Sample Type / Medical Specialty: Surgery
Sample Name: Cardiac Cath & Coronary Angiography
Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.
(Medical Transcription Sample Report)
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.
surgery, left cardiac catheterization, left ventriculography, coronary angiography, stent placement, coronary artery disease, unstable angina, cardiovascular disease, anterior descending artery, descending artery, circumflex artery, anterior descending, cardiac catheterization, coronary artery, stent, coronary, angiography, artery, ventriculography, circumflex, cardiac, catheterization,
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