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Please read the report below and answer the coding/reimbursement questions that follow.
CARDIAC CATHETERIZATION REPORT CENTER
CONTRAST MEDIUM: OPTIRAY
Pressures
Right Atrium
8
BSA
1.93 m2
Right Ventricle 20/4
Heart Rate
74 beats/minute
Pulmonary Arteries 20/8
Cardiac Output 3.7 L/min
Pulmonary Wedge
8
Cardiac Index 1.9 L/min/m2
Left Ventricle 140/8
Aorta
140/8
DIAGNOSES:
Status post orthotopic heart transplantation in 09/03/98.
Normal coronary arteries.
Minimal intimal hyperplasia in the left anterior descending and left circumflex arteries.
Normal left ventricular systolic function and 1-2+ mitral regurgitation.
LEFT CORONARY ARTERY:
Left Main Trunk:
The left main trunk was normal. It bifurcated into the left anterior
descending and left circumflex arteries.
Left Anterior Descending: The left anterior descending artery was normal.
Circumflex:
The left circumflex artery was dominant and normal.
RIGHT CORONARY ARTERY:
The right coronary artery was small, nondominant and free of disease.
LEFT VENTRICLE:
Left ventriculogram not dictated. Please advise.
HEIGHT:
174 cm
AGE: 49 years
BLOOD PRESSURE:
GENDER:
Male HEART RATE: 79
154/104
CHIEF COMPLAINTS:
The patient currently is here for heart transplant follow-up of 09/03/98.
INDICATIONS AND PATENT STATUS:
Indication for catheterization is heart transplant follow-up. The patient’s status is elective.
MEDICAL HISTORY:
There is no other cardiac history. Coronary artery disease risk factors are hypertension. There
are no other medical problems. Chest x-ray __________. The patient has no known allergies.
BLOOD WORK:
ELECTROCARDIOGRAM: Sinus rhythm.
CATHETERIZATION TECHNIQUE: The patient’s jugular vein area and the right femoral artery
area were prepped and draped in the usual fashion. Local anesthesia was given, and an #8
French short sheath was introduced into the right internal jugular vein. After local anesthesia, a
#7 French short sheath was introduced into the right femoral artery. An #8 French Swan-Ganz
catheter was introduced through the jugular venous sheath and advanced into the wedge
position. Pressures were recorded. Cardiac output was obtained through the thermodilution
method. The remainder of the right sided pressures were obtained. Once the right sided
catheterization was concluded, the catheter was withdrawn.
We then proceeded with the biopsy, utilizing a Fehling bioptome. Four fragments of the right
ventricular endocardium were obtained. A #6 French pigtail catheter was introduced through the
femoral arterial sheath and advanced through the aorta to the aortic root and introduced into the
left ventricular cavity through the aortic valve. Pressures were recorded and the left
ventriculogram was performed in the right anterior oblique position. This concluded the
procedure with the right coronary angiogram. For this, a #6 French JR4 catheter was introduced
and selective engagement into the right coronary ostium and angiogram obtained. The catheter
was withdrawn, and a #6 French JL4 guiding catheter was advanced and engaged into the left
coronary ostium. Selective angiogram was obtained. We then proceeded with the intravascular
ultrasound of both the left circumflex artery and the left anterior descending artery. The
procedure was then concluded, the femoral sheath was removed, and an angioseal was placed.
We obtained good hemostasis and the patient was transferred to his recovery room in good
condition.
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