Memorial Medical Center

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1 Memorial Medical Center Cardiac Catheterization Report Patient Name: Diaz, John R Study Date: 3/31/2016 Gender: M Height: 68.9 in BP: 135/72 Weight: 175 lb BSA: 1.95 m² Inpatient History/Clinical: Chest pain, Coronary artery disease, Diabetes Procedure: LHC w/pci Prox OM1, IVUS Previous Study: Date: 03/30/2016 Patient ID: Priority: DOB, Age: RH ROUTINE 11/8/1953, 62 yr Coronaries: Stage 1 Stent 75% OM1 Prox Indications: History of shortness of breath with angina. Normal sinus rhythm with ST elevation Summary of procedure: An informed, witnessed and signed consent was obtained and placed in patients chart. The patient received Versed and Fentanyl for conscious sedation and was continuously monitored per hospital protocol. (See nursing notes for medications administered.) The patient was prepped and draped in the usual sterile fashion. 2% lidocaine was infiltrated into the skin and subcutaneous tissue of the right groin for anesthesia. A 6FR sheath was placed into the right femoral using modified Seldinger technique. 6FR JL4 & JR4 catheters were used to selectively cannulate the left and right coronary arteries. Multiple angiographic images were obtained in standard projections. A 6FR angled pigtail catheter was advanced across the aortic valve and LV pressure was recorded. Left ventriculography was performed using 40 cc contrast agent in the standard RAO projection. Post-ventriculography LV pressure of 126 mmhg / 12 mmhg was obtained. The catheter was gradually withdrawn into the aorta under continuous pressure monitoring. LV 126 mmhg/ao 132 mmhg pressure was recorded and the catheter was removed. Diaz, John R 03/31/2016 RH Cath Lab Report Page 1

2 Diaz, John R 03/31/2016 RH Upon completion of the Left Heart Catheterization procedure, coronary artery disease of the obtuse marginal 1 artery involving the proximal segment(s) was noted on angiographic imaging. After further evaluation of angiographic images, it was determined that appropriate PCI was to follow. A 6FR JL4 guide catheter was used which provided adequate support. The patient was properly anticoagulated using Heparin with 60mg Effient(see nursing notes for medications administered). The vessel was wired with a 185cm Choice PT wire. The lesion was pre dilated to a maximum of 14 ATM using a 2.5 x 15 mm Apex Monorail balloon. Following pre dilation a 2.75 x 20 mm Taxus Liberte Stent RX was deployed at a maximum of 12 ATM. The stent was postdilated using a 2.75 x 15 mm NC Quantum Apex RX balloon throughout the stented area to a maximum of 10 ATM. This provided a favorable final angiographic result with no significant residual stenosis, dissection, thrombus or spasm. The 6FR JL4 guide catheter and 185cm Choice PT wire were removed. At the conclusion of the procedure, the 6FR sheath was removed and hemostasis was achieved without complications. The patient left the cath lab in stable condition with an intact 2+ dorsalis pedis pulse. Recommendations Based on today's cardiac catheterization, recommendations are: Admission to CCU, Follow up office visit in cardiology clinic in 2 weeks. Albert Cheng, MD Cath Procedure Description: FLTime: FLDose: CINEDose: TotalDose: IntFLTime: TotalRuns: 3 Medications Administered: Heparin, 3500 units, IV,. Procedural Fentanyl,.75 mcg, IV,. Procedural Versed, 2 mg, IV,. Percutaneous entry: Right Femoral artery Closure Device: Angio-Seal Complications: Patient tolerated procedure without complications Post Procedure Pulses Bilateral DP: 3+ Bilateral PT: 3+ Diaz, John R 03/31/2016 RH

3 Memorial Medical Center Cardiac Catheterization Report Patient Name: Diaz, John R Patient ID: RH Study Date: 7/14/2015 Gender: M Priority: ROUTINE Height: 70 in Referring MD: Shirley Simmons, MD Weight: 190 lb DOB, Age: 8/15/1960, 54 yr BSA: 2.04 m² Outpatient Indications: Claudication, Hyperlipidemia, Peripheral arterial disease History/Clinical: Diabetes, Claudication Procedure: Abdominal Aorta Angiography, Billateral lower extremity angiography, Revasculariztion of Left Common Iliac Artery w/ stent, Percantaneous closure of arterial access site Cath Procedure Procedure Description: Left femoral access for Distal Aortic Lesion Stenting. Images Pre-Procedure Lab Values Hgb 12.4 g/dl Hct 32 % PT 11 sec PTT 32 sec INR 1 Potassium 3.8 meq/l Sodium 120 meq/l Creatinine 1 mg/dl BUN 16 mg/dl WBC 9.8 /mcl Glucose 96 mg/dl Platelets 220 /mcl Staff Cardiac Cath Physician Interventionalist Scrub Nurse Circulating Nurse Radiologic Tech Recording Tech Pre-Procedure Medications Aspirin 85 mg Plavix 80 mg Pre-Procedure Pulses Bilateral DP: Present with Doppler Bilateral PT: Present with Doppler David Carnes, MD David Carnes, MD Jeanette Williamson, RN Adele Brooks, RN Nicholas Saint, RT Angela Turner, RN Medications Administered: Heparin, 6000 units, IV. Percutaneous entry: Left Femoral artery Closure Device: Angio-Seal Findings Interventional Peripheral Intv Periph AO: Endovascular intervention of the aorta in the abdominal segment was successful following bare metal stent placement. Contrast/Fluoro Contrast/Fluoro: Total contrast used: 250 ml of Isovue Total fluoro time for procedure was 45 minutes with a total fluoro dose for procedure of 1500 mgy. Diaz, John R 07/14/2015 RH Cath Lab Report Page 1

4 Diaz, John R 07/14/2015 RH Summary An informed, witnessed and signed consent was obtained and placed in patients chart. The patient received Versed and Fentanyl for conscious sedation and was continuously monitored per hospital protocol. (See Nursing notes for medications administered.) The patient was prepped and draped in the usual sterile fashion. 1% lidocaine was infiltrated into the skin and subcutaneous tissue of the left groin for local anesthesia. A 5FR sheath was placed into the left femoral artery using modified Seldinger technique. A 5FR straight pigtail catheter was advanced to distal aorta and aortography with lower extremity run off was performed. The catheter was removed over a guide wire and switched for a 5FR Quick-Cross catheter. The catheter was gradually withdrawn across the distal aorta and into the left iliac artery. A 30mmHg AO/LCIa pullback gradient was recoded. Upon completetion of diagnostic angiography, futher image review determined appropriate intervention for nonobstructive atherosclerosis in the infrarenal abdominal aorta noted. Endovascular intervention of the abdominal aorta involving the distal segment. The intervention was performed after patient was anticoagulated with Heparin. (See Nursing notes for medications administered.) The vessel was wired with a 200cm Amplatz Super Stiff wire. The lesion was pre dilated to a maximum of 8 ATM using a 4cm x 8 mm balloon. Following pre dilation a 4cm x 9 mm Atrium ICast stent was deployed at a maximum of 10 ATM. The stent was post-dilated using a 4cm x 9mm balloon throughout the stented area to a maximum of 10 ATM. This provided a favorable final angiographic result with no significant residual stenosis, dissection, thrombus or spasm. Ernesto Prado, MD Diaz, John R 07/14/2015 RH

5 Memorial Childrens Hospital Pediatric Cath Lab Patient Name: Diaz, Johnny Patient ID: RH Study Date: 6/6/2016 Gender: M Priority: ROUTINE Height: 74 cm BP: 138/67 DOB, Age: 11/8/2013, 2 yr Weight: 16 kg HR: 85 CPT: 93453, BSA: 0.53 m² Outpatient Procedure: Left and Right Heart Catheterization w/wo LV Angiography, Angioplasy and Stenting of Aortic Coarctation Stage 1 Pressures (mmhg) Sys/A Dias/V Mn/EDP AO AOAsc AODsc LV RA RV MPA RPA PCW % 102/ / / % 83/55 62 Oximetry (%, mmhg) Sat PaO2 AO 98 AOAsc 98 AODsc 97 SVC 77 SVCHi 79 IVC 79 RA 77 RV 79 MPA 79 RUPV 98 Shunts & Resistances Eff Flow (Qep) 4.6 l/min (Qep) I 8.7 l/min/m² Qp 4.9 l/min Qp I 9.2 l/min/m² L-R Shunt 0.3 l/min % L-R 776 % Rp 1 (WU) Rp I 0.53 (WU) TPR 2.7 (WU) TPRI 1.4 (WU) Cardiac Output HR 99 bpm Hgb 13 g/dl VO2 165 ml/min VO2 I 311 ml/min/m² CAo2 98 % CVo2 78 % PAo2 79 % PVo2 98 % O2cap 180 ml O2/l SAC 176 ml O2/l MVC 140 ml O2/l PAC PVC Fick CO Fick CI Baseline. 79% 79% 15/ ml O2/l 176 ml O2/l 4.6 l/min 8.7 l/min/m² Valve Areas / Gradients Peak Mean Areas (mmhg) (mmhg) (cm²) AV /8 10 Arterial Blood Gases ph 7.3 PaO2 95 mmhg PaCO2 32 mmhg HCO3 23 meq/l BE -0.9 meq/l Diaz, Johnny 06/06/2016 RH Cath Lab Report Page 1

6 Diaz, Johnny 06/06/2016 RH Stage 2 Pressures (mmhg) Sys/A Dias/V Mn/EDP AOAsc AODsc Oximetry (%, mmhg) Sat PaO2 AOAsc 98 AODsc 98 SVC / % 98/61 77 Post Coarctation Repair 98% Stent Cardiac Output VO2 52 ml/min VO2 I 98 ml/min/m² CAo2 98 % CVo2 78 % PAo2 78 % 98/ HISTORY: Diaz, Johnny is a 2 yr old M with discrete coarctation of the aorta and left ventricular hypertrophy presenting for diagnostic study and intervention. PROCEDURE: Informed consent was obtained prior to the procedure after discussing the pros and cons of all reasonable alternatives. The patient was brought to the cardiac catheterization laboratory and placed under general anesthesia by the cardiac anesthesia service. The airway was managed with an ETT. A pre-procedural time out was performed. The bilateral groins were prepped and draped in the usual sterile fashion. Access was not difficult using Sonosite. Using a modified Seldinger technique, a 5F short sheath was placed in the right femoral vein and a 4F short sheath was placed in the right femoral artery. After obtaining access, the patient was heparinized to maintain ACTs greater than 220 seconds. At the beginning of the case we performed antegrade right heart catheterization using a 5F end-hole wedge catheter and a retrograde left heart catheterization using a 4F multi-marker pigtail catheter. After obtaining baseline oximetry and hemodynamics, we performed aortic angiography in biplane projections. After imaging the coarctation, we positioned a Amplatzer SuperStiff wire in the right subclavian artery retrograde from the aorta. The arterial sheath was upsized to a 9F flex sheath and advanced across the coarctation into the distal aortic arch. A 36mm Max LD stent was hand-mounted onto a 16-4 Balloon-in-balloon (BIB) catheter. The stent was advanced to the end of the long arterial sheath and positioned at the level of the coarctation. The stent was uncovered without difficulty and the position was confirmed with small hand injections through the long sheath. The inner balloon was inflated to [5 atm] and position was again confirmed by small hand injection. The outer balloon was inflated to 6 atm and the stent was fully deployed across the coarctation. Due to residual narrowing at the mid-portion of the stent, we performed post-dilation using a 18-2 Atlas Gold. A cut pigtail catheter was then advanced across the coarctation and pressures were measured above and below the stent simultaneously. The wire was removed and a final angiogram was performed through the cut pigtail. Diaz, Johnny 06/06/2016 RH

7 Diaz, Johnny 06/06/2016 RH Cath Lab Report Page 3 At the end of the case, ropivacaine was infused for additional analgesia. Sheaths were pulled and hemostasis was obtained by manual pressure. There was no hematoma and no pulse loss. The patient was extubated in the cath lab and transferred to the cath recovery unit in stable condition. Angiography a. A 3D rotational angiography was performed with a power injection in the ascending aorta with RV pacing. Angiography showed a mildly dilated ascending aorta with a normal transverse aorta. There is a Left aortic arch with normal branching pattern of the head and neck vessels. There is severe discrete coarctation of the distal arch with normal caliber descending aorta. There are multiple collaterals seen on this injection b. In straight AP and lateral projections, a multi-marker pigtail catheter has been advanced retrograde across the coarctation into the distal aortic arch. Power injection into the distal aortic arch demonstrate mildly dilated ascending aorta with a normal transverse aorta. There is a Left aortic arch with normal branching pattern of the head and neck vessels. There is severe discrete coarctation of the distal arch with normal caliber descending aorta. There are multiple collaterals seen on this injection. IMPRESSION: Diaz, Johnny is a 2 yr old M with discrete coarctation of the aorta and left ventricular hypertrophy presenting for diagnostic study and intervention. 1) Normal baseline cardiac index. 2) Severe juxtaductal coarctation with peak-to-peak gradient of 30 mmhg gradient. 3) Coarctation stented primarily with 36 mm Max LD and post-dilated using 18 mm Atlas Gold with significant angiographic improvement and reduction in peak-to-peak gradient to < 10mmHg. 4) No complications. Hector Garcia, MD Cath Procedure Images Description: Complications: none. Total fluoroscopy time: 10 min Total contrast used: 20 ml Estimated Blood Loss: 20 ml Medications Administered: Heparin, 500 units, IV, Bolus. Anticoagulation Percutaneous entry: Right Femoral artery Complications: NONE Post Procedure Pulses Bilateral DP: Bounding Staff: Cardiac Cath Physician Interventionalist Scrub Staff Circulating Nurse Radiologic Tech Monitoring Staff Hector Garcia, MD Hector Garcia, MD Bill Taylor, RCIS Dave Minor, RN Julia Chris, RT Gregg Abbott, RCIS Diaz, Johnny 06/06/2016 RH Cath Lab Report Page 3