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Heart Catheterization, Ventriculography, & Angiography – 1

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.

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%.

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.

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