CARDIAC CATHETERIZATION

MIMIC Database Record 237

20/07/1995

BRIEF HISTORY

The patient is a 62 year old woman with a history an inferior MI in 1988, which was treated with TPA, followed by PTCA of the RCA. At that time, she had an EF of 41%, as well as significant stenoses in her OM1 and D1. She has been treated medically since without significant angina. She presented to an outside hospital at 2:30AM with 1.5 hours of chest pain and dyspnea, was intubated for pulmonary edema, and had VF arrest X 2 and an episode of asystole, treated promptly with atropine with return of sinus rhythm. She had transient complete heart block, and external pacing was secured but not used. EKG revealed an acute inferior and RV MI, and she was transferred by helicopter for primary intervention.

INDICATIONS FOR CATHETERIZATION

Acute Inferior/RV MI

PROCEDURE

Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 French Baim-Turi catheter, advanced to the PCW position through a 8 French introducing sheath. Cardiac output was measured by the Fick method.

Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 7 French left Judkins catheter, advanced to the ascending aorta through a 8 French introducing sheath.

Coronary Angiography: was performed in multiple projections using a 7 French JL4 and a 8 French AR-1 guiding catheter, with manual contrast injections.

Percutaneous Revascularization: was performed on multiple lesions using balloon angioplasty. In addition stent placement was used. Temporary pacing: was secured by placement of a 7 French bipolar Baim-Turi catheter in the right ventricle.

RESULTS

  **HEMODYNAMICS RESULTS:
BODY SURFACE AREA: 2.10 m2
HEMOGLOBIN: 13.8 gms %
                                               ENTRY                        

  **PRESSURES
PULMONARY ARTERY {s/d/m}                    36/24/28                        
PULMONARY WEDGE {a/v/m}                       -/-/19                        
AORTA {s/d/m}                             145/88/108                        
  **CARDIAC OUTPUT
HEART RATE {beats/min}                            90                        
RHYTHM                                            SR                        
O2 CONS. IND {ml/min/m2}                         125                        
A-V O2 DIFFERENCE {ml/ltr}                        47                        
CARD. OP/IND FICK {l/mn/m2}                  5.6/2.7                        
  **RESISTANCES
PULMONARY VASC. RESISTANCE                       129                        
  **% SATURATION DATA (NL)
PA MAIN                                           75                        
AO                                               100                        
  **ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N                      100% ETT                        
pO2                                              213                        
pCO2                                              35                        
pH                                              7.44                        

                                                FICK                        
  **% SATURATION DATA (FL)
IVC HIGH                                           -                        

OTHER HEMODYNAMIC DATA:      The oxygen consumption was assumed.

  **ARTERIOGRAPHY RESULTS
                                   MORPHOLOGY     % STENOSIS   COLLAT. FROM

  **RIGHT CORONARY
1) PROXIMAL RCA                      DISCRETE          80
2) MID RCA                            TUBULAR       50,70
2A) ACUTE MARGINAL                   DISCRETE          60
3) DISTAL RCA                          NORMAL            
4) R-PDA                             DISCRETE       40-50
4A) R-POST-LAT                         NORMAL            
  **LEFT CORONARY
5) LEFT MAIN                         DISCRETE          20
6) PROXIMAL LAD                      DISCRETE          50
6A) SEPTAL-1                           NORMAL            
7) MID-LAD                            TUBULAR          70
8) DISTAL LAD              DIFFUSELY DISEASED            
9) DIAGONAL-1                          NORMAL            
10) DIAGONAL-2                         NORMAL            
11) INTERMEDIUS                      DISCRETE       60-70
12) PROXIMAL CX                      DISCRETE       60,50
13) MID CX                             NORMAL            
14) OBTUSE MARGINAL-1                  NORMAL            
15) OBTUSE MARGINAL-2                  NORMAL            

  **PTCA RESULTS
                          PROX RCA  MID RCA                                    

  **BASELINE
STENOSIS PRE-PTCA               80       70                                    
  **TECHNIQUE
GUIDING CATH                8 F HS  8 F JR4                                    
GUIDEWIRES                0.014 HT 0.014 ST                                    
INITIAL BALLOON (mm)           3.5      3.5                                    
FINAL BALLOON (mm)             3.5      3.5                                    
# INFLATIONS                     6        4                                    
MAX PRESSURE (PSI)             300      300                                    
  **RESULT
STENOSIS POST-PTCA               0        0                                    
DISSECTION (0-4)                 0        0                                    
SUCCESS? (Y/N)                   Y        Y                                    
NUMBER OF BALLOONS USED:         4

PTCA COMMENTS

Preliminary angiography disclosed an 80% stenosis in the proximal RCA, with haziness consistent with residual thrombus. There was a long 70% mid-RCA stenosis as well. The vessel had normal flow. The proximal stenosis was crossed easily with a 0.014 HTF wire, via the 8F JR4 guide, which provided good support. The stenosis was dilated with a 3.5 Predator, and after initially good result, there was noted to be considerable recoil and a 1+ dissection limited to the proximal RCA. It was therefore decided to place a stent. However, because there would be impedance to runoff, the mid-RCA lesion was first addressed. It was predilated with the 3.5 Predator at low pressure. A 3.5 Palmaz Schatz coronary stent was deployed and post dilated at high pressure with a 3.5 Titan. A 3.5 Palmaz Schatz stent was then deployed in the proximal vessel and postdialted similarly.

TECHNICAL FACTORS

Total time (Lidocaine to test complete) = 1 hour 54 minutes.
Arterial time = 1 hour 47 minutes.
Fluoro time = 36 minutes.

Contrast:	Isovue, vol 330 ml, Indications - Hemodynamic
Anesthesia:	1% Lidocaine subq.
Anticoagulation:	Heparin 17,500 units IV
Other medication:	Lidocaine 1-3 mg/min iv infusion TNG 140-240 mcg/min IV infusion Lopressor 2.5 mg IV
Balloons used:	3.5 14, PREDATOR 3.5 5, SCHATZ-PALMAZ STENT 3.5 5, SCHATZ-PALMAZ STENT 3.5 14, TITAN 18, 18MM

COMMENTS

1. Coronary angiography revealed three vessel CAD in this right dominant system. The RCA had an ulcerated plaque with thrombus proximally with an 80% stenosis, which was considered the culprit lesion. The mid RCA was diffusely diseased and moderate stenoses were seen in the proximal acute marginal and PDA. The LMCA had minimal disease. The proximal LAD had diffuse disease with a 50-60% stenosis before and after the first septal branch. A long tubular 70% stenosis was present in its mid segment and distally there was mild diffuse disease. The diagonal branches were small and a very large intermedius had serial 60-70% proximal and mid stenoses. The Cx had a 60% proximal stenosis.
2. Resting hemodynamics revealed elevated mean PCWP=19mmHg and PA diastolic pressure =24mmHg with borderline normal cardiac index and normal pulmonary vascular resistance.
3. Left ventriculography was not performed.
4. Stenting was successfully performed on stenoses in the proxiaml and mid RCA (see PTCA comments).

FINAL DIAGNOSIS

1. Three vessel coronary artery disease.
2. Moderate diastolic and systolic dysfunction.
3. Acute inferior myocardial infarction managed by primary PTCA and Palmaz-Schatz stent placement.