Left Heart Catheterization Template

Patient is a 67-year-old male with a past medical history of hypertension and hyperlipidemia who presents for diagnostic coronary artery catheterization with possible intervention due to unstable angina. Summary: - In summary, a 90% stenosis was found in the proximal left anterior descending artery. A PTCA balloon was used, followed by the placement of a 3.0 x 18 mm DES stent. No balloon pump or impella placement was required. - LVEDP: 18 mm Hg - LV EF: 55% Right Heart Catheterization: - RA Pressure: 5 mm Hg - RV Pressure: 25/5 mm Hg - PA Pressure: 25/10 mm Hg - PCWP: 12 mm Hg - PA Saturation: 98% - RA Saturation: 75% - CO: 5.0 L/min - CI: 2.5 L/min/m^2 Procedures Performed: - Coronary Angiography (Judkins Left 4) - PTCA (Emerge 2.5 x 15 mm balloon) - DES Placement (Xience 3.0 x 18 mm) Interventions: - Lesion Location: Proximal left anterior descending artery, 90% stenosis - Guide: EBU 3.5 - Wire: BMW Universal - Imaging: IVUS used, MLA 4.5 mm², MSA 5.0 mm², fibrous plaque morphology - PTCA Pre: Emerge 2.5 x 15 mm balloon - DES: Xience 3.0 x 18 mm - PTCA Post: NC Trek 3.5 x 15 mm balloon - Stenosis: Pre: 90% Post: 0% - TIMI grade: Pre: 1 Post: 3 Recommendations: - ASA + Brilinta for 12 months; high-intensity statin, beta blocker - IV fluids post-catheterization per Poseidon protocol - Monitor access site above per protocol - Monitor vitals, telemetry, labs with renal function & CBC - Risk factor management with lifestyle modifications - diet, exercise, weight loss, medical compliance - Follow-up in cardiology outpatient clinic in 1 week after discharge with primary cardiologist. Coronary Anatomy: Dominance: Right dominant Left Main Coronary Artery: Normal Left Anterior Descending Coronary Artery: Proximal 90% stenosis Ramus Intermedius: Not present Left Circumflex Coronary Artery: Minor irregularities Right Coronary Artery: Normal Dr. Thomas Kelly MD, FACC