Forum - Questions & Answers

Jul 22nd, 2014 - kristybishop

please help me code this

PROCEDURES PERFORMED:
1. Arterial access.
2. Left heart catheterization.
3. Left ventriculography.
6. Right femoral angiogram with Angio-Seal.

PREOPERATIVE DIAGNOSIS: See below.

POSTOPERATIVE DIAGNOSIS: 3 Vessel CAD

ACCESS SITE: Right common femoral arterial access.

Prior to procedure, risk and benefits discussed, risk of bleeding, perforation, renal failure, cerebrovascular accident, myocardial infarction, emergent need of surgery, thrombosis discussed. Before the procedure, I introduced myself to the patient and the family discussed the procedure, risks and benefits, went over lab data information provided to me and also discussed the case with the referring cardiologist.

INDICATIONS: Patient is a 90 year old male with recent chest pain with positive troponins and new onset atrial fibrillation. Has not undergone heart cath since early 1980.

PROCEDURE TECHNIQUE: The patient was brought to the cath lab in a fasting state. Both groins were prepped and draped in sterile fashion. A 6-French sheath was then placed in the right femoral artery after the area was infiltrated with lidocaine. After this, right and left coronary cineangiography was performed followed by left ventriculogram using 30 ml of nonionic contrast material. We then did

pull back into the aorta and pullback pressure documented. A right femoral angiogram was performed with Angoi-Seal placement at the end of the procedure to obtain hemostasis.

FINDINGS:
1. Left main: the left main gives rise to the LAD and left circumflex. There is a lesion of roughly 80% in the distal left main just proximal to the bifurcation. There was dampening with injection into the left main.
2. LAD: This was a large artery that extends into the apex of the heart. There is a high-grade lesion in the mid portion which appears to be in the 95% range. This is a long and diffuse area with the tightest stenosis of roughly 95%.
3. Left circumflex: There is a 40 to 50% hazy lesion in the proximal portion of the left circumflex.
4. RCA: The RCA is occluded. There is distal left-to-right collateral flow into the RCA. The RCA appears to be a large artery.
5. Left ventricular function: The ejection fraction is depressed with the ejection fraction between 40 to 45%. There appears to be moderate inferior hypokinesis.

CONCLUSIONS:
Severe 3 vessel coronary artery disease with left main involvement. I recommend that the patient be considered for open heart surgery. I spoke with Dr. Brown and the patient will likely be transferred to another institution for this high-risk procedure.




Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association