1. Dual chamber implantable cardioverter-defibrillator via the left subclavian Seldinger approach.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to the cardiac electrophysiology laboratory in a fasting unsedated state. Continuous electrocardiographic monitoring, noninvasive blood pressure monitoring, pulse oximetry, and standby pacing and defibrillator pads were provided. In addition, the patient was attended by the anesthesiology department who provided arterial line, blood pressure monitoring, and LMA sedation and airway control.
The left prepectoral area was prepped and draped in a sterile manner and anesthetized with 1% Xylocaine. A 4 cm incision was made 2 fingerbreadths inferior to the clavicle, near the deltopectoral groove. Using blunt dissection and electrocautery, a pocket for the AICD was formed at the level of the pectoralis fascia.
Using blunt dissection in the deltopectoral groove, the left cephalic vein was exposed and isolated. The distal portion of the vein was tied with a 0 Ethibond tie and the proximal portion was looped with another 0 Ethibond suture for control. The vein was incised and lumen was exposed with the vein pick. An attempt was made to pass the AICD lead through the left cephalic vein; however, the vein was of too fragile quality to accept the lead. Therefore, the proximal tie on the cephalic vein was tied off with excellent hemostasis and cephalic vein approach was abandoned.
Because of the patient's body habitus and elevated clavicle, it was felt that it would be prudent to locate the patient's left subclavian vein fluoroscopically prior to accessing it via Seldinger technique. Therefore, using 10 cc of intravenous nonionic contrast, left upper extremity venogram was performed, which visualized the course of the left subclavian vein, which was rather small and inferiorly located. Under fluoroscopic visualization, the extrathoracic portion of the left subclavian vein was cannulated with Seldinger technique x2 and two 0.035 guidewires were placed under fluoroscopic guidance into the left subclavian vein in the superior vena cava. The first guidewire was used to introduce a 7-French sheath, which was in turn used to introduce the ventricular lead, and the second wire was used to introduce another 7-French peel-away introducer, which was used in turn to introduce the atrial lead both under fluoroscopic guidance into the left subclavian vein and superior vena cava.
The ventricular lead was placed in the right ventricular apex under fluoroscopic guidance and the active fixation screw was advanced with parameters measured as below. High output pacing did not capture the diaphragm. The lead was sutured in place using suture sleeve using 0 Ethibond sutures x2 under the pectoralis fascia.
Next, the atrial lead was placed in the high right atrium and the active fixation screw was advanced under fluoroscopic guidance with parameters measured as below. The lead was sutured in place using the suture sleeve and 0 Ethibond sutures x2 under the pectoralis fascia.
Careful attention was paid to hemostasis in the pocket. The pocket was irrigated with antibiotic solution. The AICD leads and atrial lead were attached to the AICD generator, and proper operation was confirmed. The leads and generator were placed in the pocket. Defibrillation threshold testing was carried out as below with excellent defibrillation threshold and lead parameters. A fluoroscopic survey was made of the pocket as well as the leads. The deep portion of the pocket was lined with Surgicel absorbable hemostat. The pocket was closed with 2 layers of 3-0 Vicryl running sutures, subcuticular 4-0 Vicryl running sutures, as well as Dermabond adhesive and a pressure dressing on the surface. The patient tolerated the procedure well and was discharged from the cardiac electrophysiology laboratory without any immediate postprocedure complications. A chest x-ray was ordered to exclude pneumothorax.
The AICD generator is a Medtronic model 7288, serial # PUB103491H. The ventricular ICD lead is a Medtronic model 6949, 58 cm active fixation, serial # LFJ022148V. The atrial lead is a Medtronic active fixation, model 5076, 52 cm, serial # PJN694043V.
In the final position, the endocardial R-wave potential was 7.5 millivolts with a pacing threshold of 1.3 volts at 0.5 milliseconds and an impedence of 902 ohms.
In the final position, the endocardial R-wave potential was 1.2 millivolts with a pacing threshold of 0.7 volts at 0.5 milliseconds and an impedance of 671 ohms.
High output pacing in both the atrial and ventricular channels did not result in diaphragmatic capture.
Defibrillation threshold testing was carried out using T-wave shock protocol. Ventricular fibrillation was induced and was detected by the device without dropouts, which charged this program to 11 joules and provided an 11-joule shock that cleanly terminated ventricular fibrillation and restored sinus rhythm. The shock impedance was nominal.
Therefore, the defibrillation threshold was less than or equal to 11 joules, which provides greater than or equal to 24 joules safety margin in this device.
The device brady parameters were programmed for AAIR mode with automatic backup to DDD mode to allow for conduction of the patient's native QRS and to minimize wide complex ventricular pacing in this patient with reduced ejection fraction and relatively narrow native QRS complex. The minimum rate was set to 50 and the maximum rate was set to 120 with mode switching enabled.
INDICATION FOR PROCEDURE: Non-ST elevated MI and chest pain.
PROCEDURES PERFORMED: Left heart catheterization, selective coronary angiogram, catheter placement into left ventricle and selective right femoral artery angiogram.
DESCRIPTION OF PROCEDURE: The patient provided written informed consent and was brought to the cath lab in elective condition. The right groin was draped and prepped in the sterile fashion. Twenty mL of 2% lidocaine was used for anesthesia. A 5-French sheath was placed in the right femoral artery via the Seldinger technique using an 18 gauge needle and guidewire. A JL4 catheter was advanced up the sheath to engage the ostium of the left main coronary artery where multiple views of left coronary artery system were taken. Following this, a JR4 catheter was used to engage the ostium of the right coronary artery; however, this was unsuccessful. The use of a 3DRC catheter was successful with engagement of the right coronary artery's ostium and multiple views of the right coronary system were then taken. Finally, a pigtail catheter was used to cross the aortic valve, going to the left ventricle where LVEDP and left ventricular pressures were measured. Pullback pressure was then obtained and was within normal limits. The final shot was a selective right femoral artery angiogram sheath shot. After reviewing the films, there was no clear indication that the patient would benefit from PCI at this time, so the sheath was removed and pressure was applied manually for 20 minutes. The patient is to remain in bed rest for the next 6 hours.
HEMODYNAMIC FINDINGS: LVEDP was 18.
ANGIOGRAPHIC FINDINGS: The left main coronary artery was big in caliber and short in length and had heavy calcium. The left main did bifurcate into an LAD and left circumflex system. The LAD had moderate diffuse coronary artery disease and was normal in size and caliber, tapering around the apex. The proximal portion of the LAD was very calcified, had segmental lesions of 20% followed by a very eccentric 40% lesion just proximal to a previous stent. Within the stent of the LAD was least 20% stent restenosis. The rest of the mid LAD had diffuse segmental disease of 40%. The distal aspect of the LAD also was subtotaled with a 99% lesion. The LAD gave off one large diagonal branch that bifurcated distally and had mild luminal irregularities throughout. The left circumflex was nondominant and had mild diffuse luminal irregularities throughout. The OM1 was small and wispy and it was severely diseased. OM2 was large and branching and had mild to moderate diffuse luminal irregularities. OM3, OM4 and OM5 were small in size, heavily diseased and served as posterolateral branches. The right coronary artery was dominant. It was proximally to mid occluded. It gave off a large acute marginal branch, did fill retrogradely with left to right collaterals, filling up to approximately the crux of the PDA and PLV branches.
1. Severe two-vessel coronary artery disease.
2. Culprit lesion likely was the distal left anterior descending artery, being subtotal now.
PLAN: Given the fact that the patient's MI was quite far out from now and that the apex appeared to have minimal movement on echo and the fact that the lesion is very distal, it was decided that the patient would best benefit from medical management. In terms of right coronary artery, this would be a very high-risk procedure to consider fixing in the future given its distance from the occlusion to the retrograde backfilling. Again, the patient would likely benefit best from medical management.
PROCEDURE: Insertion of dual chamber pacer with atrial and ventricular leads of St. Jude Medical.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in a fasting state. Informed consent was obtained from the patient. All the complications, benefits, risks, and alternatives to the procedure were explained to the patient. He consented for the procedure.
Left side of the chest was prepped in the usual sterile fashion and 1% lidocaine was used as local anesthetic. An 18 gauge needle was introduced into the left subclavian vein. Through the needle, the guidewire was passed in position, in superior vena cava, under fluoroscopic guidance. Once the guidewire was in position, the pacer pocket was made on the left side of the chest.
Through the preplaced guidewire, #9 French introducer along with a sheath was inserted. The introducer was removed, and through the sheath, ventricular leads of St. Jude Medical, model #1646T-58, serial #UB18080 was introduced, and with the help of J-wire, advanced into the right ventricular outflow tract. The J-wire was replaced with a straight wire, and the lead was positioned in the right ventricular apex. The following parameters were obtained, which were within acceptable range. The R-wave amplitude was 19.1 millivolts. Lead impedance was 680 ohms. There was no diaphragmatic stimulation at 10 volts. Ventricular capturing threshold was 0.4 volts. All these parameters were within acceptable range.
Once the ventricular lead was positioned, another #9 French introducer along with the sheath was inserted through the preplaced guidewire into the left subclavian vein. This time, the introducer and the guidewire were removed, and through the sheath, atrial leads of St. Jude Medical, model #1688TC-46, serial #DM25661, was introduced into the lower one-third of the right atrial cavity. The straight wire was replaced with a J-shaped wire and the lead was positioned in the right atrial appendage, where the following parameters were obtained. Atrial capturing threshold was 0.5 volts. The P-wave amplitude was 3.1 millivolts. Lead impedance was 425 ohms. There was no diaphragmatic stimulation at 10 volts. All these parameters were within acceptable range. At this stage, atrial and ventricular leads were secured to the chest wall with #2-0 silk.
Both atrial and ventricular leads were connected to pulse generator of St. Jude Medical, model #5380, serial #920226. The generator was placed in the preformed pocket and the pocket was closed. The patient tolerated the procedure very well. X-ray of the chest was obtained, which confirmed the appropriate position of atrial and ventricular leads and no pneumothorax.
The patient returned to his room in stable condition.
1. Insertion of pacing cardiodefibrillator with generator and testing.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, placed in supine position, and administered mild general anesthesia. The patient was identified. The chest and abdomen were prepped and draped in the usual sterile fashion.
A transverse incision was made just below the lateral aspect of the clavicle, taken down to the pectoralis major muscle, where a pocket was developed deep to the pectoralis major muscle. Under fluoroscopic guidance, a right ventricular lead, Medtronic model 6949, serial #LFJ030238V was inserted in the right ventricular apex where there was a threshold of 0.7 volts, current of 0.7 milliamperes, impedance of 1066 ohms, and a PR wave of 25.3 with a slew rate of 4.0 volts per second. A second lead was inserted under fluoroscopy, which was a right atrial lead, Medtronic model 5076, serial #PJN724661V. The threshold on this atrial lead was 0.8 volts with a current of 1.5 milliamperes and impedance of 599 ohms and a PR wave of 3.3 with a slew rate of 1.5 volts per second. These leads were connected to a Medtronic generator, model 7288, serial #PUB105995H.
The generator and leads were placed in the pocket, and the patient was subsequently fibrillated twice to ventricular fibrillation and rescued at 24 joules and subsequently at 20 joules. The pocket was then irrigated with copious amounts of warm antibiotic solution. The pocket was closed in standard fashion. The patient was awakened and taken to the recovery room in stable condition.
PROCEDURE: Dual chamber permanent pacemaker implant.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the electrophysiology laboratory in a fasting state. She was prepped and draped in the usual sterile fashion with multiple layers of Betadine. Lidocaine 1% infiltration was used to achieve local anesthesia.
Using sharp and blunt dissection, a generator pocket was created in the left infraclavicular area. Using an 18-gauge needle, access was obtained into the left subclavian vein. Over appropriate-sized introducers, Guidant screw and atrial and ventricular leads were advanced to appropriate sites in the right atrium and right ventricular apex. The atrial lead was Guidant 4469-422776. P wave was 1.2 millivolts. Threshold was 0.9 volts at 0.5 milliseconds with impedence of 500 ohms. The ventricular lead was Guidant 4470-432629 with a threshold of 0.3 volts at 0.5 milliseconds and impedence of 370 ohms and an R wave of 16 millivolts. Both leads were secured to the fascial layer with 0 silk and then attached to a Guidant dual-chamber permanent pacemaker, model 1298-187253. It was also secured to the fascial layer with 0 silk. The lower layers were then closed with 2-0 and 4-0 Vicryl. The final dressing was made with Steri-Strips and benzoin. The patient tolerated the procedure quite well.
PROCEDURES: Implantation of leads in atrium and ventricle, insertion of a pacing electrode for left ventricular pacing, electrophysiologic evaluation of leads and device implant, fluoroscopy and radiography, and venography of left upper extremity for coronary sinus anatomy.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient prior to the procedure, and the patient was brought to the electrophysiology laboratory in a fasting state. The patient was positioned supine on the operating table, connected to the ECG, BP, and O2 saturation monitoring equipment. Now, two pads were applied in the AP position. The left hemithorax was prepped and draped in the usual sterile fashion. One gram of intravenous vancomycin was given preoperatively as prophylaxis. Conscious sedation was provided by the anesthesia service. Lidocaine 1% was used for local anesthesia.
A transverse incision was made below the left clavicle and subcutaneous tissue, transected with Bovie, diathermy, and blunt dissection until the pectoralis major fascia was reached. The left axillary vein was percutaneously cannulated three times and a guidewire inserted using the modified Seldinger technique. Sheath assembly was passed over each guidewire and the dilator subsequently removed. The right ventricular lead, using curved stylet, was advanced through the sheath into the pulmonary trunk under fluoroscopic guidance. Sheath was removed. Stylet was changed to a straight stylet and the leads were pulled back and subsequently screwed into the right ventricle apex. Sensing and pacing thresholds as well as lead impedance was determined. The lead was anchored to the fascia with 0 silk suture. The atrial lead was advanced through the sheath into the right atrium under fluoroscopic guidance. The sheath was removed. Straight stylet replaced with a J-stylet and the lead tip screwed into multiple areas in order to get a good pacing threshold and good sensing threshold. Eventually, one site was selected upon, and standard pacing and sensing measurements were obtained from that region. The lead was anchored to the fascia with 0 silk suture. Attention was then turned to the left ventricular lead. The _____ coronary sinus was obtained under fluoroscopic guidance with Worley lead delivery system advanced through the third sheath. Contrast was injected to verify positioning of the Guidant catheter in the coronary sinus. A balloon catheter with a lumen was passed through the Guidant catheter and 10 cc of radiocontrast was injected to obtain a venogram of the coronary sinus. The balloon catheter was removed and the lead was positioned in the posterolateral portion of the left ventricle, about one-half way down. Standard pacing and sensing measurements were obtained. No phrenic nerve or diaphragmatic pacing was noted. The Guidant catheter was removed and the lead anchored to the fascia with 0 silk suture.
The pocket was washed with bacitracin solution. RA, RV, and LV lead terminal pins were connected appropriately. Pulse generator ports and screws were tightened. The device was then placed securely in the pocket and the pocket irrigated again with bacitracin solution. Defibrillation threshold testing was then performed with 5-minute waiting period between episodes. The incision was closed in three layers of Vicryl. Dermabond and Steri-Strips were placed over the suture line and incision covered with 4 x 4 dry gauze and Tegaderm. Fluoroscopy at the end of the procedure demonstrated all hardware to be in the correct position. Estimated blood loss was 25 cc. The patient was in sinus rhythm during the procedure and was transferred to the holding area in stable condition.
IMPLANT OF ICD SYSTEM:
PSA based intraoperative measurements are P wave of 2.9 millivolts, atrial pacing threshold of 2.9 volts at a pulse width of 0.5 milliseconds. The right ventricular R-wave is 16.4 millivolts. The right ventricular pacing threshold is 0.7 volts at a pulse width of 0.5 milliseconds. The left ventricular R-wave is 16.0 millivolts. The left ventricular pacing threshold is 0.7 volts at a pulse width of 0.5 milliseconds. Atrial lead impedance of 122 ohms, right ventricular impedance of 778 ohms, and the left ventricular impedance of 1058 ohms.
DEVICE MEASURED DATA: P wave is 2.4 millivolts and the ventricular pacing threshold is 2.5 volts at a pulse width of 0.4 milliseconds. R-waves in the right ventricle were 9.1 millivolts and right ventricular pacing threshold was 1 volt at a pulse width of 0.2 milliseconds. Left ventricular pacing threshold was 1 volt at a pulse width of 0.2 milliseconds. Impedances are 448 for the atrial lead, 632 ohms for the right ventricular lead, and 576 ohms for the left ventricular lead.
Defibrillation threshold is equal to or less than 20 joules.
PROGRAM SETTINGS IN THE OR:
1. Cardiac resynchronization therapy with a defibrillator implantation.
DESCRIPTION OF PROCEDURE: The benefits, risks, and alternatives of CRT-D were discussed in detail. Informed consent was obtained. The patient was brought to the electrophysiology laboratory in a fasting state and prepped and draped in the usual sterile fashion. Lidocaine 1% was used for local anesthesia. A combination of fentanyl and Versed was used for conscious sedation. Preoperative antibiotics were administered.
An incision was made along the left upper chest and careful dissection was performed down to the pectoris major fascia and muscle. Two left subclavian vein punctures were performed under fluoroscopic guidance without incident and two guide wires were inserted using a modified Seldinger technique. Over one guide wire, a 10.5 French sheath was advanced in position. Through the sheath, a Guidant RELIANCE model 0157-59 cm, serial #127916, dual coil active fixation AICD lead was advanced in position in the right ventricular apical septum. The active fixation mechanism was deployed and following measurements were obtained including R-waves of 6 millivolts and impedance to 750 ohms and a threshold of 0.6 volts at 0.5 milliseconds. There was no diaphragmatic pacing at 10 volts output. The guidewire was inserted along the side of the sheath. The sheath was then removed. The lead was secured to the underlying muscle and fascia using 0 silk. Over the newly inserted guidewire, an 8-French sheath was advanced in position. Through the sheath, a Guidant active fixation bipolar atrial pacing leads FLextend model 40860, serial #219211-45 cm was advanced in position in the right atrium. Multiple positions were tested. Final position yielding good results was found. The active fixation mechanism was deployed and the following measurements were obtained including T-waves of 1.6 millivolts, and impedance of 450 ohms and a threshold of 1 volt at 0.5 milliseconds. There was no diaphragmatic pacing at 0 volts output. The sheath was removed. This lead was secured to the underlying muscle using 0 silk.
Over the remaining guidewire, a 9-French sheath was advanced in position. Through the sheath, a guided extended hook coronary sinus guiding sheath was advanced in position under fluoroscopic guidance in the right atrium. Through the sheath, a Cordis Webster deflectable quadripolar catheter was advanced and the coronary sinus was cannulated. There was subselections of middle cardiac vein, and the guiding sheath was advanced into the middle cardiac vein. The deflectable catheter was removed. Through the coronary sinus guiding sheath, a Guidant left ventricular pacing lead, EASYTRAK 2, serial #4543, serial #105593 was advanced in position in the middle cardiac vein. The following measurements were obtained including R-waves of 4 millivolts and impedance of 700 ohms and a threshold of 8 volts at 1.5 milliseconds. Manipulations were performed with the lead, unfortunately all revealing extremely high thresholds. Pacing at 10 volts caused diaphragmatic capture. The lead was withdrawn and the guiding sheath was withdrawn, and attempts were made to cannulate the main body of the coronary sinus. There was extreme tortuosity of the main body of the coronary sinus. Attempts of cannulating this resulted in dislodgement of the coronary sinus guiding sheath. Further attempts at entering the coronary sinus with a deflectable catheter were unsuccessful.
Using a long guidewire and a multipurpose coronary sinus guiding sheath, the main body of the coronary sinus was cannulated. A inner Rapido catheter was then utilized to provide stability in the main body of the coronary sinus. Over the inner Rapido, the multipurpose coronary sinus guiding sheath was advanced in position. An occlusive balloon angiogram catheter was advanced in position under fluoroscopic guidance into the coronary sinus. Coronary sinus angiography was performed. The coronary sinus main body was large, tortuous. There was a middle cardiac vein, which had previously been cannulated. There is an extremely small posterolateral branch, which would not accommodate a lead. There were no further lateral branches. There were a number of anterior and medial branches, which would accommodate the lead. A decision was made to try to cannulate one of those anterior medial veins.
Using an EASYTRAK 2 lead and a Whisper wire, an anteromedial vein was cannulated and the lead was positioned. The following measurements were obtained including R-waves at 7.5 millivolts, impedance of 595 ohms and a threshold of 4 volts at 1.5 milliseconds. There was no diaphragmatic pacing at 10 volts output.
The guiding sheath was slit and removed. The Whisper wire was then removed. Careful attention was given to the slack. The left ventricular lead was sutured to the underlying muscle and fascia using 0 silk.
The pocket was then fashioned along the incision site and checked for hemostasis. The pocket was vigorously irrigated with antibiotic solution. The leads were connected to a Guidant generator Renewal Contak model H170, serial #50816. All set screws were tightened and the system was implanted. The generator was loosely sutured to the underlying muscle using 0 silk.
After further sedative medication was administered, ventricular fibrillation was induced through the device. A 21 joule shock was successful in restoring normal sinus rhythm. Charge time was 3.8 seconds and the shock impedance was 40 ohms. There was no signal dropout at least sensitivity. After waiting a period of 5 minutes, ventricular fibrillation was reinduced. A 21 joule shock was successful in restoring normal sinus rhythm. The charge time was 3.8 seconds and the shock impedance was 38 ohms. The patient tolerated defibrillation threshold testing well without complications. The atrioventricular and left ventricular pacing leads were also analyzed.
The wound was closed in three layers using 2-0, 3-0, and 4-0 Vicryl. Steri-Strips were applied. The patient tolerated the procedure well without complications. The sponge and needle counts were correct at the end of the procedure.
The AICD was programmed as a two-zone device with ventricular tachycardia detection programmed at 175 beats per minute. The VT therapy was programmed. Two sequences of ATP, 21 joules and then 31 joules maximum shock. Ventricular fibrillation detection was programmed at 205 beats per minute. The pacemaker was programmed with DDDR 70 to 120 beats per minute. The AV delay was programmed at 120 milliseconds. The outputs were adjusted. The patient was sent to the holding area in stable condition.
PROCEDURE: Noninvasive program stimulation and defibrillation threshold check.
DESCRIPTION OF PROCEDURE: The patient was brought to the lab in a fasting state. He was connected to the hemodynamic monitoring equipment. The device was interrogated. The patient has a Guidant Contak Renewal device. On interrogation, his P wave amplitude measured between 0.6 to 2.3 millivolts, R wave amplitude measured 8.3 millivolts, atrial pacing lead impedance measured 444 ohms, ventricular pacing lead impedance measured 607 ohms in the right ventricle and 537 ohms in the left ventricle, shock impedance measured 31 ohms, and pacing threshold measured 2.8 volts of 0.5 milliseconds in the atrium, 1.6 volts at 0.5 milliseconds in the right ventricle, and 3.5 volts at 0.5 milliseconds in the left ventricle. VF was then induced by means of T-wave shock. This is detected appropriately at least sensitivity and terminated abruptly by a 21-joule shock in reverse polarity. Charge time measured 3.8 seconds and the shock impedance measured 31 ohms. After a 4-minute waiting interval, the VF was again induced by means of T wave, this was again detected appropriately at least sensitivity and terminated abruptly by 21-joule shock in reverse polarity. Shock impedance measured 31 ohms and the charge time measured 3.6 seconds.
PROCEDURE: Left heart catheterization.
DESCRIPTION OF PROCEDURE: After obtaining adequate consent from this patient, he was brought into the cardiac cath lab area where the right groin was prepped and draped in the usual sterile fashion. Local anesthesia was injected, 1% lidocaine. With the modified Seldinger technique, the right femoral artery was cannulated and 6-French sheath was advanced over a guidewire. Good blood flow return was obtained. Following this, coronary artery catheter was advanced to left and right coronary artery position. For visualization of their anatomy, we had injection of dye. The catheters utilized were a 6-French JL4 and 6-French JR4. The latter one was also used to measure left ventricular intracavitary pressures, but there was no left ventriculogram performed.
The results of the coronary angiography are as follows:
1. Left main coronary artery: The left main is a short vessel giving away LAD and left circumflex coronary arteries and a very small ramus intermedius. No significant lesions are seen in this territory.
Following the coronary angiography, the right coronary catheter was advanced to the left ventricular cavity for measurement of intracavitary pressures. The left ventricular end-diastolic pressure was estimated to be 14 mmHg. On pullback, there was no gradient across the aortic valve.
At the end of the procedure, the catheters were removed as well the sheath from the right groin area. Hemostasis achieved by gentle compression of the right groin. The patient will be transferred to the holding section of the cardiac cath lab for hydration and observation.
PROCEDURE: Left heart catheterization.
PROCEDURE IN DETAIL: After obtaining adequate consent from this patient, he was brought to the cardiac cath lab area, where the right groin was prepped and draped in the usual sterile fashion. Local anesthesia was injected using 1% lidocaine. With modified Seldinger technique, the right femoral artery was cannulated and a 6-French sheath was advanced via guidewire. Following this, coronary catheter was advanced to left and right coronary artery, positioned. For visualization of the anatomy, we had injection of dye. The catheters utilized were 6-French JL4, 6-French JR4, and a pigtail catheter. The latter one was used to measure left ventricular intracavitary pressures.
The results of coronary angiography are as follows:
Following the coronary angiography, a pigtail catheter was advanced to the left ventricular cavity for measurement of intracavitary pressures. The left ventricular end-diastolic pressure is estimated to be approximately 50 mmHg. Upon pullback, there is no gradient across the aortic valve.
At the end of the procedure, the catheters were removed as well as sheath from the right groin area. Hemostasis was achieved by gentle compression of the right groin. The patient will be transferred to the holding section of the cardiac cath lab for hydration and observation.
Additional terms encountered in these types of reports:
Biosense Webster Navistar catheter
Bi-V ICD implant
Medtronic Marquis VR model
Medtronic bipolar active fixation ventricular pacing lead
Medtronic Maximo DR model
Medtronic InSync Maximo
Medtronic Enpulse E2DR01
Medtronic Attain guiding catheter
French Judkins catheter
JR-4 and JL-4
RAO or LAO projection
fluoro or fluoroscopic
no gradient seen on pullback
Vessels viewed in cardiac cath reports:
1. Left main.
2. LAD or left anterior descending
3. Left circumflex (referred to as "circ" in slang)
4. Diagonal branches
5. Obtuse marginal one (OM1) and obtuse marginal two (OM2)
6. RCA or right coronary artery.
8. Posterior descending artery or PDA.