PREOPERATIVE DIAGNOSIS: Not dictated.
POSTOPERATIVE DIAGNOSIS: Not dictated.
PROCEDURES PERFORMED:
1. Selective coronary angiography.
2. Left heart catheterization.
3. Percutaneous coronary intervention and stent placement, right coronary artery.
INDICATIONS:
1. ST elevation myocardial infarction.
2. Extensive coronary artery disease with history of stent placement in the right coronary artery as well as the left anterior descending artery.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
PROCEDURE IN DETAIL: Indications and benefits of the procedure were fully explained to the patient and consent was obtained. The right femoral area was prepped and draped in a sterile technique in the usual fashion. Lidocaine 2% was used for local anesthesia. A #5 French sheath was placed in the right femoral artery using single-entry technique. Using a JL4 catheter, the left main coronary artery was engaged and multiple shots were obtained. Using a JR4 catheter, the right coronary artery was engaged and multiple shots were obtained. Using the same catheter, the aortic valve was crossed and LV pressure measurements were obtained. No left ventriculogram was performed.
FINDINGS:
1. The left main coronary artery is angiographically normal.
2. The left anterior descending artery has an ostial and proximal 50% stenosis before a previously deployed stent. The rest of the LAD has multiple luminal irregularities with 20-30% in the mid to distal vessel. The LAD appears to be a 2.5-3.0 vessel. The stented segment was larger than the rest of the vessel.
3. The left circumflex artery gives off two early obtuse marginal branches. The first one is a small caliber vessel and has diffuse luminal irregularities and the second one is a larger vessel and also has multiple luminal irregularities. The circumflex artery continues in the AV groove and gives off other smaller obtuse marginal branches. The mid circumflex has additional 40-50% stenosis.
4. The right coronary artery has a patent stent in its proximal segment with diffuse 50-60% stenosis and a more focal 80% stenosis. The distal right has a 60% stenosis at the origin of a small PD branch. This PD branch has probably 99% stenosis. This was noted on previous angiograms per report. The second PD branch, which is a larger vessel, has 80-90% proximal stenosis. The PL branch continues with luminal irregularities.
5. The left ventricular end diastolic pressure was 15. There was no gradient upon pullback from the LV to the aorta.
Because of the above findings, the decision was to proceed with percutaneous coronary intervention of the right coronary artery. Integrilin was given in two boluses. The patient was also given heparin. He was already on Plavix. A #8 French sheath was placed in exchange for the previously placed sheath. A JR4 guide catheter was used to engage the right coronary artery. A Choice PT wire was then advanced into the PD branch and a BMW wire into the PL branch. A 2.5 x 12 balloon was then advanced over the wire and placed across the ostium of the PDA and the balloon was inflated up to 10 atmospheres for 30 seconds. Next, a 2.5 x 13 Cypher drug-eluting stent was then advanced over the wire and placed across the ostium in the proximal part of the PDA. With half of it in the distal right coronary artery, a 2.5 x 15 balloon was then parked in the distal right coronary artery to the PL branch. The stent was inflated up to 12 atmospheres for 30 seconds and the wire was pulled back. The balloon and the PL branch were then inflated up to 12 atmospheres. Next, the balloon was then placed in the proximal right coronary artery and was inflated up to 14 atmospheres. The reason this was done is because another 2.5 x 23 stent was attempted to be delivered into the PL branch; however, it could not cross the mid segment. Next, after the inflation of the mid right coronary artery, a 2.5 x 23 Cypher drug-eluting stent was then advanced over the wire and placed across the distal right coronary artery and the PL branch and the balloon was inflated up to 16 atmospheres crushing the previously crushed stent. Next, a Pilot wire was then advanced through the stent struts in the PL branch and a 2.25 x 12 balloon was then advanced over the wire and placed across the ostium and the balloon was inflated up to 14 atmospheres. Next, another 2.5 x 15 balloon was then advanced over the distal part and both balloons were inflated in a kissing technique fashion. Repeat angiogram revealed excellent angiographic results in this segment. Next, a 3.0 x 23 Cypher drug-eluting stent was then advanced over the wire and placed across the mid LAD in the previous stented segment and the balloon was inflated up to 18 atmospheres for 30 seconds. Repeat angiogram demonstrated excellent angiographic results.
CONCLUSIONS:
1. Moderate coronary artery disease involving the LAD and severe stenosis involving the PD branch of the right coronary artery and the mid right coronary artery.
2. Successful PTCA and a 2.5 x 15 and 2.5 x 23 Cypher drug-eluting stent in the distal right coronary artery being deployed in a crush technique fashion with excellent angiographic results and with reduction of the stenosis to 0% and with successful 3.0 x 23 Cypher drug-eluting stent placement in the mid right coronary artery with reduction of the stenosis from 70% down to 0%.
PLAN: The patient will be observed overnight. He will be on aspirin and Plavix. Further management will be outlined.
