Ask Dr. Z

Please help with this HTC. Here is what I was thinking: 416.8, 746.89, 424.0, 93531-26. Is there anything else I can code for this? What about the mention of congential heart? or what about "both by Fick and dermal dilution multiple times"? Thank you, PROCEDURE: 1. Insertion of 7 French sheath in right femoral vein. 2. Right heart catheterization with saturations and cardiac output check. 3. Based on the results of the right heart catheterization, we did put a 4 French sheath in the right femoral artery and did left heart catheterization with a pigtail catheter. 4. Simultaneous recording of left ventricle and right ventricle for the indication of suspected constriction. 5. Simultaneous recording of left ventricle and wedge pressure for the suspicion of mitral valve stenosis. 6. Fluoroscopy of the mitral valve done in the LAO position. PREPROCEDURE DIAGNOSIS: 1. Congenital heart disease. 2. Suspected Eisenmenger syndrome. 3. Persistent hypoxemia. 4. Mitral valve disease, status post a St. Jude mechanical mitral valve replacement. POSTPROCEDURE DIAGNOSES: 1. Moderately severe pulmonary hypertension although with severely elevated left ventricular end-diastolic pressure. 2. Evidence of a 20 mm or greater resting gradient on the mitral valve. Mitral valve area calculated to 1.35 sq cm consistent with severe mitral stenosis functionally. 3. Moderate elevation of right heart filling pressures appropriate to her degree of pulmonary hypertension. COMPLICATIONS IMMEDIATE TO PROCEDURE: None noted. MEDICATIONS: Medications given during the procedure include Fentanyl and Versed. The patient was taken off and put back on her oxygen by nasal cannula during this procedure. PROCEDURE IN DETAIL: The patient was informed and consented. She was brought to the cath lab in a fasting state. Her right groin was prepped and draped in a normal sterile fashion. Her Coumadin had been held and her last dose of low molecular weight heparin was well over 12 hours ago. INR was subtherapeutic. She received some conscious sedation. It was noted that hen we turned her oxygen off to do a saturation run she promptly drops her pulse oxygenation down to the range of 84 to 87% on room air. The patient received infiltration to the right groin after it was prepped and draped in a normal sterile fashion. A 7 French sheath was introduced in the right femoral artery and a Swan-Ganz catheter was introduced from this approach. Although she is a pulmonary hypertension workup patient, I was not able to go from above due to the presence of a dialysis catheter which we did not want to disturb. Although I was prepared to leave the Swan in, the findings were not consistent with isolated systolic pulmonary hypertension but rather with secondary pulmonary hypertension due to elevated left heart pressures. Therefore the Swan-Ganz catheter was not left in at the end of the procedure. Due to the finding suggesting that she has either constriction or mitral valve disease, we went ahead and put a 4 French sheath into the right femoral artery without difficulty and introduced a 4 French pigtail catheter into the left ventricle. Left heart pressures including simultaneous recordings during wedge pressure tracing and during right ventricular tracing with dual transducer system was performed. Cardiac outputs had been performed with a right heart catheter and cardiac index was obtained both by Fick and dermal dilution multiple times. At this point in time we did a fluoroscopy of the mitral valve from the LAO position and demonstrated what appeared to be reasonably good excursion of both leaflets to fluoroscopy. Results were reviewed, sheaths discontinued and pressure applied for hemostasis. RESULTS: 1. Hemodynamic findings: Again, the patient had severely elevated biventricular filling pressures. Right atrial pressure was 35, right ventricular pressure was variable with respiration ranging between 45 and 65 over 16 to 30. Pulmonary wedge pressure was a 45 aortic the left ventricular pressure was 92 over an end-diastolic pressure that ranged between 30 and 35. Again, PA pressure ranged between 65 and 75 systolic with diastolics in the 38 to 250 range. 2. Normal mitral valve leaflet excursion to fluoroscopy. 3. Dual transudate transducer measurements do not support constriction. The patient did have repeatedly splitting of the diastolic pressures between the right ventricle and left ventricle with gentle inspiration. 4. The dual transducer measurements did suggest that the patient has functional mitral stenosis with a mean resting gradient of 20 mmHg and a calculated mitral valve area of 1.35 sq cm. CONCLUSION: Severely elevated biventricular filling pressures, left greater than right, which suggests that the patient would benefit from volume reduction and possibly may benefit from further evaluation of her mitral valve function. I would like to see if with the use of a pressor we cannot effect more aggressive volume reduction with dialysis and otherwise consider a transesophageal echocardiogram. There certainly is some pulmonary hypertension but I suspect given the magnitude compared to the magnitude of left heart filling pressure elevation this is primarily secondary pulmonary hypertension. Pulmonary will be consulted and additional contributors to pulmonary hypertension such as sleep apnea, hypoxia and anemia should be addressed, as well.