DATE OF PROCEDURE: MM/DD/YYYY
PREPROCEDURE DIAGNOSES:
1. Nonsustained ventricular tachycardia.
2. Normal left ventricular ejection fraction.
3. History of coronary disease. Status post coronary artery bypass graft with patent bypass grafts on cardiac cath.
PROCEDURE: Electrophysiology study.
DETAILS OF PROCEDURE: The patient was brought to the electrophysiology lab where ECG and vital signs were continuously monitored. The right groin was meticulously prepared with Betadine solution and was draped in the usual sterile fashion. Lidocaine 1% was administered subcutaneously for local anesthetic. Using modified Seldinger technique, two #6 French introducer sheaths were inserted into the right femoral vein. Two quadripolar EP catheters were inserted into the sheaths and advanced under fluoroscopic guidance. One was positioned in the area of the high right atrium and one in the area of the His bundle. The high right atrial catheter was later moved to the RV apex for ventricular stimulation. Endocardial potentials were recorded and baseline measurements were performed. The sinus cycle length was 1195 milliseconds. The AH interval was 115 milliseconds. The HV interval was 45 milliseconds with a pacing cycle length of 800 milliseconds. The sinus node recovery time was 1430 milliseconds with the pacing cycle length of 700 milliseconds. The sinus node recovery time was 1465 milliseconds with a pacing cycle length of 600 milliseconds. The sinus node recovery time was 1570 milliseconds. AV Wenckebach recorded an atrial pacing cycle length of 450 milliseconds. The AV node effective refractory period was 320 milliseconds with the pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 600 milliseconds. The pacing threshold from the right ventricular apex was 0.5 milliamps, 1:1 VA conduction was present at a ventricular pacing cycle length of 600 milliseconds. The ventricular effective refractory period was 240 milliseconds with a pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 400 milliseconds. After single, double and triple extrastimuli were performed at two pacing cycle lengths from the RV apex, Isuprel was started at 2 mcg per minute. This was gradually increased to 4 mcg per minute in order to achieve a good heart rate response. The ventricular effective refractory period was 220 milliseconds with the pacing cycle length of 400 milliseconds. All ventricular pacing was performed from the RV apex. After completion of programmed electrical stimulation, catheters were removed. Good hemostasis was achieved using manual compression. The patient was then transferred to the recovery room in good condition.
IMPRESSION:
1. Mildly abnormal sinus node function.
2. Normal atrioventricular node function without evidence of dual atrioventricular node physiology.
3. Normal His-Purkinje function without evidence of infra-His block.
4. Frequent nonsustained ventricular tachycardia with single, double and triple ventricular extrastimuli from the right ventricular apex. The morphology of the nonsustained ventricular tachycardia varied between left bundle, left axis and left bundle right axis morphology. Nonsustained ventricular tachycardia or prolonged nonsustained ventricular tachycardia was induced.
RECOMMENDATIONS: The patient will be continued on beta blocker, which should be increased as tolerated. If the patient has recurrent symptoms, despite medications, an ablation procedure may be considered. However, given the differing morphologies of the nonsustained VT, this may make ablation difficult
Sample #2
PROCEDURE PERFORMED:
1. Selective coronary angiography.
2. Left heart catheterization.
3. LV gram.
INDICATIONS FOR PROCEDURE:
1. Recurrent episodes of angina pectoris.
2. Multiple risk factors for coronary artery disease with new onset of chest pain suggestive of angina.
DESCRIPTION OF PROCEDURE: The indications and benefits of the procedure were fully explained to the patient. Written 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 JL5 catheter, the left main coronary artery was engaged and multiple shots were obtained. Using a 3DRC catheter, the right coronary artery was engaged and multiple shots were obtained. Next, using a pigtail catheter, the aortic valve was crossed and RV pressure measurements were obtained. An LV gram was performed in the RAO projection using power injector.
PROCEDURE FINDINGS:
1. The left main coronary artery is angiographically normal. It bifurcates into an LAD and a circumflex artery.
2. The left anterior descending artery is a large and tortuous vessel. It gives off a large diagonal branch that in some of the views appears to have ostial 30-40% stenosis, but probably this is a reflection of tortuosity. The LAD and the diagonal branches have minimal luminal irregularities.
3. The left circumflex artery is a large vessel and continues as a large obtuse marginal branch with multiple distal branches. The circumflex artery and the obtuse marginal branch have minimal luminal irregularities.
4. The right coronary artery is also very tortuous and has mid segment luminal irregularities.
5. Left ventriculography. Global left ventricular systolic function is preserved. The estimated ejection fraction is 55%. The left ventricular end-diastolic pressure was 18. There was no gradient upon pullback from the LV to the aorta.
CONCLUSIONS:
1. Minimal plaques in the coronary arteries.
2. Normal left ventricular systolic function.
Sample #3
DATE OF PROCEDURE: MM/DD/YYYY
PREPROCEDURE DIAGNOSIS: Status post ICD lead revision.
PROCEDURE: Testing of implantable cardioverter-defibrillator.
DETAILS OF PROCEDURE: The patient was brought to the electrophysiology lab where she was continuously monitored and blood pressure was monitored basically every 10 minutes. The patient’s defibrillator, St. Jude model # XXXX was interrogated. The R wave was greater than 12 millivolts. The ventricular pacing threshold was 0.5 volts at 0.5 milliseconds. The ventricular pacing impedance was 550 ohms. After administration of anesthesia, ventricular fibrillation was induced via DC. Adequate sensing was noted and a 20-joule shock was delivered by the device with successful conversion to sinus rhythm. The shock impedance was 51 ohms and the charge time was 4 seconds. The patient was then transferred to the recovery room in good condition.
IMPRESSION:
1. Normal pacing/implantable cardioverter-defibrillator function.
2. Defibrillation threshold less than or equal to 20 joules.
Sample #4
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Severe 80% stenosis, left carotid artery.
POSTOPERATIVE DIAGNOSIS: Severe 80% stenosis, left carotid artery.
PROCEDURES PERFORMED:
1. Thoracic arteriogram.
2. Selective left carotid arteriogram.
3. Left carotid angioplasty and stent.
SURGEON: John Doe, MD
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
ANESTHESIA: Lidocaine 1% without epinephrine, local anesthetic and intravenous sedation with Versed and fentanyl.
FINDINGS:
1. Severe 80% stenosis of left carotid artery.
2. Normal aortic arch with some calcification at the origin of the innominate artery.
3. No residual stenosis, status post carotid angioplasty and stenting.
DESCRIPTION OF PROCEDURE: The patient was brought into the endovascular suite and placed in the supine position on the angio table. The right groin was sterilely prepped and draped in the usual fashion. Percutaneous access to the right femoral artery was gained with micropuncture technique. A 5 French sheath was placed in a retrograde fashion in the right femoral artery. A 5 French pigtail catheter was advanced over the wire and reformed in the ascending aorta. Thoracic arch aortogram obtained with 30 mL of contrast, injection rate 15 mL/sec for 2 seconds. The pigtail catheter was then exchanged for a 3DRC catheter, which was selectively advanced over the wire into the left common carotid artery. Catheter was advanced to mid common carotid artery and selective left carotid arteriography at the cervical and cerebral level obtained in anterior and lateral views. The 3DRC catheter was used to selectively advance a 0.035 Amplatz wire into the external carotid artery using roadmap technique. The 3DRC catheter was removed. A 5 French sheath was removed and a 90 cm long 6 French shuttle sheath was advanced over the Amplatz wire and positioned with the tip of the sheath in the left common carotid artery. Angiograms were obtained to size for the filter wire and for the stent. The distal internal carotid artery at the petrous portion measured 3.78 cm in size and a 4.5 filter wire was chosen for the distal cerebral perfusion protection. A 6 x 8 tapered Acculink stent was chosen. The Amplatz wire was removed and the 0.014 filter wire advanced across the carotid stenosis using roadmap technique. The filter was deployed at the intra-petrous portion of the carotid artery and maintained in that position throughout the remainder of the procedure. The patient had received 5000 units of heparin and 300 mL of Plavix prior to the angiographic procedure being initiated. The 6 x 8 cm long Acculink stent was then advanced over the filter wire and deployed across the stenosis using roadmap technique. The stent was then postdilated with a 5 x 2 balloon. Some residual stenosis was noted and therefore further dilation was performed with a 6 x 1.5 balloon. The patient received a total of 2 mg of atropine during the stent deployment and angioplasty. The patient was hemodynamically stable at the end of the procedure. There was no hemodynamic instability during the procedure. Some mild bradycardia with a pulse rate in the range of 54 was noted during the angioplasty. The filter wire was recaptured with the capture device and removed. The sheath was removed over 0.035 Bentson wire and exchanged for a short 6 French sheath, which will be removed in the recovery room when the ACT is normalized. Completion angiography revealed that there was no residual stenosis noted following CAS with postdilatation angioplasty with 5 x 2 followed by 6 x 1.5 balloon. The patient tolerated the procedure well with no apparent complications and was neurologically intact upon transfer to the recovery room.
Sample #5
DATE OF CATHETERIZATION: MM/DD/YYYY
PROCEDURES PERFORMED: Left heart catheterization, left ventriculography.
REASON FOR PROCEDURE: Unstable angina and abnormal stress test.
FINDINGS:
1. The left main coronary artery was short and patent.
2. The left anterior descending coronary artery had total occlusion in the proximal and mid portion.
3. The circumflex coronary artery had 95% lesion in the proximal portion.
4. The right coronary artery had 90% proximal and 100% total occlusion in the mid.
GRAFTS: The left internal mammary artery graft to the left anterior descending coronary artery was patent. The saphenous vein graft to the diagonal vessel was also patent. The saphenous vein graft to the obtuse marginal was not located and was not selectively engaged.
COLLATERALS: There were collaterals noted from the left anterior descending, septal and obtuse marginal to the right side.
Left ventriculography revealed an overall ejection fraction of around 40% with inferobasal akinesis and mid anterior and septal hypokinesis. End-diastolic pressure was normal at 13 mmHg. There was no gradient across aortic valve on pullback.
At the end of the procedure, the decision to proceed with angioplasty and stent placement of the critical circumflex lesion was made.
Sample #6
PROCEDURE PERFORMED: Left heart catheterization, selective coronary angiography, left ventriculography.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was brought to the cath lab premedicated. The right radial was attempted, but because of vasospasm, we could not enter the vessel so we switched out to the right groin. The right femoral artery was cannulated and a 6 French sheath was placed. The coronaries were identified using standard Judkins left and right size 4 catheters and serial views were obtained. There was no evidence of disease in the right coronary to explain the infarct pattern. The previous area of stenting in the right coronary was widely patent. A pigtail was placed into the left ventricular cavity and RAO ventriculogram was obtained. Then the femoral sheath was injected and the vessel was appropriate for a closure device so a 6-French Angio-Seal was deployed and the patient was returned to the ward in stable condition.
FINDINGS:
1. The left ventricular end-diastolic pressure is 16. No gradient across the aortic valve.
2. The left ventricle is dilated and globally hypokinetic. The inferior wall is basically akinetic. The ejection fraction is calculated at 30%. No mitral regurgitation.
3. The left main coronary is normal.
4. The left anterior descending has luminal irregularities but nothing high grade. It gives rise to a large diagonal branch, which also has some encroachment in its proximal portion but not critical. A smaller second diagonal branch is identified.
5. The circumflex distribution gives rise to one major obtuse marginal branch, which bifurcates distally. Again, there are some luminal irregularities but nothing high grade noted.
6. The right coronary artery is dominant. It has luminal irregularities throughout its course, but again, there is nothing high grade. Posterior descending is identified. Posterolateral branches are noted. At the crux, a previously deployed stent is widely patent.
Sample #7
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURES PERFORMED:
1. Comprehensive electrophysiologic study with programmed stimulation and attempted induction of arrhythmia with cannulation of the coronary sinus.
2. Detailed mapping of the tachycardia focus.
3. Radiofrequency catheter ablation for typical atrial flutter.
DESCRIPTION OF PROCEDURE: The benefits, risks and alternatives of radiofrequency catheter ablation were discussed in detail and informed consent was obtained. The patient was brought to the electrophysiology lab in a fasting state and prepped and draped in the usual sterile fashion. Lidocaine 1% was used for local anesthesia and a combination of fentanyl and Versed were administered in divided doses using the conscious sedation protocol. The 8-French and 7-French sheaths were placed in the right femoral vein and two 7-French sheaths were placed in the left femoral vein, all using the modified Seldinger technique. Through the groin sheaths, a Cordis Webster deflectable quadripolar catheter was positioned in the atrioventricular junction, a Cordis Webster multipolar catheter was positioned in the coronary sinus, a Cordis Webster multipolar Halo catheter was placed in the right atrium under fluoroscopic guidance. The 8-French sheath was removed and in its place a long Mullins sheath with its tip cut was advanced into the right atrium under fluoroscopic guidance. Through this sheath an EPT 8 mm 7-French large curve mapping and ablation catheter was placed in the right atrium under fluoroscopic guidance. When the patient was brought to the electrophysiology laboratory, he was in atrial flutter with a ventricular rate of 86 beats per minute. The patient spontaneously converted before intracardiac catheters could be placed. When cardiac catheters were placed, the patient was in normal sinus rhythm. The following conduction intervals were recorded, including a basic cycle length of 1072 milliseconds, a PR interval equal to 234 milliseconds, a QRS duration equal to 111 milliseconds, a QT interval of 484 milliseconds, an AH interval of 111 milliseconds, and a HV interval of 50 milliseconds. Atrial pacing to assess sinus node function was performed. The longest corrected sinus node recovery time was 411 milliseconds at a pacing cycle length of 610 milliseconds. Atrial pacing to assess AV node function was performed. There was early block in the AV node with Wenckebach block occurring at a pacing cycle length of 552 milliseconds. Single premature stimuli delivered in the atrium. The effective refractory period of the AV node was 362 milliseconds at 700 milliseconds. The effective refractory period of the atrium was 292 milliseconds at 700 milliseconds. Single, double and triple premature extra stimuli delivered in the atrium. The tightest coupling intervals obtained were 600/270/260/190. Burst atrial pacing was performed. Atrial flutter was not inducible. A decision to proceed with empiric isthmus ablation was made. Detailed mapping of the inferior vena cava-tricuspid annulus isthmus region was performed. Radiofrequency energy was delivered, line of lesions across the isthmus. Radiofrequency energy was delivered with a power of 65 watts at a temperature of 60 degrees for a total of 60 seconds. Pacing from the coronary sinus was performed during radiofrequency ablation. Conduction across the isthmus was assessed with Halo activation. In this fashion, a total of 30 radiofrequency lesions were administered with the creation of unidirectional isthmus block. Isthmus block was rate independent. The interval between the stimulus from the coronary sinus to the distal Halo measured 180 milliseconds. Pacing was then performed from the low lateral right atrium confirming presence of unidirectional block in the other direction. The patient experienced slight chest pain during RF energy delivery, which was treated with sedation. The ablation catheter was then positioned under fluoroscopic guidance in the ventricle and thresholds were measured. There was no VA conduction at pacing at 700 milliseconds. Single premature stimuli delivered in the ventricle. The effective refractory period in the right ventricular apex was 280 milliseconds at 600 milliseconds. The catheter was withdrawn into the atrium. After a waiting period of 30 minutes, bidirectional isthmus block persisted. The catheters and sheaths were removed and direct pressure was applied to obtain hemostasis. The patient tolerated the procedure well without complications. The patient was sent to the holding area in stable condition.
PROCEDURE FINDINGS:
1. Borderline normal sinus node function.
2. Early block in the AV node secondary to drug effect, intrinsic AV nodal conduction disease and medication effect and vagal tone.
4. Normal His-Purkinje function.
5. Normal ventricular function.
6. Abnormal atrial function with spontaneous atrial flutter.
PROCEDURE RESULTS: Successful radiofrequency catheter ablation of the inferior vena cava-tricuspid annular isthmus for the treatment of typical atrial flutter. There was creation of bidirectional isthmus block.
RECOMMENDATIONS:
1. Resume anticoagulation.
2. Discontinue amiodarone, digoxin and Cartia.
3. Continue low-dose beta blocker.
Sample #8
PROCEDURE PERFORMED: Left heart catheterization with coronary angioplasty and double stent placement for right coronary artery.
DESCRIPTION OF PROCEDURE: The left groin was prepped and draped in the usual manner. After infiltration with 1% lidocaine, a #6 French Hemaquet sheath was introduced percutaneously into the left femoral artery. Heparin was administered through the side arm of the sheath. A #6 French Judkins right coronary guiding catheter was introduced through the sheath and advanced to the aortic root where the right coronary origin was engaged. A 2 x 15 mm Maverick balloon dilating catheter was introduced through the guiding catheter together with a 0.014-inch Forte Medium Support Marker Wire.
The balloon catheter was introduced partly into the right coronary artery and the guidewire advanced to the point of total occlusion. It did not prove possible to readily cross the occluded area and the guidewire was exchanged for a ZIPwire. This wire was readily able to cross the stenotic area and pass into the distal part of the right coronary artery. The balloon catheter was then passed along the wire and withdrawn and a small injection made to confirm that the guidewire was indeed in the distal part of the right coronary artery. The balloon catheter was again advanced into the distal section of the right coronary artery and the guidewire exchanged for the original one. The balloon was positioned within the stenotic area and inflated up to 8 atmospheres. The balloon catheter was withdrawn and exchanged for a 2.75 x 15 mm Vision stent deployment system.
Prior to the introduction of this device, nitroglycerin and verapamil were administered intracoronary. The stent was carefully positioned across the previously occluded and now stenotic area and deployed at 9 atmospheres with the pressure carried up to 16 atmospheres. The stent balloon catheter was withdrawn and further angiograms recorded. It was now apparent that there was significant stenosis with an irregular appearance a short distance proximal to the previous point of total occlusion. The previous stent balloon had been difficult to remove from the guidewire and a BMW guidewire was now introduced in “buddy” fashion and passed into the distal part of the right coronary artery and the original guidewire removed. A 2.75 x 12 mm Liberte stent deployment system was introduced and the stent carefully positioned across the more proximal stenotic area. This stent was also inflated up to 9 atmospheres and then the pressure carried up to 16 atmospheres. The stent balloon catheter was then removed and further angiograms recorded. The guidewire and guiding path removed. An injection was made into the femoral artery through the sheath to assess for placement of a closure device but this proved not to be appropriate and the sheath was sutured in place for later removal.
The procedure was uneventful and the patient was returned to room in satisfactory condition. Additional medication given during the procedure included Integrilin by bolus and infusion.
