PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Selective coronary angiography.
INDICATION FOR PROCEDURE: Non-ST elevation MI.
DESCRIPTION OF PROCEDURE: The patient was brought to the cardiac catheterization lab in fasting state, informed consent was obtained and the patient was prepped and draped in sterile fashion. Mild sedation was administered via IV Versed and fentanyl with attending present during administration of sedation. The right common femoral region was then anesthetized via 10 mL of 2% lidocaine and the right common femoral artery was accessed via single wall puncture technique and a 4-French femoral arterial sheath was advanced over a guidewire using modified Seldinger technique. Next, a 4-French angled pigtail catheter was advanced over a guidewire to the level of the ascending aorta. This catheter was used to cross the aortic valve and enter the left ventricle where hemodynamic measurements were obtained. Due to significantly elevated left ventricular end-diastolic pressures, no left ventriculography was performed. The pigtail catheter was then used to obtain hemodynamic measurements upon pullback across the aortic valve into the ascending aorta. This pigtail catheter was then subsequently withdrawn over a guidewire. Next, a 4-French 3DRC catheter was advanced over a guidewire to the level of the ascending aorta. This catheter was used to selectively engage the right coronary artery. The right coronary artery and its branches were then imaged in multiple planes and views. The 3DRC catheter was then withdrawn over a guidewire. Next, a 4-French JL4.5 catheter was advanced over the guidewire to the level of the ascending aorta. This catheter was used to selectively engage the left main coronary artery. The left main coronary artery and its branches were then imaged in multiple planes and views. The JL4.5 catheter was then withdrawn over the guidewire. At the conclusion of the procedure, the patient had the femoral arterial sheaths removed in the cardiac catheterization lab with hemostasis obtained via manual compression, and the patient was transferred to the coronary care unit for further observation and care.
SELECTIVE CORONARY ANGIOGRAPHY:
1. Left main: The left main bifurcates into the left anterior descending and circumflex coronary artery. The left main is angiographically free of significant stenosis.
2. Left anterior descending: The left anterior descending coronary artery is noted to provide two diagonal branches and terminates as the apical recurrent branch. The proximal LAD after this first small caliber diagonal branch is noted to have a 90-95% stenosis.
3. Circumflex: The circumflex coronary artery is noted to provide four obtuse marginal branches with OM2 being largest caliber obtuse marginal branch. This OM2 branch is noted to have subtotal occlusion proximally.
4. Right coronary artery: The right coronary artery is dominant and is noted to be completely occluded in its mid segment after supplying an acute marginal branch. Also noted is the presence of bridging collaterals that faintly fill the distal vessel. Additionally, during left coronary injections, the presence of left to right collaterals from the apical LAD supplying the distal right coronary artery is also noted.
LEFT HEART CATHETERIZATION:
Left ventricular end-diastolic pressure 27 pre-A wave and 40 post-A wave. There was no gradient noted upon pullback.
FINAL DIAGNOSIS:
1. Severe three-vessel coronary artery disease in a diabetic patient.
2. Significantly elevated left ventricular end-diastolic pressures.
PLAN: The patient was referred for coronary artery bypass grafting and received IV Lasix in the cardiac catheterization lab given his significantly elevated left ventricular end-diastolic pressures.
