Cardiac Catheterization/Coronary Angiography Procedure Report

Patient name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Procedure date: [Date]

Start time: [HH:MM]

End time: [HH:MM]

Location: [Procedure location/lab]

Primary operator: [Operator name, credentials]

Referring physician: [Referring clinician name]

Procedure(s) performed: [List specific procedures completed (e.g., diagnostic coronary angiography, left heart catheterization, right heart catheterization, left ventriculography)]

Indication

[Primary clinical indication and context] (Summarize the reason for catheterization in 2–4 sentences. Include presenting syndrome or test finding, current clinical status, relevant prior coronary history such as PCI/CABG, and risk factors affecting technique such as CKD or contrast allergy. Avoid vague phrasing; do not document "rule out CAD" without specific clinical framing.)

Consent and Safety Verification

[Consent source and status] (State that informed consent was obtained from patient or surrogate, or document emergency exception with rationale.)

[Pre-procedure verification and time-out] (Document that pre-procedure verification and procedural time-out were completed with team participation.)

[Safety checks] (Note allergies with any prophylaxis provided, anticoagulation status, and pertinent labs reviewed such as creatinine and INR if applicable.)

Procedure Technique

Access: [Site and side: right radial / left radial / right femoral / left femoral / other], [Sheath size: 5F / 6F / 7F / other], [Ultrasound guidance: used / not used], [Access details: uncomplicated / difficult / crossover required with details]

Catheters: [List diagnostic catheters used (e.g., JL4, JR4, multipurpose, pigtail)]

Anticoagulation/Medications: [Anticoagulant with dose and ACT if obtained]; [Other procedural medications with dose and indication]

Contrast: [Contrast agent name], [Total volume in mL], [Contrast-sparing strategies or reactions if applicable]

Radiation: [Total fluoroscopy time in minutes], [Cumulative air kerma in mGy and/or dose-area product in Gy·cm²] (If institutional high-exposure threshold exceeded, note patient notification and follow-up plan.)

Hemostasis: [Method: manual compression / radial compression device / closure device with type], [Time hemostasis achieved if tracked], [Post-closure assessment: pulses/perfusion and site status]

Sedation

(Include this section only if moderate sedation was administered by the procedural team. If anesthesia provided sedation, state "Anesthesia-provided sedation; see anesthesia record" and omit further detail.)

Sedation type: [Moderate / minimal]

Responsible clinician: [Name and role]

Total intra-service sedation time: [Minutes]

Medications: [Drugs and doses administered]

Monitoring: [Continuous ECG, pulse oximetry, blood pressure, capnography as applicable]

Airway/events: [Airway issues, interventions, or reversal agents used / None]

Hemodynamics

(Include when hemodynamic measurements were obtained. If not performed, state "Hemodynamic assessment not performed" and omit the tables below.)

Left Heart Catheterization

Parameter	Value
Aortic pressure (systolic/diastolic/mean)	[###/##/(##) mmHg]
LV pressure (systolic)	[### mmHg]
LVEDP	[## mmHg]
Aortic valve gradient (if assessed)	[Peak-to-peak ## mmHg / Not assessed]

(Note any technical limitations or arrhythmias affecting measurements.)

Right Heart Catheterization

(Include if performed.)

Chamber/Vessel	Pressure
RA (mean)	[## mmHg]
RV (systolic/diastolic)	[##/## mmHg]
PA (systolic/diastolic/mean)	[##/##/(##) mmHg]
PCWP (mean)	[## mmHg]
Cardiac output/index	[CO ## L/min, CI ## L/min/m²] [Method: thermodilution / Fick]
O2 saturations (if shunt evaluation)	[SVC ##%, RA ##%, RV ##%, PA ##%]

(Note any measurement limitations such as unreliable wedge position.)

Coronary Angiography Findings

Dominance: [Right / Left / Co-dominant]. Coronary anomalies: [None / Describe].

(Report vessels in consistent order. For each diseased segment, include location, percent diameter stenosis, qualitative descriptors such as calcification or thrombus, and TIMI flow for significant lesions. Document collaterals if present. For normal or minimally diseased vessels, a brief statement such as "No significant disease" is sufficient. Do not infer findings for non-visualized vessels; explicitly state if not imaged and why.)

Left Main: [Caliber and stenosis by location: ostial / body / distal-bifurcation; qualitative descriptors; TIMI flow if significant disease]

LAD: [Proximal/mid/distal segments with percent stenosis and descriptors; major diagonals (D1, D2); TIMI flow for significant lesions]

LCx: [Proximal/mid/distal segments with percent stenosis and descriptors; obtuse marginals (OM1, OM2); TIMI flow for significant lesions]

RCA: [Proximal/mid/distal segments with percent stenosis and descriptors; PDA and posterolateral branches; TIMI flow for significant lesions]

Bypass grafts: [LIMA/SVG to target vessel, patency, and lesions with percent stenosis; TIMI flow if significant disease. If known grafts not injected, state reason. If no prior CABG, omit this line.]

Left Ventriculography

(If not performed, state "Left ventriculography not performed" and omit the list below.)

• LVEF: [Estimated percent] with [normal / mildly reduced / moderately reduced / severely reduced] global function
• Regional wall motion: [Normal / Territory-based abnormalities]
• Mitral regurgitation: [None / Trace / Mild / Moderate / Severe / Not assessed]
• LV thrombus: [Present / Absent / Not assessed]

Coronary Physiology and Intravascular Imaging

(Include only if FFR, iFR, IVUS, or OCT was performed. Omit entire section if not performed.)

• Target vessel/lesion: [Vessel and segment]
• Technique: [FFR / iFR / IVUS / OCT]; [Hyperemic agent and dose if FFR]
• Results: [Numeric values and pertinent measurements]
• Interpretation: [Clinical implication and how results guided management]

Intervention

(If no intervention performed, state "No coronary intervention performed" and omit the list below.)

• Lesion: [Vessel and segment]. Indication: [Culprit / staged / physiology-guided]. Pre-PCI: [Percent stenosis, TIMI flow]. Devices: [Balloon and stent type/dimensions; deployment pressures]. Post-PCI: [Percent residual stenosis, TIMI flow]. Adjuncts: [Thrombectomy, imaging, vasodilators / None]. Result: [Angiographic outcome].

(Repeat bullet for each treated lesion.)

Complications

[No immediate procedural complications. / Complication description with timing, objective details, actions taken, and patient status at case conclusion]

Post-Procedure Status

Condition: [Stable / Hemodynamically unstable / Intubated / On vasopressor support]

Access site: [Hemostasis status, device in place if applicable, distal pulses/perfusion, hematoma assessment]

Disposition: [Recovery unit / Floor / ICU], [Responsible service]. Orders: [Bed rest duration, compression device protocol, lab checks, hydration plan, antiplatelet/anticoagulation plan]

Impression and Recommendations

Impression:

• [Overall CAD assessment: no CAD / non-obstructive CAD / obstructive 1-vessel / 2-vessel / 3-vessel CAD / left main involvement]
• [Culprit lesion identification if applicable]
• [LV function summary if assessed]
• [LVEDP or hemodynamic summary if measured]
• [Intervention summary and result if performed]
• [Complications: none / summarized]

Recommendations:

• [Revascularization plan: optimized medical therapy / staged PCI / CABG referral / Heart Team discussion]
• [Medical therapy optimization: antiplatelet regimen and duration, statin, beta-blocker, ACE inhibitor/ARB]
• [Renal protection and creatinine monitoring if contrast nephropathy risk]
• [Access site care and activity restrictions]
• [Communication completed: patient/family discussion, referring physician notification]
• [Follow-up: clinic visit timing, additional testing if indicated]