Munroe Regional Medical Center

Cardiac Catheterization Lab

131 SW 15th Street

Ocala, FL 34478

(352) 351-7206

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Patient Name:  BUCH****, MA**** G

Date of Birth:                         Age: 64

Gender:  Female

Ht:  64.0 inches         Wt: 77.7 kg

​

BSA:  1.83

MRN #  0000816854

ACCT #  ******0133

Procedure Date: 06-05-2012

Procedure Status:  Out-Patient - Routine Scheduled

Referring Physician:  Acevedo, Celso MD; Das, Chandranath MD; Addisu, Anteneh MD

Cathing Physician(s):  Bittl, John A. MD

PROCEDURE:

  • Right and Left Coronary Artery Angiography
  • Coronary Drug Eluting Stent Placement to the Proximal Left Anterior Descending Artery Time Two
  • Coronary Drug Eluting Stent Placement to the First Diagonal Marginal Branch
  • Coronary Drug Eluting Stent Placement to the Mid Left Anterior Descending Artery
  • Coronary Drug Eluting Stent Placement to the Distal Left Anterior Descending Artery
  • Echocardiogram

INDICATIONS: Coronary Indication: Ablation Procedure; Acute Coronary Occlusion

COMPLICATIONS: No Complications

HEMODYNAMICS:

OXYGEN REST
Pressure (mmHg)

HR: 78

AO: 81/62

​BP improved from: 76/54 to 136/69

​AIR REST

FINDINGS:

  • Single vessel CAD
  • PCI LESN: 12 Proximal LAD
  • Previous Treatment? No
  • Medium Risk (B) Irregular contour
  • Lesion Length: 5 mm
  • 60% Pre Stenosis, Pre TIMI-3: Complete flow/perfusion
  • 0% Post Stenosis, Post TIMI-3: Complete flow/perfusion
  • Promus <P>
  • Size: 3 mm x 8 mm
  • PCI LESN: 15 1st Diagonal
  • Medium Risk (B) Irregular contour
  • Previous Treatment? No
  • Lesion Length: 18 mm
  • 100% Pre Stenosis, Pre TIMI-0: No flow/perfusion
  • 0% Post Stenosis, Post TIMI-3: Complete flow/perfusion

FINDINGS (CONTINUED):

  • Maverick <P>
  • Size: 2.5 mm x 20 mm
  • Promus <P>
  • Size: 2.75 mm x 20 mm
  • PCI LESN: 12 Proximal LAD
  • Previous Treatment? No
  • Medium Risk (B) Irregular contour
  • Lesion Length: 15 mm
  • 100% Pre Stenosis, Pre TIMI-0: No flow/perfusion
  • 0% Post Stenosis, Post TIMI-3: Complete flow/perfusion
  • Promus <P>
  • Size: 2.5 mm x 16 mm
  • PCI LESN: 13 Mid LAD
  • Previous Treatment? No
  • Lesion Length: 18 mm
  • Medium Risk (B) Irregular contour
  • 80% Pre Stenosis, Pre TIMI-2: Partial flow/perfusion
  • 0% Post Stenosis, Post TIMI-3: Complete flow/perfusion
  • Promus <P>
  • Size: 2.25 mm x 20 mm
  • PCI LESN: 14 Distal LAD
  • Medium Risk (B) Irregular contour
  • Lesion Length: 20 mm
  • Previous Treatment? No
  • 60% Pre Stenosis, Pre TIMI-2: Partial flow/perfusion
  • 0% Post Stenosis, Post TIMI-3: Complete flow/perfusion
  • Promus <P>
  • Size: 2.25 mm x 24 mm
  • Site Closure: Manual Pressure -
  • Conclusions: Single Vessel Disease - Severe
  • Recommendations: aspirin 81 mg po QD for life
  • Recommendations: Brilinta or Plavix for one year
  • Recommendations: pravastatin
  • Comments: 1. Several minutes after completion of the endocardial
  • ablation procedure, the patient developed ST elevation and
  • hypotension and was found to have complete occlusion of the
  • LAD-diagonal system, requiring emergency export thrombectomy
  • (minimal effect) and extensive stenting for refractory vessel
  • closure. The etiology of the vessel closure remains uncertain
  • but could be have caused by extensive vessel dissection (though
  • only focal intimal disruption and no spiral-type dissections
  • were seen) or extrinsic hematoma formation. Surgical consultation obtained with Dr. Galat.
  • Comments: 2. Although no evidence of cardiac tamponade was
  • seen, an emergency echocardiogram was obtained that showed a small to moderate pericardial effusion.
  • Comments: 3. The patient had not received any antiplatelet
  • pretreatment and needed oral aspirin and a P2Y12 inhibitor.
  • Before she could take po meds because of sedation, she was treated with 2 boluses of eptifibatide.
  • Right Dominant
  • MARG1 (Ostial), Complex 100% lesion STENT to 0%
  • LAD (Ostial), Complex 100% lesion STENT to 0%STENT to 0%STENT to 0%
  • LAD (Proximal), Complex 100% lesion STENT to 0%
  • Comments: 4. Addendum 8:03 PM: After blood pressure fell to 80
  • mmHg, pericardiocentesis was performed because emergency
  • echocardiogram showed increased pericardial fluid and RV
  • collapse after 500 cc NS, and ECG showed no ST elevation. Blood pressure rose promptly to 168 mmHg.

PROCEDURE NOTES:

Anesthetic:

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

Procedural Approach: No access obtained

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Post Sheath Status:

  • CLOSURE DEVICE 1-Manual Compression - successful
  • Sheath(s) Intact, sutured in RFA , transpac attached.
  • Sheath(s) Intact, sutured in RFV , transpac attached.
  • Sheath(s) Intact, sutured in LFV.
  • Sheath(s) Intact, sutured in LFV.

Post Site Status:

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

INTERVENTIONAL PROCEDURE DATA:

VESSEL

Diagonal LAD

DEVICES USED

INTERVENTION NOTES

EQUIPMENT:

  • Boston Scientific 0.035 J (175cm)
  • Boston Scientific FL 4 - 6F
  • Boston Scientific FR 4 - 6F
  • Procedure Pack
  • Chloraprep 25 ML
  • Boston Scientific Advantage Kit (26)
  • Boston Scientific 0.014 Choice PT Extra Support 182 (cm)
  • Boston Scientific 6F Runway VL 3.5
  • Boston Scientific 6F Runway FL 3
  • Boston Scientific 6F Runway VL 3
  • Medtronic Export Aspiration Catheter 6 F
  • Boston Scientific Maverick 2.5 x 20 mm
  • Boston Scientific Promus Element Plus 2.75 x 24 mm
  • Boston Scientific 7F Mach 1 FL 3
  • Boston Scientific 0.014 Choice PT Extra Support 182 (cm)
  • Boston Scientific Maverick 2.0 x 20 mm
  • Boston Scientific Promus Element Plus 2.5 x 16 mm
  • Boston Scientific Encore inflation device
  • Boston Scientific Promus Element Plus 3.0 x 8 mm
  • Boston Scientific Promus Element Plus 2.25 x 20 mm
  • Boston Scientific Promus Element Plus 2.25 x 24 mm
  • MEDICATIONS GIVEN DURING PROCEDURE:
  • Oxygen: 2 L/min via nasal cannula by Micah OLeary, RN, BSN ~ 15:13:23
  • Sa02 = 99% by Micah OLeary, RN, BSN ~ 15:13:24
  • IV Fluids: 0.9NS IV started @ 50 ml/hr by Micah OLeary, RN, BSN ~ 15:13:26
  • Fentanyl 100 mcg IV ,patient awake, by Micah OLeary, RN, BSN ~ 15:16:40
  • Versed 2 mg IV ,patient awake, by Micah OLeary, RN, BSN ~ 15:16:41
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 15:22:17
  • Heparin 5000 units IV by Micah OLeary, RN, BSN ~ 15:40:19
  • Heparin Witnessed by Mark Randolph, RN ~ 15:40:30
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 15:50:48
  • Fentanyl 50 mcg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 15:50:56
  • Fentanyl 50 mcg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 15:56:44
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 16:06:55
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 16:08:55
  • MEDICATIONS GIVEN DURING PROCEDURE (CONTINUED):
  • Fentanyl 50 mcg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 16:11:20
  • Phenergan 12.5 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 16:11:56
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 16:12:00
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 16:15:24
  • Fentanyl 50 mcg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 16:16:04
  • Isuprel 1mg/250ml NS 60 ml/hr by Micah OLeary, RN, BSN ~ 16:18:15
  • Isuprel 1mg/250ml NS DC by Micah OLeary, RN, BSN ~ 16:26:22
  • Heparin 3000 units IV by Micah OLeary, RN, BSN ~ 16:35:31
  • Heparin Witnessed by Mark Randolph, RN ~ 16:35:40
  • Nitroglycerin 60 mcg IV by Micah OLeary, RN, BSN ~ 16:40:28
  • Versed 2 mg IV ,patient restless, by Micah OLeary, RN, BSN ~ 16:56:52
  • Angiomax 12 mls IV by Nicole Baquie, RN ~ 17:00:47
  • IV Fluids: 0.9NS increased to 450 ml/hr by Nicole Baquie, RN ~ 17:01:15
  • Angiomax 250mg/50ml IV started @ 28 ml/hr by Nicole Baquie, RN ~ 17:01:25
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 17:06:29
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 17:10:50
  • Angiomax DCd, fluids decreased to 50 ml/hr IV by Nicole Baquie, RN ~ 17:12:41
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 17:22:43
  • Versed 1 mg IV ,patient arousable, by Micah OLeary, RN, BSN ~ 17:25:46
  • Fentanyl 50 mcg IV ,patient restless, by Micah OLeary, RN, BSN ~ 17:25:53
  • Nitroglycerin 150 mcg IC by Dr John Bittl, MD ~ 17:38:41
  • Verapamil 50 mcg IC by Dr John Bittl, MD ~ 17:41:24
  • Nitroglycerin 100 mcg IC by Dr John Bittl, MD ~ 18:00:27
  • Integrilin 6.8 mls IV by Nicole Baquie, RN ~ 18:11:01
  • Brilinta 180 mg PO by Mark Noble, RCIS ~ 18:14:58
  • Integrilin 6.8 mls IV by Nicole Baquie, RN ~ 18:22:37
  • Fentanyl 50 mcg wasted by Micah OLeary, RN, BSN ~ 18:22:50
  • Aspirin Suppositorty (300mg) by Nicole Baquie, RN~ 18:28:09

_______________________________________

Bittl, John A. MD

JAB/ijr

COPIES TO:

Acevedo, Celso MD; Das, Chandranath MD; Addisu, Anteneh MD