LEFT MAIN
LEFT ANTERIOR DESCENDING (LAD)
LEFT CIRCUMFLEX (Circ in slang)
DIAGONAL BRANCHES
OBTUSE MARGINAL ONE AND OBTUSE MARGINAL TWO (OM1 and OM2) BRANCHES
COLLATERALS (collateral vessels)
RIGHT CORONARY ARTERY (RCA)
POSTERIOR DESCENDING ARTERY
AV groove is atrioventricular groove

They sometimes look at ramus intermedius. And, sometimes they look at the renal arteries, too.

Note: It is interventricular septum (not intra - NOT intraventricular).

Common phrase: There was no gradient seen on pullback. :)

Dictated: “A 3.5 mm by 14 mm TAXUS stent was deployed.”

Correctly transcribed: “A 3.5-mm x 14-mm TAXUS stent was deployed.”

Whenever they say “by” it should be transcribed as an “x.”

Click for the link to the video (you can choose your connection speed)

CARDIOLOGIST: Abraham Lincoln, M.D., F.A.C.C. (Note: FACC stands for Fellow of the American College of Cardiology)

REFERRING PHYSICIAN: George Washington, M.D.

DATE OF PROCEDURE: January 1, 2005.

PROCEDURES PERFORMED: Selective coronary angiography, right and left coronary arteries; selective renal angiography; contrast ventriculography with left heart catheterization; aortogram of the mid-abdominal aorta.

CLINICAL HISTORY: Non-Q wave myocardial infarction, unstable angina, known history of abdominal aneurysm.

APPROACH: The procedure was performed from the right groin using Visipaque. Contrast was tolerated well, a total of 190 cc. The procedure was performed from the right groin using a 5-French catheter and sheath.

CLOSURE DEVICE: 6-French Angio-Seal.

DISPOSITION: Subsequently, the patient was remanded to the intensive care unit. Integrilin was initiated in the cardiac catheterization laboratory.

DESCRIPTION OF PROCEDURE: Standard angle and views were used for the right and left coronaries. Left heart catheterization was performed. Selective angiograms of the renals were performed and the right coronary and then an aortogram was performed to evaluate the abdominal aortic aneurysm.

HEMODYNAMICS: Demonstrated the left ventricular end diastolic pressure at 20, arising to 25 post-LV gram.

Aortic pressure was normal demonstrating a systolic pressure of 117 to 124/70.

The contractility pattern on the left ventriculogram demonstrated a normal ejection fraction, minor apical lateral wall motion abnormality consistent with a probable obtuse marginal disease which is subsequently noted on the report.

CORONARY ANATOMY:

RIGHT CORONARY ANGIOGRAM: Demonstrated diffuse irregularities with proximal irregularities of 40-50%. Distally, there is a high-grade 99% narrowing prior to the bifurcation of the posterior descending artery in the posterolateral system. There is a fairly significant beading and irregularity of the PDA as it becomes diffusely diseased, although the posterolateral branch is quite large.

LEFT MAIN CORONARY ARTERY: Free of disease and it branches into a nondominant left circumflex coronary artery.

CIRCUMFLEX CORONARY ARTERY: Has initial first obtuse marginal, very proximal, in the AV groove that extends two-thirds of the way to the apex where it tapers with diffuse irregularities noted within it. A second obtuse marginal appears within 0.5 cm of the first, and demonstrates a larger distribution to the apical lateral surface. The proximal portion, just as it leaves the AV groove, demonstrates a 90% narrowing, the size of the distal vessel approximately 1.8 to 2 mm in diameter providing a reasonable target for revascularization. The circumflex coronary artery continues in the AV groove and demonstrates what appears to be a third small obtuse marginal which may well have been subtotally occluded at one time. The vessel ends at the AV groove at the inferior surface as a rapidly tapered posterobasilar branch.

LEFT ANTERIOR DESCENDING CORONARY ARTERY: Demonstrates a proximal plaque and in the worst view, appears to be in the AP cranial, approximately a 50% lesion. There are then two diagonals that arise just short of each other in the proximal one-third, the first diagonal arising high and running to an obtuse marginal territory, the second one paralleling the LAD to the mid-anterior wall and then swinging laterally as a second obtuse marginal type territory branch. The LAD then demonstrates irregularity and a high-grade 90% narrowing with the distal vessel running from the apex and wrapping around the apex with a moderate-sized vessel appearing to be approximately 1-mm at the mid-course.

The cranial RAO view of the left anterior descending coronary artery demonstrates another area proximally (previously mentioned to be 40-50% and may actually be closer to 70%) just after the left main. This degree of stenosis would suggest the need for revascularization of the two diagonals and not simply the left anterior descending coronary artery alone.

CONCLUSIONS:

1. Multi-vessel coronary artery disease with good targets for revascularization:
A. Dominant right coronary artery, distal 99% stenosis at the crux.

B. Proximal left anterior descending coronary artery 70% prior to the two diagonals and mid-90% narrowing just after the two diagonals in the left anterior descending coronary artery.

C. First obtuse marginal with 90% narrowing but with distal target.

2. Normal left ventricular systolic function with ejection fraction of 60% range with minor apical lateral wall motion abnormality of little consequence.

3. Abdominal aortic aneurysm, small, probably no more than 3 cm maximum in the infrarenal area.

4. Diffuse luminal irregularities in the aortoiliac system, none of which appear to be critical.

BRIEF HISTORY:
The patient is a 44-year-old cigarette smoker with a markedly positive family history of coronary artery disease who has an electrocardiogram showing an old anterior septal myocardial infarction. Nuclear study showed a fixed anterior defect. He has had episodes of chest pain and coronary angiography has been recommended.

DESCRIPTION OF THE PROCEDURE:
One percent lidocaine was infiltrated over the right femoral artery. A 6-French sheath was placed in the right femoral artery. Diagnostic coronary angiography was performed with a 6-French JL-4 and 6-French JR-4 diagnostic catheters. Following coronary angiography, a 6-French pigtail catheter was placed in the left ventricle where left ventriculography was performed with 36 cc of contrast injected at 12 cc per second. At the conclusion of the procedure, the catheter and sheath were removed and Angio-Seal plug was deployed.

TECHNICAL FACTORS:
Medications: Fentanyl 100 mcg and Versed 2 mg.
Contrast: Isovue 130 cc.
Fluoroscopy time: 2 minutes.

HEMODYNAMICS:

Opening aortic pressure 103/58.

Following coronary angiography, the left ventricular pressure was 107/12.

There was no aortic stenosis on left heart pullback.

CORONARY ANGIOGRAPHY:

There was no significant obstructive coronary artery disease in this right dominant system. There is a 10% to 20% stenosis in the distal left main.

The left circumflex artery is a moderate-sized vessel filling a large first obtuse marginal and diminutive second obtuse marginal and there is no significant disease.

The left anterior descending coronary artery is a large vessel which extends to the apex. It fills several small diagonal branches. There are no significant stenoses. There is a large ramus intermedius which fills the lateral wall. It, too, has no significant disease.

The right coronary artery is a large dominant vessel filling a moderate-sized posterior descending artery and two larger posterolateral branches. There are no significant obstructions in the right coronary artery.

LEFT VENTRICULOGRAPHY:

The left ventricular systolic function is normal. There are no regional wall motion abnormalities. There is no mitral regurgitation.

DIAGNOSTIC IMPRESSION:

1. There is no significant obstructive coronary artery disease in this right dominant system. There is a plaque in the distal left main, but there is no significant obstruction.

2. Left ventricular systolic function is normal. There is no evidence of previous anterior wall myocardial infarction.

PLAN:

I do not have a definite explanation for the patient's abnormal electrocardiogram or abnormal nuclear study. Coronary spasm remains in the differential diagnosis and we have encouraged him to completely discontinue smoking, which he has accomplished. He certainly can take nitroglycerin on an as-needed basis in the future. I would continue aspirin indefinitely.

REFERRING PHYSICIAN: Roger Rogers, M.D.

INDICATIONS FOR PROCEDURE: The patient is a 60-year-old with a long history of atrial flutter who has converted back to atrial flutter. He is on amiodarone, Coumadin, and Prinivil. His INR is between 2 and 3.

DESCRIPTION OF THE PROCEDURE: The patient was sedated with Versed 80 mg and fentanyl 100 mcg. Cardioversion was performed with a single discharge of 50 joules from a biphasic defibrillator. This converted him from atrial flutter to sinus rhythm. There were no complications.

DIAGNOSTIC IMPRESSION: Successful cardioversion of atrial flutter.

This is a technically excellent study.

M-MODE MEASUREMENTS: Aortic diameter is 3.6-cm, left atrial diameter is 3.2-cm, interventricular septum is 0.3-cm, left ventricular posterior wall is 0.3-cm. The left ventricular internal diameter end-diastole is 4.5-cm, end-systole is 3.1-cm. Ejection fraction (Teich) is 60%.

2-D ECHOCARDIOGRAPHY, COLOR FLOW, AND DOPPLER ASSESSMENT:

LEFT VENTRICLE: The left ventricular size and function is normal. The calculated ejection fraction is 60%. There are no regional wall motion abnormalities seen. There is moderate concentric left ventricular hypertrophy.

LEFT ATRIUM: The left atrial size is normal.

AORTIC ROOT: The aortic root appears normal.

RIGHT-SIDED HEART CHAMBERS: The right ventricular size and function are normal. The RVSP was calculated at 40 mmHg consistent with mild to moderate pulmonary hypertension. The right atrial size is on the upper limits of normal. There is the appearance of a pacing wire noted in the right ventricle.

MITRAL VALVE: The mitral valve leaflet morphology and excursion is normal. On Doppler assessment there is mild mitral regurgitation, however, there is no mitral stenosis.

AORTIC VALVE: The aortic valve is highly sclerotic. However, it appears to open normally. On Doppler assessment there is no evidence of aortic stenosis or regurgitation.

TRICUSPID VALVE: The tricuspid valve leaflet morphology and excursion is normal. On Doppler assessment there is mild to moderate tricuspid regurgitation.

PULMONIC VALVE: The pulmonic valve appears normal in morphology. On Doppler assessment there is no pulmonic insufficiency or stenosis seen.

PERICARDIUM: The pericardium is normal. There is no pericardial effusion.

SYSTEMIC VEINS: The IVC responded normally to inspiration. This correlates with the right atrial pressure of 5 mmHg.

DIASTOLIC FUNCTION: Hemodynamic parameters suggest at least grade 1 diastolic dysfunction (abnormal relaxation).

SUMMARY:

1. Normal left ventricular function with ejection fraction of 60%. There are no regional wall motion abnormalities seen. There is moderate concentric left ventricular hypertrophy.

2. Mild to moderate pulmonary hypertension with RVSP of 40 mmHg.

3. Mild mitral regurgitation and mild to moderate tricuspid regurgitation.

4. Diastolic dysfunction.

MEASUREMENTS:
Aortic root 3.2.
Left atrium 3.4.
Left ventricular end-diastolic diameter 4.2.
End-systolic diameter 2.5.
Septal thickness 1.1.
Posterior wall thickness 1.0.

SUMMARY:

1. A 2-Dimensional, color Doppler, pulse-wave/continuous-wave Doppler study is performed. The acoustic window quality is adequate.

2. Aortic, mitral, tricuspid valves are without structural abnormality with trace tricuspid regurgitation. The pulmonic valve is not well demonstrated. The aortic root is normal in size.

3. Normal left ventricular dimensions evident on 2-Dimensional images. Estimated left ventricular ejection fraction is greater than 65%. No regional wall motion abnormalities are evident, Doppler mitral inflow demonstrates normal pattern. Left atrium, right atrium, right ventricle are of normal size with grossly preserved right ventricular systolic performance.

4. No pericardial effusion.

5. Appearance of inferior vena cava suggests normal central venous pressure.

6. Sinus rhythm during study.

7. No previous study available for comparison.

(TERMS: Note dictator says "diastolic septal bounce" and "E:A ratio" and "E-wave.")

TAPE # 2000 1:44:05

DATE OF STUDY:08/20/2004

SUMMARY:

1. A 2-Dimensional, color Doppler, pulse-wave/continuous-wave Doppler study is performed. The study is technically difficult due to limited acoustic window quality.

2. Mild aortic valve sclerosis suggested. Aortic valve opening appears adequate. There is no aortic insufficiency. The mitral and tricuspid valves are without structural abnormality with very mild (1+) mitral regurgitation and mild to moderate (1+ to 2+) tricuspid regurgitation. Pulmonic valve was not well demonstrated. Estimated systolic PA pressure by Doppler is approximately 40 mmHg. Aortic root is grossly normal in size.

3. Normal left ventricular dimensions suggested on 2-Dimensional images. Estimated left ventricular ejection fraction appears to be at least 55%. Diastolic septal bounce is suggested. No other wall motion abnormalities are evident. Doppler of mitral inflow demonstrates E:A equalization with increased E-wave deceleration time suggesting impaired left ventricular relaxation. The left atrium is borderline enlarged. Right atrium and right ventricle are grossly normal in size with grossly preserved right ventricular systolic performance.

4. No pericardial effusion.

5. The inferior vena cava is dilated consistent with patient being on ventilator, as reported.

6. Sinus rhythm during study.

7. Since previous echocardiography report, no significant interval change is appreciated. Aortic valve sclerosis is again demonstrated, as reported on previous study. However, quality of images on current study does not permit sufficient scrutiny for small echodensities. If clinically indicated, would consider transesophageal echocardiography if there is sufficient clinical suspicion for endocarditis.

Augmented Limb Leads (Unipolar)

The positive electrodes for these augmented leads are located on the left arm (aVL), the right arm (aVR), and the left leg (aVF). In practice, these are the same electrodes used for Leads I, II and III.

Source: http://www.cvphysiology.com/Arrhythmias/A013.htm

More Links:

EKG Library
Echocardiography Journal
Cardiovascular Perfusion

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