CPC sample question # 12

Description of Procedure: Left heart catherterization, left ventriculography, and selective coronary arteriography were performed percutaneously via the right femoral artery under local xylocaine anesthesia. At the conclusion of the procedure, the catheters were withdrawn and hemostasis was obtained with firm pressure at the puncture site. The procedure was uncomplicated and the patient tolerated the procedure well.

Left Ventriculography: The left ventriculography was performed with the patient in the right anterior oblique position. The left ventricle was normal in size and demonstrates normal systolic function. There is a 1 + mitral insufficiency. There are frequent premature ventricular contractions noted with ventriculography.

Coronary Arteriography: Selective coronary arteriography was performed with the patient in various right anterior and sagittal oblique positions. The left main coronary artery is heavily calcified and irregular. The left main coronary artery is narrowd approximately 30-40 percent. The left anterior descending coronary artery is large in caliber and extends over the apex. The left anterior descending artery provides several diagonal branches. The first diagonal branch is medium in caliber and narrowed 70 percent proximally. The left anterior descending coronary artery is then heavily calcified in its proximal half. It is hazy following the first diagonal branch. The second diagonal branch is small and irregular, but free of significant disease. The left anterior descending artery is narrowed approximately 60-70 percent after the second diagonal branch at the junction between proximal and middle thirds of the vessel. The distal left anterior descending artery is calcified and irregular, but free of significant obstructive disease.

The left circumflex coronary artery is calcified and nondominant. The left circumflex coronary artery provides a medium caliber first obtuse marginal branch. This is narrowed 90 percent proximally. The left circumflex coronary artery is narrowed 90 percent in the atriventricular groove at the level of the takeoff of the first marginal branch. The second obtuse marginal branch is medium to large  in caliber and irregular, but free of significant disease. The rightcoronary artery is large and dominant. The right coronary artery is subtotally occluded in its proximal on third, with an eccentric plaque that appears to have a resemblance to the intraluminal thrombus. The distal right coronary arteery is irregular and calcified. The distal right coronary artery may also be seen filling via-left-to-right collateral circulation.

Conclusions: 1. Coronary artery disease, with severe, triple vessel. 2. Normal left ventricle systolic function.
 
Comments: The patient has rest angina with severe triple vessel coronary artery disease and coronary artery bypass surgery is recommended.

a.    93514, 93543, 93545, 93555, 93556
b.    93510, 93543, 93545, 93556
c.    93510, 93555, 93556
d.    93510, 93543, 93545, 93555, 93556 

Answers