Munroe Regional Medical Center

Cardiac Catheterization Lab

131 SW 15th Street

Ocala, FL 34478

(352) 351-7206

​

Patient Name:  M**, M*** K******

Date of Birth:                         Age: 69

Gender:  Female

Ht:  58.5 inches         Wt: 56.9 kg

BSA:  1.51

MRN #  *******775

ACCT #  ******0512

Procedure Date: 03-07-2012

Procedure Status:  In-Patient - Urgent

Referring Physician:  Gummadi, Siva MD; Martin, Carlos MD; Patel, Sanjay MD

Cathing Physician(s):  Santoian, Edward C. MD

PROCEDURE:

  • Right and Left Heart Catheterization
  • Left Ventricular Angiography
  • Right and Left Coronary Artery Angiography
  • Abdominal Aortic Angiography
  • Right Common Iliac Artery Angiography

INDICATIONS:

  • Coronary Indication: Chest Pain; Shortness of Breath; Dyspnea on Exertion; Non ST Elevation Myocardial Infarction
  • Peripheral Indication: Difficult Access Occlusion of Abdominal Aorta

COMPLICATIONS: No Complications

HEMODYNAMICS:

OXYGEN REST

Pressure (mmHg)

HR: 77

RA: 15


RV: 60/15

PA: 60/32

PCWP: 32
LV: 143/32

AO: 143/78
FA: 69/45 (57)

FINDINGS:

  • Right Dominant
  • RCA (Mid), Calcified 50% lesion
  • RT PDA (Ostial), Tubular 30% lesion
  • RCA (Ostial), Luminal Irregularities 20% lesion
  • LAD (Ostial), Complex 95% lesion
  • LAD (Mid), Tubular 50% lesion
  • LMCA (Mid), Tubular 40% lesion
  • CX (Ostial), Luminal Irregularities 40% lesion
  • LMCA (Ostial), Tubular 40% lesion

FINDINGS (CONTINUED):

  • LVEF Status: LV Gram - 60%
  • LV Normal Systolic Function
  • LV Normal EDP post angio
  • LV Wall Motion: Normal
  • Valve: Aortic Insufficiency - Not Assessed
  • Valve: Aortic Stenosis - No
  • Valve: Mitral Insufficiency - No
  • Valve: Mitral Stenosis - No
  • Valve: Mitral Regurgitation - Yes: Mild
  • Aortic Findings: Aortic Aneurysm Small Needs sizing study
  • Site Closure: Manual Pressure - Successful.
  • Conclusions: Single Vessel Disease - Severe
  • Conclusions: Double Vessel Disease - Moderate
  • Conclusions: Valvular - Mitral insufficiency Mild (2+)
  • Conclusions: Pulmonary Hypertension Severe
  • Conclusions: CHF Bilateral Diastolic
  • Recommendations: Medical Therapy Cholesterol Lowering
  • Recommendations: Medical Therapy ACE Inhibitor
  • Recommendations: Medical Therapy Beta Blockade
  • Recommendations: Medical Therapy Aspirin Life Time Otherwise MD Changes
  • Recommendations: Surgery Consult
  • Recommendations: Medicine: vs. Surgical Intervention
  • Aorta (Mid), Luminal Irregularities 100% lesion
  • Graft from Aorta to Rt Common Iliac
  • Graft from Aorta to Lt Common Iliac
  • Catheter Tip: Right Radial Artery to Abdominal Aorta
  • Catheter Tip: Right Radial Artery to Right Femoral Artery
  • Catheter Tip: Right Radial Artery to Right Iliac Artery

PROCEDURE NOTES:

Anesthetic:

  • Local Anesthetic to right inguinal region with 2% Lidocaine
  • Local Anesthetic to right radial region with 2% Lidocaine

Procedural Approach:

  • Access: 6 Fr sheath inserted in Rt femoral vein
  • Access: 4 Fr sheath inserted in Rt femoral artery
  • Access: 4 Fr Merit Prelude sheath inserted in Rt radial artery

Post Sheath Status:

  • Sheath(s) Pulled, Hemoband applied. Rt Radial Artery
  • CLOSURE DEVICE 2-Mechanical Compression - successful
  • Sheath(s) Pulled, Manual pressure for 10 mins to RFA
  • Sheath(s) Pulled, Manual pressure for 7 mins to RFV
  • CLOSURE DEVICE 1-Manual Compression - successful

Post Site Status:

  • Procedure Site: No Bleeding or Hematoma. Rt Radial
  • Procedure Site: No Bleeding or Hematoma. Rt groin.

Tip of Catheter:

  • Abd. Aorta --- Vessel imaged- Abd. Aorta
  • Abd. Aorta --- Vessel imaged- Bilateral Iliacs
  • Abd. Aorta --- Vessel imaged- Bilateral renals
  • Rt Common Femoral --- Vessel imaged- Rt Common Femoral
  • Rt Common Iliac --- Vessel imaged- Rt Common Iliac

EQUIPMENT:

  • Boston Scientific  Sheath 4F (11cm)
  • Boston Scientific  Sheath 6F (11cm)
  • Boston Scientific 0.035 J (175cm)
  • Cordis PIG (110) - 4F
  • Cordis FL4 - 4F
  • Cordis 3DRC - 4F
  • Arrow  Wedge pressure catheter -6F
  • Chloraprep 25 ML
  • Procedure Pack
  • O2 Set Up.
  • SAO2 Monitor.
  • Boston Scientific Zip 0.035 stiff angled (180cm)
  • Chloraprep 10.5 ML
  • Brachial Kimberly Clark
  • Merit Prelude Sheath 4F
  • Terumo large torque device (0.010-0.038)
  • Suture

MEDICATIONS GIVEN DURING PROCEDURE:

  • Sa02 = 93% by Ashlee DeLuca, RN ~ 16:09:55
  • Oxygen: 2 L/min via nasal cannula by Carl R Baquie, RN ~ 16:10:00
  • Versed 0.5 mg IV ,patient anxious, by Jill McCullors, RCIS ~ 16:18:32
  • Fentanyl 50 mcg IV ,patient anxious, by Jill McCullors, RCIS ~ 16:18:39
  • Versed 0.5 mg IV ,patient awake, by Jill McCullors, RCIS ~ 16:21:24
  • Heparin 2500 units IA Dr. Edward C Santoian, MD ~ 16:36:57
  • Heparin Witnessed by Carl R Baquie, RN ~ 16:37:03
  • Fentanyl 25 mcg IV ,patient restless, by Jill McCullors, RCIS ~ 16:37:44
  • Versed 0.5 mg IV ,patient arousable, by Jill McCullors, RCIS ~ 16:42:43
  • Fentanyl 25 mcg wasted by Jill McCullors, RCIS ~ 17:14:08
  • Versed 0.5 mg wasted by Jill McCullors, RCIS ~ 17:14:15

_______________________________________

Santoian, Edward C. MD

ECS/ijr

COPIES TO:

Gummadi, Siva MD; Martin, Carlos MD; Patel, Sanjay MD