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A 60-year-old gentleman with markedly abnormal stress test in my office today who is admitted with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization. I discussed the procedure in detail with the patient and his wife as well as perform a risk/benefit/alternative analysis with benefits being more definitive exclusion of significant obstructive coronary artery disease and evaluation of such to help guide further treatment, alternatives being alternative stress imaging or empiric medical therapy which I was not recommending nor was the patient interested in and risks including but not limited to and the patient and his wife were aware that this was not an all inclusive list of over-sedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of excessive fluoroscopic exposure causing skin necrosis, risk of dye reaction as well as due to the inherent invasive nature of cardiac catheterization at least 1 in 1,000 risk of stroke, heart attack, heart failure, death, kidney failure, peripheral vascular disease, femoral arteriotomy access site complications including bleeding, need for surgical intervention of the femoral arteriotomy access site, aneurysmal formation, pseudoaneurysmal formation, and/or need for blood transfusions. The patient expressed understanding of this risk/benefit/alternative analysis and stated in a clear competent and coherent fashion that he wished to go forward with the cardiac catheterization which I felt was appropriate.

The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.

PROCEDURE NOTE: The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed. Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff. He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect. Bilateral groins had been prepped and draped in the usual fashion. Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle. All catheters were passed using a J-tipped guide-wire. Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter. Left system coronary angiography performed using a 6-French JL4 catheter. Right system coronary angiography performed using a 6-French CDRC catheter. Following the procedure, all catheters were removed. Manual pressure was held with the Neptune pad and the patient was discharged back to his room. I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses. There were no apparent complications. A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.

FINDINGS:

HEMODYNAMICS: LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.

LV function is normal, EF 60%, no wall motion abnormalities.

CORONARY ANATOMY:
1. Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.
2. The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.
3. The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.
4. The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity. There is a moderate distal PDA lesion of 60% seen.

IMPRESSION:
1. Mild to moderate left main stenosis.
2. Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.

We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin. We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.

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