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RSNA CCTA WITH BYPASS GRAFTS TEMPLATE
Clinical Indication: [#] year old [woman |man] with coronary artery
disease risk factors of [hyperlipidemia; hypertension; diabetes;
autoimmune disease; prior MI; prior stroke; smoking history; family
history of heart disease] presenting with [exertional angina; atypical
chest pain; chronic chest pain; shortness of breath; arm pain; jaw pain;
palpitations; ECG changes; prior abnormal single photon emission computed
tomography study; prior abnormal echocardiogram; heart failure;
cardiomyopathy; pre-surgical assessment] for evaluation of the presence
of coronary artery disease.
Comparison studies: [type; date]
Imaging Technique: A [#]-slice multidetector computerized tomography
coronary angiogram was obtained using [prospective | retrospective] ECG
gating. [{only insert this sentence if retrospective ECG gating was
used}ECG tube modulation [*was used to reduce the radiation exposure |
was not used because of arrhythmia| was not used because of the need for
systolic and diastolic imaging]. The coronary CT angiogram was performed
with [#] mL of [type] contrast administered intravenously. Imaging was
performed from the level of the [pulmonary artery bifurcation | carina]
to the level of the hemidiaphragms. In order to provide better evaluation
of the anatomy and disease process, advanced off-line 3-D post-processing
techniques, including [multiplanar reconstruction; maximal intensity
projections; curved reconstructions; and volume rendering] were
performed.
Medication administered in preparation for the examination:
ß- blocker: [[#] mg [type] p.o. x [#] doses]; [[#] mg [type] IV x [#]
doses] for heart rate/rhythm control
[Calcium channel blocker: [#] mg [type] IV x [#] doses for heart
rate/rhythm control]
Nitroglycerin: [* 0.4] mg SL [*spray | tablet] for coronary vasodilation
{Describe any pre-examination steroid preparation or Benadryl
administration here for contrast allergy}
Vital Signs: Before medication administration, the heart rate was [#]
beats per minute and the blood pressure was [#] mm Hg. Upon discharge,
the heart rate was [#] beats per minute and the blood pressure was [#] mm
Hg.
Procedure Complications/ Allergic reactions: [*none].
Radiation Dose: The CT dose index-volume was [#] mGy, and dose length
product of the examination was [#] mGy-cm.
Coronary CT Angiogram Quality: The overall quality of the CT angiographic
examination is [excellent| good| fair | poor | nondiagnostic] and is
limited by [poor arterial opacification; misregistration artifacts;
patient motion; calcium blooming artifacts; metal artifact; arrhythmia].
Coronary Artery Angiogram Findings:
Stenoses are reported as maximum percentage diameter stenosis.
Stenosis grading is reported using the following scheme:
Normal:
no stenosis
Mild: 1-49% stenosis
Moderate: 50-70% stenosis
Severe:
>70% stenosis
Occluded
Dominance of the coronary artery system: [*right | left | co-dominant]
with [*normal | anomalous] origins and course.
Left Main: The left main is a [*normal | small] caliber vessel which
gives rise to the [* LAD and circumflex arteries | LAD and circumflex
arteries as well as a ramus intermedius artery {if this option is chosen,
the qualities of the ramus intermedius branch need to be reported}]. The
left main [has no stenosis | has mild stenosis | has moderate stenosis |
has severe stenosis | is occluded | is nonevaluable] with [no |
noncalcified | mixed | calcified] plaque. {If present, stents should be
described by size (if known), type (if known), number, and segmental
location. Any relation to the adjacent branch vessel ostium should be
described. In addition, the stent should be described as patent,
occluded, or stenosed. Any in-stent stenosis, fracture, or calcification
should also be described}
Left Anterior Descending Artery: The proximal left anterior descending
artery and first diagonal branch [have no stenosis | have mild stenosis |
have moderate stenosis | have severe stenosis | are occluded | are
nonevaluable] with [no | noncalcified | mixed | calcified] plaque. The
mid-distal LAD, D2 and D3 branches [have no stenosis | have mild stenosis
| have moderate stenosis | have severe stenosis | are occluded | are
nonevaluable] with [no | noncalcified | mixed | calcified] plaque.
[There is a [short | long] [superficial | deep] myocardial bridge in the
[proximal; mid; distal] segment]. {If present, stents should be described
by size (if known), type (if known), number, and segmental location. Any
relation to the adjacent branch vessel ostium should be described. In
addition, the stent should be described as patent, occluded, or stenosed.
Any in-stent stenosis, fracture, or calcification should also be
described}
[The ramus intermedius branch [has no stenosis| has mild stenosis | has
moderate stenosis | has severe stenosis |is occluded |is nonevaluable]
with [no | noncalcified | mixed | calcified] plaque].]
Left Circumflex Artery: The left circumflex artery and its obtuse
marginal [and left posterior descending artery; and left posterolateral]
branches [have no stenosis | have mild stenosis | have moderate stenosis
| have severe stenosis | are occluded | are nonevaluable] with [no |
noncalcified | mixed | calcified] plaque. {If present, stents should be
described by size (if known), type (if known), number, and segmental
location. Any relation to the adjacent branch vessel ostium should be
described. In addition, the stent should be described as patent,
occluded, or stenosed. Any in-stent stenosis, fracture, or calcification
should also be described}
Right Coronary Artery: The right coronary artery and acute marginal [and
right posterior descending artery; and right posterolateral] branches
[have no stenosis | have mild stenosis | have moderate stenosis | have
severe stenosis | are occluded | are nonevaluable] with [no |
noncalcified | mixed | calcified] plaque. {If present, stents should be
described by size (if known), type (if known), number, and segmental
location. Any relation to the adjacent branch vessel ostium should be
described. In addition, the stent should be described as patent,
occluded, or stenosed. Any in-stent stenosis, fracture, or calcification
should also be described}
Bypass Grafts:
A [LIMA | RIMA | saphenous venous | radial artery | gastroepiploic artery
| graft to the [proximal; mid; distal] [ LAD; D1; D2; D3; circumflex;
OM1; OM2; OM3; RCA; PDA; posterolateral artery] [is well separated from |
abuts] the sternum [#]cm below the sternal notch. The graft [has no
stenosis | has mild stenosis | has moderate stenosis | has severe
stenosis | is occluded | is nonevaluable].
[A [LIMA | RIMA | saphenous venous | radial artery | gastroepiploic
artery | graft to the [proximal; mid; distal] [ LAD; D1; D2; D3;
circumflex; OM1; OM2; OM3; RCA; PDA; posterolateral artery] [is well
separated from | abuts] the sternum [#]cm below the sternal notch. The
graft [has no stenosis | has mild stenosis | has moderate stenosis | has
severe stenosis | is occluded | is nonevaluable]].
[A [LIMA | RIMA | saphenous venous | radial artery | gastroepiploic
artery | graft to the [proximal; mid; distal] [ LAD; D1; D2; D3;
circumflex; OM1; OM2; OM3; RCA; PDA; posterolateral artery] [is well
separated from | abuts] the sternum [#]cm below the sternal notch. The
graft [has no stenosis | has mild stenosis | has moderate stenosis | has
severe stenosis | is occluded | is nonevaluable]].
Cardiac Morphology:
The right atrium is [*normal | dilated]. The right ventricle is [*normal
| dilated | hypertrophied]. The left atrium is [*normal | dilated]. The
left ventricle is [*normal | dilated | hypertrophied]. [There are
features of [an interatrial septal defect | an interventricular septal
defect | an interatrial and interventricular septal defect | a patent
foramen ovale]. The pericardium is [*normal | thickened | calcified] and
there is [*no | a small | a moderate | a large] pericardial effusion. The
aortic valve [* is tricuspid | is congenitally bicuspid | is functionally
bicuspid] with [*normal leaflets | leaflet thickening | leaflet
thickening and calcification] [and [*there is no evidence for motion
abnormality | regurgitation | stenosis] {reported only if retrospective
ECG gating has been used}]. The mitral valve leaflets are [*normal |
thickened | thickened and calcified] [and [*there is no evidence for
motion abnormality | prolapse of the [anterior; posterior; anterior and
posterior] leaflet | a flail [anterior; posterior; anterior and
posterior] leaflet | stenosis] {reported only if retrospective ECG gating
has been used}]. The heart is [*well separated from | abuts] the sternum.
[Cardiac Function {reported only if retrospective ECG gating has been
used}
The calculated left ventricular ejection fraction is [#] %, the left
ventricular end-diastolic volume is [#] mL, and the left ventricular endsystolic volume is [#] mL. There [are no regional wall motion
abnormalities | is [hypokinesia | akinesia | dyskinesia] of the [basal;
mid ; apical; apex] [anterior wall; anterolateral wall; anteroseptal
wall; lateral wall; inferolateral wall; inferoseptal wall; septal wall;
inferior wall] of the left ventricle.]
[Cardiac Devices and Indwelling Central Venous Lines: {the presence of a
pacemaker, central venous line, etc should be discussed here}]
Extracardiac findings:
The [main; right; left] pulmonary artery is [*normal; enlarged;
stenotic]. There [are | are no] filling defects in the [lobar; segmental;
subsegmental] pulmonary artery branches consistent with pulmonary
arterial embolism. The visualized thoracic aorta is [*normal | enlarged].
{If the aorta is enlarged, dissected, or transected: size, location, and
description should be dictated especially for findings of acute aortic
syndromes.} The [*lungs; right upper lobe; right middle lobe; right
lower lobe; left upper lobe; lingual; left lower lobe] [* are normal | is
consolidated | is atelectatic | has a [#] mm nodule | has a calcified
granuloma]. The included portion of the upper abdomen [* is normal |
demonstrates a [small | moderate | large] sized hiatal hernia | [other]].
Impression:
1. [*Normal coronary CTA without evidence for coronary artery stenosis |
Abnormal coronary CTA with []]. {Describe the important coronary CTA
findings here. If a calcium score was performed, the total score should
also be included in the report impression.}
2. [* Normal | Abnormal] global and regional wall motion and function of
the LV. {If abnormal give pertinent findings here.}
[3. {Any additional pertinent cardiac findings.}]
[4. {Any non-cardiac pertinent findings including lung nodule
recommendations. If a lung nodule is described without known malignancy,
a statement of the Fleishner Society guidelines for appropriate follow-up
should be included in the dictation.}]
Result Communication:
[Dr. [name] | Dr. [name]’s assistant [name] | [other] was notified [by
telephone | in person] of the [*study findings | critical result] at
[time] on [date] and they acknowledged receipt of the result. {If this
was a critical result, the appropriate critical result guidelines of your
institution should be followed.}]
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