Coronary Procedure Report

Cardiologist's Note - Coronary Procedure Report Procedure Coronary angiography was carried out, including a left ventriculogram. A graft study was also performed to assess the patency of previously placed bypass grafts. Indication - Patient presented with stable angina pectoris, Canadian Cardiovascular Society (CCS) Class III. - Relevant past medical history includes hypercholesterolemia (LDL 3.2 mmol/L), hypertension (average BP 145/85 mmHg), and type 2 diabetes mellitus (HbA1c 7.8%). - Known history of coronary artery bypass grafting in 2018 (LIMA to LAD, SVG to OM1, SVG to PDA). - Mild left ventricular impairment with an estimated ejection fraction of 45-50% on recent echocardiogram. Pre-Procedure Preprocedural antiplatelet therapy included 75mg Clopidogrel and 75mg Aspirin. The patient was anticoagulated with unfractionated heparin prior to the procedure. Metformin was withheld on the morning of the procedure. Procedure The procedure was performed via right femoral artery access, utilising a 6 French sheath. A 6 French Judkins Left 4.0 catheter was successfully used for selective cannulation of the left coronary artery. A 6 French Judkins Right 4.0 catheter was used for selective cannulation of the right coronary artery. A 6 French Amplatz Left 1.0 catheter was used for the graft study. The coronary anatomy is right dominant. Left Main Stem: Smooth and normal, no significant disease. Left Anterior Descending: Diffuse disease with moderate stenosis (50-60%) in the mid-segment. No significant occlusion. Circumflex: Mild atheromatous changes with no flow-limiting stenosis. Right: Focal severe stenosis (80%) in the proximal segment, with TIMI flow grade 2. Retrograde filling from the left circumflex artery is present. Grafts. LIMA to LAD: Patent with brisk flow, no significant stenosis. SVG to OM1: Patent with diffuse mild disease, no flow-limiting stenosis. SVG to PDA: Occluded at the distal anastomosis with no antegrade flow. Left Ventriculogram There was apical and infero-posterior hypokinesis. The estimated ejection fraction was 40%. The LVEDP was 22 mmHg. Right Heart Catheter RA mean pressure: 8 mmHg RV systolic pressure: 45 mmHg, end diastolic pressure: 10 mmHg PA systolic: 45 mmHg, diastolic: 20 mmHg, mean: 30 mmHg PCW mean pressure: 18 mmHg, v wave: 20 mmHg Saturations and sampling locations: - SVC: 68% - RA: 70% - RV: 70% - PA: 72% - PCW: 98% No significant shunt identified. Fick cardiac output: 4.5 L/min. Transpulmonary gradient: 12 mmHg. Pulmonary vascular resistance: 2.6 Wood Units. Pressure Wire, IVUS, And OCT Intravascular ultrasound (IVUS) was performed in the Left Anterior Descending artery. It revealed significant plaque burden with minimum lumen area (MLA) of 2.8 mm2, confirming moderate stenosis. Coronary Intervention Right Coronary Artery: Intervention was performed on the proximal Right Coronary Artery. A 6 French Judkins Right 4.0 guide catheter was used. A 0.014" Runthrough NS guidewire was advanced across the lesion. Predilation was performed with a 2.5 x 15 mm Maverick balloon at 12 atm. A 3.0 x 28 mm Xience Skypoint drug-eluting stent was deployed at 14 atm, achieving excellent angiographic result with TIMI 3 flow. Post-dilation was performed with a 3.25 x 12 mm non-compliant balloon. No periprocedural complications were observed. Summary The coronary angiography revealed a critical stenosis in the proximal Right Coronary Artery, which was successfully treated with drug-eluting stent implantation. The previously placed SVG to PDA graft was found to be occluded. The left ventriculogram showed reduced ejection fraction with regional wall motion abnormalities. The right heart catheterisation revealed elevated pulmonary pressures. Plan - Optimise antiplatelet therapy: continue Aspirin 75mg daily, switch Clopidogrel to Ticagrelor 90mg twice daily for 12 months. - Intensify lipid-lowering therapy with high-dose statin and consider PCSK9 inhibitor. - Referral to heart failure clinic for optimisation of medical therapy for reduced ejection fraction. - Follow-up with cardiology in 3 months. - DVLA advice given: No driving of Class I vehicles for at least one week following elective coronary intervention. For Class II vehicles, the patient must not drive and must inform the DVLA, who will consider relicensing if a satisfactory exercise test is performed.