Percutaneous Coronary Intervention (PCI) Procedure Report

Patient: [Patient name] | MRN: [Medical record number] | DOB: [Date of birth]

Encounter: [CSN/FIN]

Procedure Date/Time: [Procedure date] [Start time–End time]

Location: [Facility]; Cath Lab Room [Room number]

Primary Operator: [Interventional cardiologist name] (If unknown, enter "Unknown")

Assistant(s)/Fellow(s): [Names and roles] (If unknown, enter "Unknown")

Sedation Provider: [Name] (Include if separate from primary team; if unknown, enter "Unknown")

Referring Clinician: [Name and service] (If unknown, enter "Unknown")

Procedure(s): [List all procedures performed]

Procedure Summary

• Post-procedure diagnosis: [Diagnosis]
• Procedures performed: [Target vessel(s) and lesion(s) treated]
• Access: [Site(s) and laterality] — [Sheath size(s)] — [Hemostasis/closure method]
• Lesion result(s): [Pre→post stenosis %; pre→post TIMI flow] (If values not yet documented, state "Pending final report")
• Complications: [Complications and management] (State "None" if none occurred)
• Antithrombotics in lab: [Medications administered]
• Estimated blood loss: [Volume]
• Disposition: [ICU/CCU / telemetry / observation / same-day discharge]

Indication and Clinical Context

Indication: [STEMI / NSTEMI / unstable angina / stable ischemic heart disease with documented ischemia / cardiogenic shock / high-risk anatomy / other]

Procedural priority: [elective / urgent / emergent / salvage]

ACS timing: [Symptom onset time] | [First medical contact time] | [Door time] | [Wire time] (Include only times available; omit line if not ACS)

Procedure context: [Ad hoc PCI / staged PCI with prior angiography date / culprit-only intervention / complete revascularization]

Culprit determination: [Basis: ECG territory / angiographic appearance / intravascular imaging / other] (Include for ACS cases)

Pre-Procedure Verification

• Consent: [Informed consent obtained / emergency exception applied with rationale]
• Allergies reviewed: [Relevant allergies: contrast, latex, antiplatelets, other]
• Time-out: [Performed, confirming correct patient, procedure, site, and anticoagulation plan]
• Pre-procedure labs: [Creatinine, hemoglobin, platelets, INR] (Include only if they informed decisions)

Vascular Access and Hemostasis

• Access site(s): [Right/Left radial / Right/Left femoral / other] — [Sheath size(s)] — [Sheath exchanges if performed]
• Ultrasound guidance: [used / not used]
• Hemostasis: [Radial: band type and application time / Femoral: closure device type and deployment success / Manual compression]
• Access complications: [Hematoma / spasm / dissection / diminished pulse / other] (State "No access complications" if none)

Sedation and Monitoring

• Sedation type: [moderate sedation / MAC / general anesthesia]
• Sedation/analgesia: [Medications and doses] (Or state "See anesthesia record")
• Intra-procedural events: [Hemodynamic instability requiring vasopressors / temporary pacing / cardioversion / mechanical support initiation] (Omit if none)

Antithrombotic Therapy (In-Lab)

• Anticoagulation: [Heparin total dose, ACT values and times / Bivalirudin bolus and infusion with stop time / other] (If ACT not recorded, state "ACT not documented")
• Antiplatelet loading: [Aspirin dose] | [P2Y12 inhibitor: agent, dose, administration time]
• GP IIb/IIIa inhibitor: [Agent, bolus/infusion details, planned duration] (Include if used)
• Intracoronary medications: [Nitroglycerin / adenosine / verapamil / other] — [Indication] (Include if used)
• Adjunctive devices: [Aspiration thrombectomy / distal protection device / intracoronary thrombolytic] (Include if used)

Coronary Angiography Findings

(Include when diagnostic angiography performed same session; otherwise state "Per prior angiography [date]")

• Dominance: [right / left / co-dominant]
• Left main: [Findings or normal]
• LAD/diagonals: [Disease by segment/branches]
• LCx/obtuse marginals: [Disease by segment/branches]
• RCA/PDA/PLV: [Disease by segment/branches]
• Culprit lesion: [Vessel/segment] — [Baseline TIMI flow] (Include for ACS)
• Left ventriculography: [EF estimate] — [Wall motion summary] (Include if performed)
• Right heart catheterization: [Key hemodynamic measurements] (Include if performed)

PCI Procedure Details

Strategy Overview

[Brief narrative (2–4 sentences): rationale for device selection, imaging guidance strategy, bifurcation technique, CTO approach, hemodynamic support rationale, reason for deferring non-culprit lesions if staged]

Lesion Interventions

(Create one block per lesion where intervention was attempted)

Lesion [number]: [Vessel and segment]

Baseline: [De novo / ISR / stent thrombosis] — [Native / graft] — [Bifurcation: yes/no with Medina classification if applicable] — [Diameter stenosis % by visual/QCA] — [TIMI flow] — [Lesion length] — [Reference vessel diameter] — [Morphology: calcification severity, thrombus, tortuosity, ostial, CTO features] (State "Not documented" for unavailable values)

Equipment: [Guide catheter type/size] — [Guidewire(s) with escalation sequence] — [Microcatheter/guide extension if used]

Lesion Preparation: [Predilation: balloon type, dimensions, pressure] — [Atherectomy: rotational/orbital/laser/IVL with parameters] — [Thrombectomy] (Include items as applicable)

Stent Deployment: [For each stent: type, dimensions, deployment pressure, post-dilation status] — [Overlap strategy if multiple stents]

Optimization: [Post-dilation: balloon dimensions, max pressure] — [IVUS/OCT: sizing, expansion, apposition, edge assessment] — [FFR/iFR: pre/post values, interpretation] (Include items as applicable)

Result: [Residual stenosis %] — [Post-intervention TIMI flow] — [Complications: None / dissection, perforation, abrupt closure with severity and management] — [Side branch: patent / compromised / occluded with treatment] — [Final impression: Successful PCI / Partial success / Unsuccessful with specification] (State "Not documented" for unavailable values)

If unsuccessful/aborted: [Point of failure] — [Suspected cause] — [Safety reason if applicable] — [Plan: staged attempt / surgical referral / medical therapy / alternative approach]

Procedure Metrics

• Contrast: [Agent type] — [Total volume in mL]
• Radiation: [Reference air kerma (Ka,r) in mGy / Kerma-area product (KAP/DAP) in mGy·cm² or Gy·cm² / Peak skin dose in mGy] — [Fluoroscopy time in minutes] — [Number of images] (Always specify which radiation metric is reported)
• Total procedure time: [Duration]
• Mechanical support: [IABP / Impella / ECMO / other] — [Duration] (Include if used)

Complications

Complications: [None / List each: timing (intra-procedure vs immediate post-procedure), description, severity, management] (Categories: coronary dissection/perforation/abrupt closure/no-reflow/distal embolization, arrhythmia, hemodynamic collapse, access site bleeding/hematoma, contrast reaction, neurologic event)

Post-Procedure Status and Disposition

• Clinical status: [Hemodynamically stable / description of instability]
• Disposition: [ICU/CCU / telemetry / observation / same-day discharge]
• Access site care: [Radial band protocol / Femoral bedrest duration] — [Neurovascular check frequency]
• Monitoring: [Labs: CBC, creatinine, troponin per protocol] — [Telemetry duration]
• Renal protection: [IV fluid plan] — [Nephrotoxin avoidance] — [Follow-up creatinine timing] (Include if applicable)

Post-PCI Antithrombotic Plan

• Aspirin: [Dose] — [Duration]
• P2Y12 inhibitor: [Agent] — [Dose] — [Duration] (Include rationale if deviating from standard)
• Anticoagulation: [Indication] — [Dual vs triple therapy] — [Duration of combination] — [Gastroprotection] (Include if applicable)
• GP IIb/IIIa continuation: [Duration and stop criteria] (Include if infusion ongoing)
• Next dose timing: [When antiplatelet doses due]
• Holding parameters: [Planned procedures / thrombocytopenia / bleeding precautions] (Include if applicable)

(If DAPT duration undetermined, document minimum duration with reassessment trigger)

Follow-Up Plan

• [High-intensity statin: initiation or continuation]
• [Cardiac medications: beta blocker, ACEi/ARB, MRA, SGLT2 inhibitor as indicated]
• [Smoking cessation: counseling or referral]
• [Cardiac rehabilitation referral]
• [Interventional cardiology follow-up: timeframe]
• [General cardiology follow-up: timeframe]
• [Echocardiogram: timing if indicated]
• [Stress testing: plan if incomplete revascularization]
• [Staged PCI: target lesion(s) and timing] / [Surgical referral: Heart Team discussion plan]

Signature

[Electronic signature] — [Date and time]

(If device details or results pending, note addendum will follow with specification of elements to be updated)