CONTACTS
SUBJECTS
Stent Branch Vessel Cardiac Catheterization IVUS PCI Percutaneous Co
3403 -
3403 - ..
3404 - Summary/Objective
3405 -
340501 - Follow up ref SDS E3 0000. ref SDS E1 0000.
340502 -
340503 -
340504 -
340505 - [On 200130 0911 letter notifies Doctor Simpson and medical
340506 - team that removed coban wrap and gauze dressing, because
340507 - the wrap was so tight it was putting hand to sleep; on
340508 - removal blood had leaked through gauze dressing.
340509 - ref SDS F2 I37H
340510 -
340511 -
340512 -
340513 -
340515 - ..
3406 -
3407 -
3408 - Background
3409 -
340901 - On 191206 1425 letter to VAMCSF Cardiology Doctor Simpson, ref SDS A8
340902 - NE9N, notify possible afib symptoms. ref SDS A8 N874
340904 - ..
340905 - On 191207 0927 Doctor Simpson to order ECG [...electrocariogram...]
340906 - Zio test for AFib, after he returns to work following several weeks
340907 - out of the office. ref SDS A9 NE9N
340909 - ..
340910 - On 191213 0849 call from Tina - scheduled install Zio equipment for
340911 - heart monitoring test; meeting room 2A16 on 191216 1230. ref SDS B0
340912 - NE9N
340914 - ..
340915 - On 191216 1220 Exmeralda in Cardiology at VAMCSF installed Zio XT
340916 - heart monitor on left chest; she added 2 plastic tapes to secure the
340917 - unit against fall off in shower and perspiration during hiking.
340918 - ref SDS B4 AO7H
340920 - ..
340921 - On 191214 1138 letter to Doctor Simpson in Cardiology at VAMCSF,
340922 - ref SDS B2 NE9N, reports 8 weeks ago increased hiking route with steep
340923 - hills from 11 to 15 miles per day. ref SDS B2 MX58 About a week ago
340924 - increased hiking to 20+ miles per day in order to improve weight
340925 - control and to raise lipids toward HDL 80. ref SDS B2 MX61 Weight
340926 - increased after pausing hiking due to orthopedic pain left knee and
340927 - both feet, which was solved after receiving oxycodone and gabapentin,
340928 - and applying elastic bandage to left knee. ref SDS B2 MX64 Today,
340929 - before hiking felt chest swaying indicating afib. ref SDS B2 MY30
340930 - Research indicates walking can aid recovery from afib; during hike
340931 - today, will reduce level of effort back to 15 miles per day, and avoid
340932 - steeper hills. ref SDS B2 368M Ask about medication to treat afib.
340933 - ref SDS B2 MY38 Offer to walk with Doctor Simpson to assist recovery
340934 - from hip surgery. ref SDS B2 MY41
340936 - ..
340937 - On 191214 1138 at 1324 letter from Doctor Simpson in Cardiology at
340938 - VAMCSF says to do hiking that has led to symptoms. ref SDS B3 0K4L
340940 - ..
340941 - On 191228 1416 letter to Doctor Simpson notify Zio log reports chest
340942 - pain hiking with elastic bandage on left knee. ref SDS B6 NE9N 1st
340943 - episode hiking 12 miles through Golden Gate Park on 191220, chest pain
340944 - mild lasted on ly .25 miles. Occurred again next day hiking 20 miles
340945 - up Crystal Ranch Road. ref SDS B6 B652 Occurred next day on 191222, so
340946 - stopped at mile .75 and removed elastic bandage from left leg, pain
340947 - ended for rest of 20 mile hike and on subsequent hikes 20 mile past 6
340948 - days. ref SDS B6 B655 Today on 191228, chest pain occurred hiking up
340949 - mild hills without elastic bandage on left leg, so ended hike at 7
340950 - miles. ref SDS B6 B658 HR 150 - should be 45 - 55. ref SDS B6 B662
340951 - Seems like bypass saphenous graft failed under elevated load wearing
340952 - elastic bandage on left knee. ref SDS B6 B665 Pause hiking until hear
340953 - from the doctor. ref SDS B6 B668
340955 - ..
340956 - On 191228 1416 at 1534 letter from Doctor Simpson notifies he will
340957 - order treadmill stress test. ref SDS B6 RK6L
340959 - ..
340960 - On 191228 1416 at 1537 letter to Doctor Simpson notifies will submit
340961 - Zio XT device with afib data on Monday, 191230. ref SDS B6 WO6F
340963 - ..
340964 - On 191229 1243 received letter from Doctor Simpson notifies need to
340965 - get ECG test at VAMCSF before they can schedule treadmill stress test.
340966 - ref SDS B8 NE9N Further says to get care in the ER if chest pain
340967 - recurs at rest. ref SDS B8 NH77
340969 - ..
340970 - On 191229 1243 at 1256 letter to Doctor Simpson asks where and when to
340971 - get ECG test. ref SDS B8 YH8N Notifies so far chest pain has not
340972 - occurred at rest; has only occurred when hiking. ref SDS B8 YA48
340973 - Notifies of EGD procedure in GI Clinic at VAMC Sacramento on 200107,
340974 - and getting MRI studies on feet and knees at VAMCSF on 200109.
340975 - ref SDS B8 YA51
340977 - ..
340978 - On 191229 1243 at 1420 received letter from Doctor Simpson advising
340979 - ECG is done on 2nd floor building 203, and to arrive about 1000.
340980 - ref SDS B8 LG4J Recommends notifying GI Clinic to delay EGD until
340981 - after resolution of current Cardiology issue. ref SDS B8 6H6G
340983 - ..
340984 - On 191229 1243 at 1538 received letter from Doctor Simpson advising
340985 - ECG was done in this case at the end of Oct, so do not need a new one;
340986 - next step is for VA to schedule stress test. ref SDS B8 E17N
340988 - ..
340989 - On 191229 1243 at 1619 sent letter to Jessica on notifying Doctor Lee
340990 - to delay next EGD scheduled on 200107 0730 for a month until 200204
340991 - 0730. ref SDS B8 4R7J
340993 - ..
340994 - On 191229 1243 at 1700 letter thanks Doctor Simpson for advising ECG
340995 - not needed. ref SDS B8 M48J
340997 - ..
340998 - On 191229 1243 at 1946 letter notifies Doctor Simpson that feet
340999 - elevated on footrest seem swelled. Cellphone reports HR 38. That is
341000 - low for me. Don't feel dizzy or light headed; seems like afib event,
341001 - with chest swaying back and forth. ref SDS B8 MH6N
341003 - ..
341004 - On 191229 1243 at 1946 letter notifies Doctor Simpson Zio device was
341005 - mailed to company a day early on 191229. ref SDS B8 UA47
341007 - ..
341008 - On 191230 0930 received call from Tina in Cardiology at VAMCSF
341009 - scheduled treadmill stress test on 200103, ref SDS C0 NE9N, report
341010 - first at 0700 to ASU on 3rd floor Building 200 for IV, then go to
341011 - Neuclear Medicine on ground floor building 203. ref SDS C0 GE5K
341013 - ..
341014 - On 191230 0930 at 0938 received letter from Doctor Simpson in
341015 - Cardiology explaining symptoms reported last night are okay, since not
341016 - dizzy, until after stress test. ref SDS C0 GF3G
341018 - ..
341019 - On 191230 0930 at 0949 received letter Tina in Cardiology confirming
341020 - schedule for stress test on 200103 0700, and submitting instructions
341021 - to prepare for the test. ref SDS C0 Q76I
341023 - ..
341024 - On 191230 0930 at 1021 letter to Doctor Simpson in Cardiology at
341025 - VAMCSF reporting stress test has been scheduled on 200301 0700.
341026 - ref SDS C0 9W6F Reported mild chest pain at rest for 10 minutes, but
341027 - it resolved while writing the letter. ref SDS C0 JY39
341029 - ..
341030 - On 191230 0930 at 1114 received letter from Lauren, NP and PCP in this
341031 - case; she concurs patient should go to ER if chest pain persists at
341032 - rest, and should have a driver. ref SDS C0 2S4N
341034 - ..
341035 - On 191230 0930 at 1117 received call from Aladin who is Lauren's
341036 - assistent in Medical Practice; he indicated Lauren asked him to call
341037 - and get background on chest pain issue. ref SDS C0 578G Explained
341038 - background is reported in correspondence with Doctor Simpson in
341039 - Cardiology, and this has been copied to Lauren. ref SDS C0 5W6J
341041 - ..
341042 - On 191230 0930 at 1135 responded to Lauren citing call from her
341043 - assistent, Aladin, and reporting background on current issue is
341044 - reported in correspondence with Doctor Simpson in Cardiology, who is
341045 - directing the work, and that Lauren has been copied on all
341046 - correspondence. ref SDS C0 659K
341048 - ..
341049 - On 200108 1130 Doctor Simspon ordered cardiac catheterization
341050 - (Angiogram) to evaluate for failed saphenous bypass graph. ref SDS C7
341051 - UV3M He also cordered Echocardiogram (ECHO) to evaluate cardiac
341052 - remodeling that may be causing atrial fibrillation. ref SDS C7 GG4F
341054 - ..
341055 - On 200113 0841 call from Gina in Cardiology scheduled echocardiogram
341056 - on 200214 1300 to evaluate for cardiac remodeling causing AF due to
341057 - high-intensity hiking. ref SDS D0 NE9N
341059 - ..
341060 - On 200115 0933 called VA Cardiology, ref SDS D2 Q18G; and talked to
341061 - Sue, who has taken the position of Karen for scheduling and
341062 - coordinatoing patient procedures. ref SDS D2 NB9G Sue scheduled
341063 - cardiac catheterization (angiography) on 200128 0730; and, pause
341064 - Apixaban blood thinner 2 days before the procedure. ref SDS D2 4L5N
341066 - ..
341067 - On 200115 0933 at 1747 submitted letter confirming work plan for
341068 - cardiac catheterization on 200128. ref SDS D2 5J7M
341070 - ..
341071 - On 200115 0933 at 1936 submitted another letter correcting date error
341072 - in the letter at 1747. ref SDS D2 4K5G
341074 - ..
341075 - On 200116 0948 received letter from Sue in Cardiology at VAMCSF
341076 - instructions for cardiac catheterization scheduled 200118, ref SDS D3
341077 - G367, pause Apixaban 2 days before 200118, ref SDS D3 G45M; NPO after
341078 - midnight, and until after Cath, ref SDS D3 6S30; bring list of
341079 - medications, ref SDS D3 6S76; bring charger for cellphone, ref SDS D3
341080 - 4B9H; do not drive for 24 hours after cardiac catheterization.
341081 - ref SDS D3 6S98
341083 - ..
341084 - On 200124 0705 at 0810 cardiac catheterization IVUS angiogram,
341085 - ref SDS E3 SY5I, found no evidence blocked coronary artery bypass
341086 - grafts; found 1 branch vessel with 80-90% blockage; doctor described
341087 - best condition every seen 10 years after CABG; told patient to keep
341088 - doing whatever he is doing. ref SDS E3 ME8G
341090 - ..
341091 - On 200127 0901 Carolyn called in Cardiology Department Arrhythmia
341092 - Clinic scheduled meeting with Doctor Pellegrini on 200219 1130.
341093 - ref SDS E4 9C9M
341095 - ..
341096 - On 200128 0730 Doctor Jeremy Tietjens performed cardiac
341097 - catheterization placing a stent in branch blood vessel. ref SDS 0 9L4I
341098 - Doctor Shunk attended. ref SDS 0 Y64K
341099 -
341100 -
341101 -
341102 -
341103 -
341105 - ..
3412 -
3413 -
3414 - Progress
3415 -
341501 - Cardiac catheterization today, following up prior procedure on 200124
341502 - 0705, ref SDS E3 SY5I, found no evidence blocked coronary artery
341503 - bypass grafts; found 1 branch vessel with 80-90% blockage; doctor
341504 - described best condition every seen 10 years after CABG; told patient
341505 - to keep doing whatever he is doing. ref SDS E3 ME8G
341507 - ..
341508 - Further follows up cardiac catheterization 10 years ago on 091021 0716
341509 - that found blocked arteries, ref SDS 6 025B, leading to CABG x4 the
341510 - next day on 091022 0700. ref SDS 7 PQWU
341512 - ..
341513 - Procedure today to stent branch vessel was ordered by Doctor Simpson
341514 - and Doctor Shunk, reported by Doctor Erron Titus on 200124 0705.
341515 - ref SDS E3 SF3L
341517 - ..
341518 - Drove from Concord to the hospital in San Franchsco. Bringing c23 and
341519 - keyboard downstairs and loading into car seemed to cause very mild
341520 - chest pain; think it is PAF.
341522 - ..
341523 - Arrived at the hospital about 05
341525 - ..
341526 - During drive to VAMCSF checked heart
341527 - rate....
341528 -
341529 - Heart Chest
341530 - Time Rate Pain Sinus curve
341531 - 0426...... 45......0..... very jagged curve unrecognizable
341532 - 0437...... 47......0..... very jagged curve unrecognizable
341533 - 0447...... 46......0..... very jagged curve unrecognizable
341534 - 0448...... 45......0..... very jagged curve unrecognizable
341535 - 0450...... 45......0..... very jagged curve unrecognizable
341536 - 0500...... 46......0..... jagged curve recognizable
341537 - 0501...... 44......0..... jagged curve recognizable
341539 - ..
341540 - Arrived at VAMCSF check HR sitting while working...
341541 -
341542 - 0555...... 43......0..... jagged curve barely recognizable
341543 - 0557...... 42......0..... jagged curve barely recognizable
341544 - 0604...... 43......0..... jagged curve recognizable
341545 - 0623...... 45......0..... jagged curve barely recognizable
341546 - 0630...... 43......0..... jagged curve recognizable
341547 - 0644...... 64......0..... jagged curve barely recognizable
341549 - ..
341550 - After procedure...
341551 -
341552 - 1458..... 154......0..... normal curve
341553 - 1501..... 59......0..... jagged curve recognizable
341554 - 1504..... 79......0..... smooth curve little irrebular
341555 -
341557 - ..
3416 -
3417 -
3418 - 0627
3419 -
341901 - Submitted letter notifying Doctor Simpson and the team of PAF episode
341902 - this morning, per above. ref SDS 0 496F Letter is reported in another
341903 - record today on 200128 0621. ref SDS E6 9C9M
341904 -
341905 -
341907 - ..
3420 -
3421 -
3422 - 0719
3423 -
342301 - Letter to Cynthia clinical trial assistant for Doctor Shunk, saying...
342302 -
342303 - 1. Subject: [EXTERNAL] Cath Lab Stent Branch Vessel
342304 - Date: 2020-01-28, 07:23
342308 - ..
342309 - 2. Thanks Cyn, for help with names of the Cath La team submitted
342310 - in your letter on 200127, shown below.
342312 - ..
342313 - 3. As you know, doing Cath Lab again this morning to stent the
342314 - partial blockage in a branch vessel that Doctor Tietjens found
342315 - last Friday. Not sure this is necessary, but the
342316 - powers-that-be want to do it.
342318 - ..
342319 - If time permits, stop by to wish me luck.
342320 -
342331 -
342332 -
342334 - ..
3424 -
3425 -
3426 - 0731
3427 -
342701 - Walked into the Cath Lab.
342702 -
342703 - Jacqueline brought me into the procedure preparation room. She said
342704 - I will be first up, so she sat me in a chair.
342706 - ..
342707 - Saw Doctor Jeremy Taitjens talking to another patient. He remembered
342708 - me from the procedure last Friday, reported on 200124 0705.
342709 - ref SDS E3 V544 The doctor said hello.
342711 - ..
342712 - Asked if he will be doing the stent procedure this morning?
342714 - ..
342715 - He said yes, that he will be doing it with Doctor Shunk. He then
342716 - resumed talking to his other patient.
342718 - ..
342719 - Told Jacqurline have to return to the cafeteria, to carry a notebook
342720 - computer and keyboard back to the car, then will return in 10 minutes.
342722 - ..
342723 - Jacqueline said that will be okay.
342725 - ..
342726 - Asked about taking medications and eating some food required for some
342727 - drugs, e.g., metropolol and apiexaban, while in the cafeteria?
342729 - ..
342730 - Jacqueline said the Cath Lab staff will administer drugs prior to the
342731 - procedure this morning. After the procedure, take drugs as directed
342732 - in discharge instructions.
342733 -
342734 - [On 200128 0726 letter notified Doctor Pellegrini and
342735 - Doctor Simpson that Cath Lab staff directed taking drugs
342736 - before the procedure. ref SDS E8 PP6K
342738 - ..
342739 - Walked back to the cafeteria. Put the computer into the case.
342740 - Carried it and the keyboard out to the car in the parking lot. Then
342741 - returned to the Cath Lab.
342743 - ..
342744 - Back in the Cath Lab, saw Sue. She said the team during last Friday
342745 - was...
342746 -
342747 - Sue
342748 - Laura
342749 - Malisa
342750 - Mike
342752 - ..
342753 - Sue also indicated I will be the 2nd procedure today, rather than 1st.
342754 -
342756 - ..
342757 - Received letter from Doctor Pelligrini saying to hold on Metoprolol
342758 - until checking into Cath Lab, reported in another record earlier today
342759 - on 200128 0726. ref SDS E7 9C9M
342761 - ..
342762 - Sent letter to Doctor Pelligrini with copies to the team, saying in
342763 - Cath Lab, and that Jacqueline said the staff will direct meds,
342764 - reported in another record on 200128 0726. ref SDS E7 PP6K
342766 - ..
342767 - While writing this, Sue said I am 1st now, because the other patient
342768 - was throwing up blood, so they delayed his procedure, while he gets
342769 - further radiology testing. Reported this in the letter to Doctor
342770 - Pellegrini and the team, reported in another record on 200128 0726.
342771 - ref SDS E7 D343
342772 -
342773 -
342774 -
342776 - ..
3428 -
3429 -
3430 - 0812
3431 -
343101 - Doctor Tietjens finished consulting with the other patient.
343102 -
343103 - He invited me to move from observer chair to a chair at the worktable.
343104 - Jeremy reviewed the consent process, explaining risks of the
343105 - procedure. After discussion for a few minutes, signed the consent for
343106 - the procedure.
343108 - ..
343109 - The doctor advised that the procedure for placing a stent today, will
343110 - access through the right wrist, rather than the left wrist accessed
343111 - for the procedure on Friday, 200124 0705, ref SDS E3 ZP9O Think he
343112 - said the blocked branch vessel is closer to access from the right arm.
343114 - ..
343115 - Asked Jeremy why the procedure on Friday, found only 1 blood vessel
343116 - with atherosclerotic plaque, which the team plans to fix today, with a
343117 - stent?
343119 - ..
343120 - Why didn't elevated HDL regress plaque in this one blood vessel, as it
343121 - did for all the other blood vessels, including the bypass grafts, as
343122 - he related during the IVUS catheteritization procedure last week on
343123 - 200124 0705. ref SDS E3 ME8G Why didn't this branch blockage register
343124 - with EKG during treadmill stress test on 200103 0700. ref SDS C3 J97F
343126 - ..
343127 - Jeremy said the branch vessel filled with plaque, which he found on
343128 - Friday, and will be treated today with a stent, is located in an odd
343129 - position that does not get normal blood flow. Therefore it gets less
343130 - HDL than the other blood vessels. He gave an explanation about
343131 - variances in shear and adherence, which was difficult to follow, but
343132 - was offered to underscore how this one blood vessel has plaque, but
343133 - all the others do not.
343135 - ..
343136 - Sounds similar to bypassed native arteries filled with plaque. The
343137 - calcium score was 1360 for CCTA procedure on 151019 0930. ref SDS 26
343138 - SU5O On 181108, calcium score increased to 1484. 181108 0930.
343139 - ref SDS 79 CH3K Jeremy's Cath report also says bypassed arteries are
343140 - filled with plaque, reported on 200124 0705, ref SDS E3 5G48, because
343141 - blood flows to the heart in the bypass grafts which are 100% open.
343143 - ..
343144 - Jeremy further seemed to say that this since this vessel, even if
343145 - fully open, does not contribute much blood flow to the heart, adding a
343146 - stent today, is not life saving, nor otherwise improve patient health.
343147 - This aligns with the explanation last week on 200124 0705. ref SDS E3
343148 - 5J8O
343149 -
343150 - [On 200128 0730 progress notes for IVUS guided PCI
343151 - procedure placing a stent reports pre-procedure stenosis
343152 - 95%; TIMI Flow: 3 - Complete flow, and Post-procedure 0%
343153 - stenosis; TIMI Flow: 3 - Complete flow. ref SDS 0 QR4M
343155 - ..
343156 - After the meeting, research found...
343158 - ..
343159 - Vein Graft Stenosis
343160 -
343161 - https://www.ncbi.nlm.nih.gov/books/NBK499947/
343163 - ..
343164 - Last Update: December 26, 2019.
343166 - ..
343167 - Pathophysiology...
343168 - Intimal hyperplasia is the universal response of a vein graft
343169 - to insertion into the arterial circulation and is considered
343170 - to result from both the migration of smooth muscle cells out
343171 - of the media into the intima and proliferation of these smooth
343172 - muscle cells.
343174 - ..
343175 - Vein grafts with lower flows are associated with greater
343176 - intimal thickening. Similarly, low shear stress is also
343177 - associated with increased development of intimal hyperplasia
343178 - in vein grafts.
343180 - ..
343181 - The record is not clear that this occlusion occurs in a branch from
343182 - SVG, but terminology is similar to Doctor Tietjens explanation, per
343183 - above. ref SDS 0 OL4G
343185 - ..
343186 - The doctor further noted that chest pain experienced during hiking and
343187 - more recently with even minimal level of effort, as occurred this
343188 - morning, per above, ref SDS 0 496F, may be resolved by treatment
343189 - today, because reduced blood flow due to blockage in this 1 vessel,
343190 - may not be compensated by increased blood flow from nearby collateral
343191 - small vessels.
343193 - ..
343194 - This seems conflicting with analysis that when blood flow is
343195 - interrupted in primary vessels, small collateral blood vessels
343196 - multiply, and elongate and increase in size, explained on 200124 0705,
343197 - ref SDS E3 EH96, and in research shown in the same record. ref SDS E3
343198 - JV6I
343200 - ..
343201 - After discussion with the doctor, Mike and Jacqueline guided me to a
343202 - gurney. Removed clothing and put on a hospital gown.
343204 - ..
343205 - Mike set EKG leads.
343207 - ..
343208 - Jacqueline placed IV on the right arm. She used the inner side, since
343209 - an IV was in the outer side all last week.
343211 - ..
343212 - Jacqueline also set an IV on top of the left hand. This is a backup,
343213 - in case the primary IV in the left arm fails.
343215 - ..
343216 - Received letter on cellphone from Doctor Simpson on cellphone
343217 - saying...
343218 -
343219 - 1. Subject: Re: [EXTERNAL] SECURE PAF Episode - Increase Metoprolol
343220 - Date: 2020-01-28, 08:18
343227 - ..
343228 - 2. I will see you later today.
343230 - ..
343231 - The doctor responds to the letter earlier today, reported in another
343232 - record on 200128 0726. ref SDS E7 PP6K
343234 - ..
343235 - Letter from Doctor Simpson continues...
343236 -
343237 - 3. Did they do an ECG when the curve was jagged?
343238 -
343239 - [...below on 200128 0730 at 1127 after Cath Lab procedure,
343240 - sent letter to the team, notifying that Mike set leads for
343241 - ECG, but not sure if in AF at time this was done.
343242 - ref SDS 0 EX4M
343244 - ..
343245 - [...below on 200128 0730 at 1507 after Cath Lab procedure
343246 - and while recovering under observation, Teresa did EKG to
343247 - monitor heart and this was while in AF. ref SDS 0 SF4G
343249 - ..
343250 - 4. Dr s
343252 - ..
343253 - This letter follows Doctor Pellegrini's letter earlier today, on
343254 - holding Metorpolol until checking with Cath Lab staff, reported in
343255 - another record on 200128 0726. ref SDS E7 9C9M
343257 - ..
343258 - Sent letter to the team advising that Mike set leads for ECG -
343259 - actually, the record sayd EKG, not sure if same thing, per above.
343260 - ref SDS 0 T66T
343262 - ..
343263 - After setup, Sue started pushing the gurney, and said someone should
343264 - get Kathy to say good luck.
343266 - ..
343267 - Jacqueline left and returned with Kathy. We only spoke briefly,
343268 - because Sue came and started rolling the gurney out of preparation to
343269 - the lab for the procedure.
343271 - ..
343272 - Cynthia was in the hall at the doorway and wished me good luck.
343273 - Smiled and said thanks, because the letter earlier today, asked to
343274 - stop by before the procedure, if she had time, reported above.
343275 - ref SDS 0 WT3N
343277 - ..
343278 - She asked about joining the PCSK9 study? In the moment this seemed
343279 - confusing. Cynthia seemed to say after Cath last Friday, that I do
343280 - not qualify for the study, because the only blockage found was in a
343281 - branch vessel, and the study was to evaluate PCSK9 for blockages in
343282 - bypass grafts. We agreed to consider this again.
343284 - ..
343285 - After the procedure, reviewing the record shows the stenting study
343286 - related to bypass grafts, and not PCSK9, reported on 200124 0705.
343287 - ref SDS E3 FH6M Seems may be able to participate in PCSK9 study
343288 - afterall.
343289 -
343290 - [On 200204 2252 letter to Cyn asks about joining PCSK9
343291 - study. ref SDS F3 9C9M
343293 - ..
343294 - [On 200205 1941 received letter from Cyn saying that
343295 - participation in PCSK9 study is not possible because some
343296 - protocols were not followed. ref SDS F4 9C9M
343297 -
343298 -
343299 -
343301 - ..
3434 -
3435 -
3436 - 0823
3437 -
343701 - Sue rolled me into Lab 2 for the procedure.
343702 -
343703 - Sat up, then stepped down from the gurney. Stepped up onto the
343704 - procedure table. Terriffic team prepared for the Cath procedure...
343705 -
343706 - Sue
343707 - Katheryn
343708 - Jacqueline
343709 - Mike
343710 - Malisa
343712 - ..
343713 - Preparation was significantly different today.
343715 - ..
343716 - The right arm was laid flat on the right side, and then wrapped
343717 - fastening it to the sidebar to hold it steady for the procedure.
343718 - There was no surgical glove nor blue cloth with adhesive on the
343719 - perimeter wrapped around the right wrist, as there was on the left
343720 - wrist last Friday, reported on 200124 0705. ref SDS E3 WW5L
343722 - ..
343723 - Catheter was injected into a vein on the right wrist for the angiogram
343724 - procedure.
343725 -
343726 - [...below on 200128 0730 at 1313 Doctor Durstenfeld removed
343727 - the catheter guide and placed gauze dressing, wrapped with
343728 - coban tape. ref SDS 0 PUWQ
343730 - ..
343731 - Entire body was drapped with clear plastic covering. Then a warm
343732 - blanket was laid over that.
343734 - ..
343735 - In all, preparations were extensive.
343737 - ..
343738 - Doctor Jeremy Tietjens arrived, per discussion this morning, above,
343739 - ref SDS 0 VW6G, and following up procedure last Friday on 200124 0705.
343740 - ref SDS E3 V544 Standing on left side he explained the work plan for
343741 - cardiac catheterization placing a stent to open a branch vessel found
343742 - during the procedure on Friday. ref SDS E3 5J8O The doctor verified
343743 - patient identification, asked the patient to state the procedure being
343744 - performed this morning.
343746 - ..
343747 - Doctor Shunk leaned over from the left side, and said good morning.
343749 - ..
343750 - Very nice seeing the doctor, following up discussions on 200122 0423.
343751 - ref SDS E1 6Y5R
343753 - ..
343754 - Doctor Tietjens said this is Doctor Shunk, Chief of Cath Lab ops.
343756 - ..
343757 - Doctor Shunk smiled and said: "That's okay. Rod and I are old
343758 - friends."
343760 - ..
343761 - Doctor Shunk further noted significant favorable results finding
343762 - bypass grafts completely clear of plaque 10 years after CABG x4 on
343763 - 091022, reported to him by Jeremy on 200124 0705, as later related by
343764 - Doctor Titus. ref SDS E3 T46M
343766 - ..
343767 - Doctor Tietjens gave the order to infuse fentyl and then versed 1 mg.
343768 - Think Susan did the infusions in the right arm catheter.
343770 - ..
343771 - There was no music during this procedure, unlike last Friday, reported
343772 - on 200124 0705. ref SDS E3 V55F
343774 - ..
343775 - There was injection in the right wrist area. This initially stung a
343776 - little.
343778 - ..
343779 - Became quite groggy from the versed so had problems following the
343780 - rest of the procedure.
343782 - ..
343783 - Felt pain level 3 at times in the right arm. The doctor ordered
343784 - additional fentyl. This quieted right arm pain.
343786 - ..
343787 - At the end, Doctor Taitjens said the procedure is over. It went well.
343788 - He hopes this will end patient chest pain.
343790 - ..
343791 - Was taken to floor 3 Telemetry North room 22 for observation.
343792 -
343794 - ..
3438 -
3439 -
3440 - 1127
3441 -
344101 - In recovery room, used cellphone sending letter to the team saying...
344102 -
344103 - 1. Subject: Re: [EXTERNAL] SECURE PAF Episode - Increase Metoprolol
344104 - Date: 1/28/20 11:29 (GMT-08:00)
344105 - From: Rod Welch
344106 - To: "Simpson, Paul"
344107 - Cc: "Pellegrini, Cara"
344108 - CC: "Rettberg, Lauren B."
344109 - CC: "Titus, Erron"
344111 - ..
344112 - 2. They did EKG not sure if still in AF.
344114 - ..
344115 - This responds to Doctor Simpson's letter received in the Cath Lab
344116 - prior to procedue, per above. ref SDS 0 TP3J
344117 -
344118 -
344120 - ..
3442 -
3443 -
3444 - 1248
3445 -
344501 - Received letter on cellphone from Doctor Simpson on cellphone
344502 - saying...
344503 -
344504 - 1. Subject: Re: [EXTERNAL] SECURE PAF Episode - Increase Metoprolol
344505 - Date: 2020-01-28, 11:35
344511 -
344512 - 2. i will see you later up in the recovery area.
344514 - ..
344515 - [...below on 200128 0730 at 1519 Doctor Simpson visits in
344516 - the hospital room. ref SDS 0 06GC
344517 -
344518 - i was told the PCI went well, so good.
344520 - ..
344521 - PCI - percutaneous coronary intervention
344522 -
344523 - See...
344524 -
344525 - American College of Cardiology
344527 - ..
344528 - IVUS in PCI Guidance
344529 -
344530 -
344531 - https://www.acc.org/latest-in-cardiology/articles/2016/06/13/10/01/ivus-in-pci-guidance
344533 - ..
344534 - Even though there are many uses of intravascular
344535 - ultrasound (IVUS) in the catheterization laboratory, the
344536 - interventional cardiologist has only two fundamental
344537 - questions and only two basic decisions when performing a
344538 - percutaneous coronary intervention (PCI):
344539 -
344540 - 1. Is a lesion significant and ischemia producing and,
344541 - therefore, should it be treated?
344543 - ..
344544 - 2. Has the PCI been optimized?
344546 - ..
344547 - This is a good article on issues in the current case, where different
344548 - views emerged on whether to perform the procedure today, discussed in
344549 - the record on 200124 0705. ref SDS E3 SF3L
344550 -
344551 -
344553 - ..
3446 -
3447 -
3448 - 1217
3449 -
344901 - Used cellphone to send letter to Doctor Erron Titus saying...
344902 -
344903 - Subject: Re: [EXTERNAL] SECURE Admit to Hospital Today For Cath Lab Tomorrow?
344904 - Date: 1/28/20 12:19 (GMT-08:00)
344905 - From: Rod Welch
344906 - To: "Titus, Erron"
344908 - ..
344909 - 3. I'm in 3rd floor room 22. Please stop by, if time permits.
344911 - ..
344912 - Responds to Erron's letter yesterday on 200127 1001. ref SDS E5 2Z4F
344914 - ..
344915 - 4. Rod
344916 -
344917 -
344919 - ..
3450 -
3451 -
3452 - 1307
3453 -
345301 - Received letter from Erron saying...
345302 -
345303 - 1. Subject: Re: [EXTERNAL] SECURE Admit to Hospital Today For Cath Lab Tomorrow?
345304 - Date: 2020-01-28, 13:00
345308 - ..
345309 - 2. Will do!
345310 -
345311 -
345312 -
345313 -
345315 - ..
3454 -
3455 -
3456 - 1313
3457 -
345701 - Doctor Mat Durstenfeld visited. He removed the catheritization guide,
345702 - which was used for placing the stent, earlier this morning, per above.
345703 - ref SDS 0 RC7F He placed a gauze pad on the wound. He held this on
345704 - the wound, while the blood clotted. This actually took nearly half an
345705 - hour. The pressure he applied to the wound hurt quite a bit. Mat
345706 - Appoligized, saying it was necessary.
345708 - ..
345709 - After blood stopped flowing from the wound, Mat placed a small piece
345710 - of gause over the wound. Taped this with orninary plastic tape, then
345711 - wrapped the bandage with coban tape, similar the wrap Jeremy applied
345712 - to the left wrist last Friday on 200124 0705. ref SDS E3 N83F
345713 -
345714 - [On 200130 0911 letter notifies Doctor Simpson and medical
345715 - team that removed coban wrap and gauze dressing, because
345716 - the wrap was so tight it was putting hand to sleep; on
345717 - removal blood had leaked through gauze dressing.
345718 - ref SDS F2 I37H
345720 - ..
345721 - Mat said he and Doctor Shunk assisted Doctor Jeremy Tietjens during
345722 - the entire procedure this morning. Remember seeing Doctor Shunk, but
345723 - thought he left the room, after saying hello, per above. ref SDS 0
345724 - Y64K Don't remember seeing Mat.
345726 - ..
345727 - Mat said he believes elevated HDL has not regressed plaque in
345728 - patient's blood vessels, because clinical trials found HDL increased
345729 - by drugs, did not reduce mortality of patients. This seems to reflect
345730 - the current cardiology paradigm, based on failed clinical drug trials,
345731 - discussed during international conference, reviewed on 131125 0005.
345732 - ref SDS 19 8H3M On 160405 1305 Evacetrapib raised HDL 130% failed
345733 - clinical trial Eli Lilly cholesterol drug CEPT inhibitor did not
345734 - reduce CV events; raised blood pressure (hypertension), ref SDS 31
345735 - AF51 Doctors discouraged Merck anacetrapib and Amgen TA-8995 which
345736 - raise HDL similarly, expect fail to improve clinical outcomes.
345737 - ref SDS 31 OH42
345739 - ..
345740 - There is no express record that failed drug trials elevated EPCs along
345741 - with HDL, essential to repair stenosis, when HDL removes LDL plaque
345742 - from endothelial lining of blood vessels, reported on 131125 0005.
345743 - ref SDS 19 RA7K
345745 - ..
345746 - Mat further indicated that Doctor Tietjens found many other blood
345747 - vessels have considerable plaque. The medical team placed only 1
345748 - stent today, because the other blood vessels are still patent, but
345749 - many are nearly too full to be patent. Mat seemed to say that within
345750 - months or a few years more stents will be needed, unless the patient
345751 - increases statin medication.
345752 -
345753 - [On 200623 0906 letter from Doctor Pellegrini cites
345754 - possibility that atherosclerosis (plaque buildup) in blood
345755 - vessels causing colitis in lower stomach region of colon.
345756 - ref SDS F5 EY6V
345758 - ..
345759 - The doctor further indicated belief that patient exercise, hiking 200
345760 - - 400 miles per month the past 10 years, prevented buildup of plaque
345761 - in main artery bypass grafts, but could not explain why "many other
345762 - blood vessels have considerable plaque," as he states today, per
345763 - above, ref SDS 0 2G6L, but somehow the bypass grafts have 0 stenosis,
345764 - found by Doctor Tietjens in progress notes on 200124 0705. ref SDS E3
345765 - 5G59
345767 - ..
345768 - Thanked Mat for helpful guidance.
345769 -
345770 -
345772 - ..
3458 -
3459 -
3460 - 1422
3461 -
346101 - Doctor Titus visited in 3rd Floor Telemetry, per planning above.
346102 - ref SDS 0 TW6J
346104 - ..
346105 - Erron was not involved in the procedure today, but has read some early
346106 - progress notes. He said progress notes report very successful stent
346107 - procedure, providing increased blood flow to the heart. This is a
346108 - positive outcome, and aligns with the letter from Doctor Simpson,
346109 - received earlier today, per above. ref SDS 0 CT4F
346111 - ..
346112 - Discussed meeting with Mat earlier today, when he came by to dress the
346113 - procedure wound, per above. ref SDS 0 PUWQ
346115 - ..
346116 - Erron indicated progress notes for IVUS procedure setting a stent this
346117 - morning, and progress notes for the prior procedure last Friday on
346118 - 200124, do not mention finding many nor any blood vessels have
346119 - considerable or any plaque, except the one branch vessel, which was
346120 - stented today. This is reported for the procedure on 200124 0705.
346121 - ref SDS E3 5G95
346123 - ..
346124 - Thanked Erron for visiting - enjoyed working with him on this
346125 - project.
346126 -
346127 -
346128 -
346130 - ..
3462 -
3463 -
3464 - 1507
3465 -
346501 - Having PAF episode. Teresa came and said the staff noticed in AF on
346502 - the monitor, and so they are trying to do EKG test while still in AF.
346504 - ..
346505 - She connected the leads, and was pleased to capture EKG reading of
346506 - PAF, while heart monitor showed PAF, same as Sherri on 200121 0552.
346507 - ref SDS D9 UC9N
346509 - ..
346510 - Follows up Mike setting leads in Cath Lab preparing for procedure, per
346511 - above. ref SDS 0 T66T At 0818, Doctor Simpson's letter asks if ECG
346512 - was done at time to evaluate AF, per above. ref SDS 0 TP3J
346513 -
346514 -
346516 - ..
3466 -
3467 -
3468 - 1519
3469 -
346901 - Doctor Simpson here, per his letter planning to visit, reported
346902 - earlier today, per above. ref SDS 0 CT4F
346904 - ..
346905 - He is concerned about PAF starting and stopping and starting before
346906 - his eyes sitting in a chair watching the vitals monitor and talking
346907 - about the case today.
346908 -
346909 - [On 200129 0724 letter to Doctor Simpson reports continuing
346910 - to go in and out of AF, while still in hospital, and
346911 - walking laps around the ward to stabalize HR. ref SDS E9
346912 - 9C9M
346914 - ..
346915 - [On 200130 0258 day after discharge following PCI for
346916 - stent, report woke up late at night with elevated HR
346917 - indicating AF, and chest pain level 4; about an hour later
346918 - this resolved to HR bradycardia and chest pain level 0.
346919 - ref SDS F1 9C9M
346921 - ..
346922 - He ordered dose of metoprolol tartrate. Terisa said the medicine team
346923 - wants to wait until dinner at 1700. Doctor Simpson asked Terisa to
346924 - call and ask the Cardiology team to visit here as soon as convenient.
346926 - ..
346927 - Doctor Simpson said there is a 2nd blocked branch vessel on the other
346928 - side of the heart. The doctor said they did not stent this 2nd
346929 - blockage today, because it is difficult to reach, and they are not
346930 - sure it is causing significant loss of blood to the heart. We did not
346931 - discuss similar grounds Doctor Tietjens cited for not placing a stent
346932 - for the 1st minor blockage, reported on 200124 0705. ref SDS E3 5J8O
346933 -
346934 -
346935 -
346937 - ..
3470 -
3471 -
3472 - 1549
3473 -
347301 - Doctor Jafar and Keven Huynh arrived.
347302 -
347303 - Doctor Simpson asked about treating the patient with Metoprolol
347304 - Tartrate immediately.
347306 - ..
347307 - They agreed to this, and left while Doctor Simpson continued with the
347308 - meeting.
347309 -
347310 -
347311 -
3474 -
SUBJECTS
Default Null Subject Account for Blank Record
3503 -
350401 - ..
350402 - Progress Notes Cardiac Catheterization PCI Stent Branch Vessel
350403 -
350404 - Follow up ref SDS E3 Q05K.
350405 -
350406 - NI3L
350407 - Request records on CD from ROI for this medical encounter due to
350408 - continual difficulties downloading medical records from VA website
350409 - at...
350410 -
350411 - https://www.myhealth.va.gov/mhv-portal-web/track-health
350412 -
350423 -
350424 -
350425 - 1. Date/Time: 28 Jan 2020 @ 1448
350426 - Note Title: CARDIAC CATHETERIZATION REPORT
350427 - Location: San Francisco CA VAMC
350428 - Signed By: TIETJENS,JEREMY
350429 - Co-signed By: TIETJENS,JEREMY
350430 - Date/Time Signed: 28 Jan 2020 @ 1448
350431 - -------------------------------------------------------------------------
350433 - ..
350434 - LOCAL TITLE: CARDIAC CATHETERIZATION REPORT
350435 - STANDARD TITLE: CARDIOLOGY CONSULT
350436 - DATE OF NOTE: JAN 28, 2020@14:48 ENTRY DATE: JAN 28, 2020@14:48:44
350437 - AUTHOR: TIETJENS,JEREMY EXP COSIGNER: SHUNK,KENDRICK A
350438 - URGENCY: STATUS: COMPLETED
350440 - ..
350441 - 2. The following is a preliminary report unless cosigned by a Staff or
350442 - Attending Physician.
350444 - ..
350445 - 3. VA CART Program for Clinical Assessment, Reporting, and Tracking
350446 - CART-PCI:066200-0038A7E6-CPS0001
350448 - ..
350449 - 4. PERCUTANEOUS CORONARY INTERVENTION REPORT
350451 - ..
350452 - 5. Patient: WELCH,RODNEY CHARLES SSN: 561720144 DOB: 3/1/1945 AGE: 74
350454 - ..
350455 - 6. Procedure Date: 01/28/2020 Associated Assessment: 1/28/2020 Case: 2020-0073
350456 -
350457 - Attending: SHUNK,KENDRICK A
350458 - Assisting: TIETJENS,JEREMY; DURSTENFELD,MATTHEW
350460 - ..
350461 - 7. Procedures:
350462 -
350463 - 1. PCI
350464 -
350465 - 2. Status: Elective
350466 - This was an outpatient procedure.
350468 - ..
350469 - 3. Type of procedure, site, and patient ID were verified with
350470 - the patient.
350472 - ..
350473 - 4. Re-assessment was performed immediately prior to conscious
350474 - sedation and no change was noted.
350476 - ..
350477 - 5. NPO status greater than 4 hours verified.
350479 - ..
350480 - 6. The attending was present throughout the procedure.
350481 -
350483 - ..
350484 - 8. Primary Indication: Unstable Angina
350486 - ..
350487 - 9. ACCESS
350488 -
350489 - Primary Arterial: Right Radial, 7F Sheath, Radial Hemostasis closure
350491 - ..
350492 - 10. INTERVENTIONS
350493 -
350494 - --------------
350495 - PCI Lesion #1: Right PL Segment 1
350496 - --------------
350497 - Guide Catheter: AL 1, 7 fr
350499 - ..
350500 - Lesion Length: 10 mm
350501 - Risk Assessment: Medium
350503 - ..
350504 - Pre-Procedure Stenosis: 95%; TIMI Flow: 3 - Complete flow
350505 - Post-Procedure Stenosis: 0%; TIMI Flow: 3 - Complete flow
350507 - ..
350508 - This report seems to indicate that despite 95% stenosis, there was
350509 - complete blood flow through the branch vessel prior to the stent being
350510 - placed. After the procedure there was no reported increase in blood
350511 - flow. Seems to align with Doctor Tietjens' assessment during IVUS
350512 - angiogram procedure on 200124 0705. ref SDS E3 VO9J
350514 - ..
350515 - Progress notes continue....
350516 -
350517 - # Method/Treatment Device/Description
350518 - ---------------------------------------------------------------
350519 - 1. PCI Wire Crossing Runthrough
350520 - 2. PCI Balloon Emerge 2mm x 12mm
350521 - peak inflation: 14 atm
350522 - 3. PCI Stent - DES Xience Sierra, 2.5mm x 15mm
350523 - peak inflation: 14 atm
350524 - ---------------------------------------------------------------
350526 - ..
350527 - 11. PCI
350528 -
350529 - After reviewing the findings, the decision was made to proceed
350530 - to percutaneous coronary intervention. Therapeutic
350531 - anticoagulation was achieved with Heparin boluses and serial
350532 - ACT monitoring. Loading doses of Aspirin and clopidogrelwere
350533 - administered. A 7 French AL 1 guide catheter was used to
350534 - intubate the right coronary ostium. A 0.014" Runthrough
350535 - coronary guidewire was advanced into the distal rPL branch past
350536 - the 95% lesion in the rPL. A 2.0 mm x 12 mm Emerge balloon was
350537 - used for pre-dilation at a maximum of 14 atm. We were unable
350538 - to deliver a stent, so then the 2.0 mm balloon was used to
350539 - predilate the proximal to mid RCA lesions with overlapping
350540 - inflations at a maximum of 14 atm. Next, a 2.5 mm x 15 mm
350541 - Xience Sierra drug eluting stent was deployed in the right
350542 - posterolateral branch at 16 atm. A 5.5 Fr Telescope guide
350543 - extender was then advanced into the artery for better
350544 - visualization. Post-intervention angiography demonstrated
350545 - conversion of the 95% stenosis to 0% with TIMI-III flow
350546 - distally. Given the excellent angiographic result including
350547 - visible step up and step down, the stent was not post dilated.
350548 - There was no angiographic evidence of vessel injury.
350550 - ..
350551 - 12. IN-LAB MEDICATIONS
350552 -
350553 - 1. Fentanyl
350554 - 2. Heparin (Unfractionated) 9000, IV
350555 - 3. Lidocaine, SC
350556 - 4. Midazolam
350557 - 5. Nicardipine
350558 - 6. Nitroglycerin
350560 - ..
350561 - 13. Start of procedure: 01/28/2020 09:36
350562 - End of procedure: 01/28/2020 10:29
350564 - ..
350565 - 14. Summary Data (PCI only totals):
350566 -
350567 - 1. Total Contrast: 180 mL, Visipaque-320 (iodixanol)
350568 - 2. Total Fluoroscopy Time: 10 min
350569 - 3. Radiation DAP: 70 dGy-cm2 Air Kerma: 616 mGy
350570 - 4. Total Fluids: 200 mL
350571 - 5. Estimated Blood Loss: 5 mL
350572 - 6. Specimen removed: No
350574 - ..
350575 - 15. COMPLICATIONS IN LAB
350576 -
350577 - No Major Adverse Events or Complications
350579 - ..
350580 - 16. FINAL RESULTS
350581 -
350582 - 1. Successful PCI of the right posterolateral artery using a
350583 - 2.5 mm x 15 mm Xience Sierra drug eluting stent, converting
350584 - the 95% stenosis to 0% residual with TIMI-III flow.
350585 -
350586 - 2. Balloon angioplasty of proximal to mid RCA lesions using a
350587 - 2.0 mm compliant balloon to facilitate stent delivery.
350589 - ..
350590 - 3. Radar band applied to right radial arteriotomy site.
350592 - ..
350593 - 17. FINAL RECOMMENDATIONS
350594 -
350595 - 1. Clopidogrel 75 mg daily for a minimum of 12 months, after
350596 - which de- escalation to aspirin 81 mg daily can be
350597 - considered.
350598 -
350599 - 2. Restart apixaban 5 mg BID tomorrow.
350601 - ..
350602 - 3. Radar band x2 hours.
350604 - ..
350605 - 4. Optimal medical therapy for CAD per current ACC/AHA
350606 - guidelines.
350608 - ..
350609 - 5. Admit to observation service overnight.
350610 -
350611 -
350612 - /es/ Jeremy Tietjens, MD
350613 - Interventional Fellow, Cardiology
350614 - Signed: 01/28/2020 14:48
350615 -
350616 - /es/ KENDRICK A SHUNK, MD, PhD
350617 - CHIEF, INTERVENTIONAL CARDIOLOGY (1760418230)
350618 - Cosigned: 02/06/2020 16:59
350619 -
350620 -
350621 -
350622 -
350623 -
350624 -
350625 -
350626 -
350627 -
350628 -
350629 -
350630 -
350631 -
3507 -