PROCEDURES PERFORMED:

1. Tilt table testing.
2. Carotid sinus massage.

OPERATOR:  John Doe, MD

REFERRING PHYSICIAN:  Jane Doe, MD

INDICATION FOR PROCEDURE:  Syncope.

FINDINGS:  Baseline sinus rhythm at 70 BPM with normal cardiac conduction intervals.

INDICATION:

1. PR interval equals 160 milliseconds.
2. QRS interval equals 80 milliseconds.
3. QT interval equals 360 milliseconds.
4. The patient was observed in a 70 degree head-up tilt position for a total of 30 minutes in a drug-free state, during which she remained asymptomatic with both stable blood pressure (BP equals 95-121/55-71) and heart rate (HR equals 75-112 BPM).
5. The patient continued to be observed in a 70 degree head-up tilt position for additional of 5-minute period of time following sublingual nitroglycerin (0.4 mg) administration, during which she developed progressive dizziness, fatigue, and diaphoresis (similar to clinical symptoms) prior to development of complete loss of consciousness associated with profound hypotension (BP equals 61/33) and inappropriate normocardia (HR equals 91 BPM). The patient awoke, returned to the supine (0 degrees) position.
6. No evidence for carotid signs of hypersensitivity with either right or left-sided carotid sinus massage.

COMPLICATIONS:  None.

IMPRESSION:

1. Neurocardiogenic syncope (mixed vasodepressor/cardiac inhibitory response).
2. No evidence for carotid sinus hypersensitivity.

RECOMMENDATION:  Consider a future empiric beta-blocker (Toprol XL 50 mg daily) therapy in place of current calcium channel blocker (verapamil 40 mg t.i.d.) for a combined management of retention and neurocardiogenic syncope.

PROCEDURE PERFORMED:  Left heart catheterization.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was brought to the cardiac catheterization laboratory and prepped and draped in the usual sterile fashion. Using a modified Seldinger technique, a 6-French sheath was inserted into the right femoral artery over a wire.

Next, using various catheters, the coronary arteries were cannulated and angiography was obtained. Next, using the right coronary catheter, it was advanced into the left ventricle. Pressures were monitored, left ventriculogram was completed, and pressures on pullback were also obtained. Afterwards, the right coronary catheter was used to cannulate the vein grafts as well as the LIMA graft.

Then, the catheter was removed, and after an appropriate groin shot for placement of the sheath was documented, on cine imaging, an Angio-Seal closure device was used to seal the right femoral artery.

The patient tolerated the procedure well. In addition, pressure was applied to the right groin for an additional 5 minutes, and the patient then left the cardiac catheterization laboratory in stable condition.

Electrophysiology Sample Reports

PROCEDURE FINDINGS:
1.  Left main coronary artery. The left main coronary artery has a normal origin and distribution. It was free of any significant coronary artery disease.
2.  Left anterior descending coronary artery. The left anterior descending coronary artery was totally occluded in its proximal portion. The total occlusion is at the take-off of the first diagonal branch, which is diffusely diseased, and there is a 50% stenosis in its proximal portion as well as other luminal irregularities. Also, there is one septal branch given off before the LAD is totally occluded.
3.  Left circumflex coronary artery. The left circumflex coronary artery has a normal origin and distribution. It runs along the AV groove and is diffusely diseased, but there is no critical obstructive blockage. However, the vessel is of a moderate caliber. It gives collaterals to the right coronary artery.
4.  Right coronary artery. The right coronary artery is totally occluded in its proximal portion, some late filling is appreciated. However, the vessel is totally occluded.
5.  The saphenous vein graft to the OM branch is patent. The stent site is patent.
6.  The saphenous vein graft to the RCA is totally occluded.
7.  LIMA graft to the LAD. There is a mild 30-40% kink in the proximal portion of the LIMA. Otherwise, the LIMA is a good caliber vessel, which is patent at the anastomosis site with the LAD, is very good and the flow is brisk.
8.  The left ventricular size is normal. There is some mild inferior hypokinesis. However, the overall ejection fraction is preserved at about 50-55%.
9.  The AO pressure is 136/60. The LV pressure is 136/22. The left ventricular end diastolic pressure is 21.

CONCLUSIONS:  Severe native coronary artery disease. Patent saphenous vein graft to OM and LIMA graft to the LAD. The patient will undergo a stress test for further evaluation and for treatment. The patient will be continued on his present medication regimen.