ASSISTANT:
ANESTHESIOLOGIST:
HISTORY: The patient is a pleasant gentleman with history
of CABG x3 who is being seen for shortness of breath and
abnormal ejection fraction.
The patient is with a history of CABG x3 approximately 6
months ago by Dr. Fee. He has continued to have shortness
of breath and recently admitted to O'Connor Hospital with
chest pain and congestive heart failure. Recent thallium
stress test revealed questionable ischemia with markedly
decreased ejection fraction. Review of all the patient's
labs and coronary evaluation require angiography.
CATHETERIZATION TECHNIQUE: The right femoral artery was
cannulated using a Seldinger technique. A 6-French
arterial sheath was placed without difficulty in the right
femoral artery. After 2000 units of heparin were given,
Jackman full curve right and left catheters were advanced
over J-wires into the appropriate position with views being
taken. Finally, a pigtail catheter was advanced into the
left ventricular cavity and an LV-gram was performed.
The LIMA catheter was able to view the left internal
mammary artery. The right coronary catheter was able to
cannulate both the free RIMA to the RCA, along with the
saphenous vein graft to the OM diagonal.
CATHETERIZATION RESULTS:
RIGHT CORONARY ARTERY: The right coronary arises from the
right sinus of Valsalva. The vessel is 100% occluded at
its origin.
LEFT MAIN LINE: The left main coronary artery arises in
the left sinus of Valsalva and bifurcates into the LAD and
circumflex systems. This vessel has an 80% proximal area
of narrowing and 70% distal left main area of narrowing.
LEFT ANTERIOR DESCENDING: The left anterior descending
coronary arises from the left main coronary artery and runs
in the interventricular groove. This vessel is subtotally
occluded in its midportion.
LEFT CIRCUMFLEX: The left circumflex coronary artery
arises from the left main coronary artery and runs in the
atrioventricular groove. A large segmental branch was also
noted to be subtotally occluded with competitive flow
appreciated.
FREE RIMA TO THE RC: A free RIMA is noted to arise from
the aorta to perfuse the PDA. Its insertion site and flow
to the PDA and PLV branches are without obstruction.
LEFT INTERNAL MAMMARY ARTERY: The left internal mammary
artery seems to perfuse the LAD. The LIMA, its insertion
and distal flow, are without significant disease.
ASSESSMENT OF GRAFT TO THE OM/DIAGONAL: A jump graft of
the OM to diagonal is noted to arise from the aorta. The
graft itself is widely patent throughout its course. Just
distal to the insertion to the OM, the OM itself has an 80%
area of narrowing in its proximal portion. The diagonal
branch was noted to have itself a 70% mid area of
narrowing.
LEFT VENTRICULOGRAM: A left ventriculogram was performed
in the 30 degree right anterior oblique position.
This
revealed an apical akinesia with markedly decreased
ejection fraction with global hypokinesis with ejection
fraction estimated at less than 25%. Trace mitral
regurgitation was noted. There was no outflow tract
obstruction noted.
CONCLUSION:
1. Markedly decreased ejection fraction of less than 25%
with wall motion abnormalities as described above.
2. Native coronary artery disease consisting of 100% RCA,
80% proximal left main, 70% distal left main, with
competitive flow noted in the midportions of both the LAD
and OM.
3. Patent RIMA to the RCA.
4. Patent LIMA to the LAD.
5. Patent saphenous vein graft of the OM diagonal with
lesions in the native OM distal to the graft insertion of
80% and 70% mid diagonal disease.
COMMENTS: It is my opinion that the main distal
___________ resides around his decreased ejection fraction.
Therefore, we will attempt medical therapy for such and
only address the OM diagonal lesions should symptomatology
or significant ischemia be acknowledged.