PROCEDURES PERFORMED: Cardiac catheterization and percutaneous revascularization of left anterior descending artery, circumflex, and right coronary artery.
INDICATION FOR PROCEDURE: Recent non-ST elevation infarct.
DETAILS OF PROCEDURE: The patient was taken to the cardiac catheterization lab, prepped and draped in the usual sterile fashion, sedated with Versed and fentanyl. The right groin was infiltrated with 2% lidocaine. A 6 French sheath was placed in the right common femoral artery.
For the diagnostic portion of the procedure, an XB 3.5 guide and 3DRC guide were utilized. For the intervention on the circumflex, an XB 3.5 guide was utilized for intervention on the LAD. Judkins left 3.5 guide was utilized for the intervention on the right coronary artery. Multiple catheters were utilized. The only one that seated reasonably was internal mammary artery guide with side holes.
For the interventions on the left coronary, Balance Middle Weight wire was utilized for the right coronary artery. A Choice PT floppy was utilized.
FINDINGS:
1. The left main is free of disease and bifurcates to a nondominant circumflex and LAD. Circumflex gives off a large marginal with a 90% stenosis in its mid section.
2. LAD wraps around the apex and bifurcates. It gives off a large first diagonal with an ostial 70% stenosis and a 70% stenosis 1 cm thereafter. The LAD then has a likely 70% stenosis in its mid section.
3. Right coronary artery is a dominant vessel, gives off posterior descending and posterolateral branches and has a 50% proximal lesion and 80% lesion in its mid portion approximately 1 cm downstream from this 70% proximal lesion. The posterior descending and posterolateral branches have no significant disease.
4. The left ventricular end-diastolic pressure is 20 mmHg. Ejection fraction is 55% with no segmental wall motion abnormality. No gradient across the aortic valve. No mitral regurgitation.
For the intervention, the patient was given weight-based heparin and Integrilin. Balance Middle Weight wire was used to cross the lesion in the circumflex and this was primarily stented with a 3.5 x 20 mm Taxus drug-eluting stent.
Subsequently, the LAD was intubated and the lesion in the LAD was primarily stented with a 2.5 x 20 mm Taxus drug-eluting stent. Subsequently, the right coronary artery was intubated. The more distal lesion was ballooned with a 2.5 x 12 mm balloon to a residual 70% stenosis. This was moderately calcified and difficult to intubate.
A 20 mm stent would not make it around the turn and get into this lesion. Subsequently, a 3.0 x 12 mm Taxus drug-eluting stent was deployed in the lesion to a residual 0% stenosis and then another Taxus 3.0 x 12 mm drug-eluting stent was deployed in the more proximal lesion to a residual 0% stenosis.
Of note, there was extensive spasm of the distal LAD. During the LAD intervention, this was relieved by withdrawing the wire and giving the patient 300 mcg of intracoronary nitroglycerin.
IMPRESSION: Successful revascularization of left anterior descending artery, circumflex, and right coronary artery. The diagonal was left alone given its ostial nature. Recommendation would be to maintain the patient on medical therapy. Continue aggressive medical therapy.
