Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF CATHETERIZATION:  MM/DD/YYYY

PROCEDURES PERFORMED:  Left heart catheterization, left ventriculography.

REASON FOR PROCEDURE:  Unstable angina and abnormal stress test.

FINDINGS:

1.  The left main coronary artery was short and patent.
2.  The left anterior descending coronary artery had total occlusion in the proximal and mid portion.
3.  The circumflex coronary artery had 95% lesion in the proximal portion.
4.  The right coronary artery had 90% proximal and 100% total occlusion in the mid.

GRAFTS:  The left internal mammary artery graft to the left anterior descending coronary artery was patent.  The saphenous vein graft to the diagonal vessel was also patent.  The saphenous vein graft to the obtuse marginal was not located and was not selectively engaged.

COLLATERALS:  There were collaterals noted from the left anterior descending, septal and obtuse marginal to the right side.

Left ventriculography revealed an overall ejection fraction of around 40% with inferobasal akinesis and mid anterior and septal hypokinesis.  End-diastolic pressure was normal at 13 mmHg.  There was no gradient across aortic valve on pullback.

At the end of the procedure, the decision to proceed with angioplasty and stent placement of the critical circumflex lesion was made.

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