Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias
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(Medical Transcription Sample Report)
PROCEDURE PERFORMED: Insertion of a VVIR permanent pacemaker.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
SITE: Left subclavian vein access.
INDICATION: This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment. It is overall a Class-II indication for permanent pacemaker insertion.
PROCEDURE: The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length. Overall options and precautions of the pacemaker and indications were all discussed. They agreed to the pacemaker. The consent was signed and placed in the chart. The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure. Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.
IV sedation, increments, and analgesics were given. Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty. A guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia. The skin was then undermined used to make a pocket for the pacemaker. The guidewire was then tunneled through the pacer pocket. Cordis sheath was then inserted through the guidewire. The guidewire and dilator were removed. ___ cordis sheath was in placed within. This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy. It was placed into the apex. Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle. The lead was then connected on pulse generator. The pocket was then irrigated and cleansed. Pulse generator and the wire was then inserted into the ____ pocket. The skin was then closed with gut suture. The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique. The area was then cleansed and dried. Steri-Strips and pressure dressing was then applied. The patient tolerated the procedure well. there was no complications.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
SITE: Left subclavian vein access.
INDICATION: This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment. It is overall a Class-II indication for permanent pacemaker insertion.
PROCEDURE: The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length. Overall options and precautions of the pacemaker and indications were all discussed. They agreed to the pacemaker. The consent was signed and placed in the chart. The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure. Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.
IV sedation, increments, and analgesics were given. Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty. A guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia. The skin was then undermined used to make a pocket for the pacemaker. The guidewire was then tunneled through the pacer pocket. Cordis sheath was then inserted through the guidewire. The guidewire and dilator were removed. ___ cordis sheath was in placed within. This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy. It was placed into the apex. Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle. The lead was then connected on pulse generator. The pocket was then irrigated and cleansed. Pulse generator and the wire was then inserted into the ____ pocket. The skin was then closed with gut suture. The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique. The area was then cleansed and dried. Steri-Strips and pressure dressing was then applied. The patient tolerated the procedure well. there was no complications.
