Tips on Transcribing Cardiac Surgery and Related Cardiology
by Kathleen Mors Woods
1989, 2007
In literature and in life, the heart is always depicted as the soul of a person and is described in vivid terms. One may be called a heartbreaker, a heart throb, a sweetheart, may be heartless, heartsick, broken‑hearted, fainthearted, good‑hearted, lighthearted, lionhearted, or have a big heart, a cold heart, a hard heart, or a heart as good as gold.
In the medical field, we are concerned with cardiology as the study of the heart, its functions, and its diseases, the identification of these diseases by diagnostic tests, and ultimately the correction of defects. When a newborn baby is diagnosed with a congenital heart defect, or a 16‑year‑old is stabbed in the chest, or a person’s aorta is literally ripped out of the chest in an automobile accident (by not wearing a seat belt and hitting the steering wheel), the cardiac surgeon is called upon to demonstrate a broad range of abilities in treating these patients. Transcribing reports on these procedures carries with it the excitement of a new technology, expanding every day through research and commitment to lifesaving techniques.
The various techniques cover pacemaker insertion for irregular rhythm, the automatic implantable defibrillator for sudden death, coronary artery bypass grafting for coronary (vessel) blockage, valve replacement and repair with either mechanical parts or real preserved harvested parts, to the ultimate procedure for end‑stage disease—heart and heart‑lung transplantation.
Cardiac Evaluation
Let’s start by imagining the following scenario: Your neighbor has chest pain and goes to a cardiologist. The other causes of chest pain (for example, kidney stones or ulcers) have been ruled out. At the cardiologist’s office, an electrocardiogram is performed. Twelve leads are attached, six at the wrists and ankles (leads I, II, III, aVF, aVL, aVR), and six on the chest (V1 through V6).
If the patient’s pain is being caused by the decrease in blood flow due to a narrowing or obstruction of an artery carrying oxygen to the heart, and if damage has been done or is occurring, this will show up on the EKG. The pain, then, is caused by an obstruction (clot) in the vessel. If this clot remains in the vessel, the vessel is damaged and the muscle of the heart (myocardium) is damaged, for the area the vessel feeds dies.
If the patient is “evolving the infarction” (having a heart attack) and admitted to a hospital in a timely fashion, several other tests are performed, including a CPK (creatine phosphokinase) curve as a measure of the infarct. CK‑MB bands are located only in the heart muscle, and blood serum levels will rise if heart cells are damaged during an infarction (but not during angina). Similarly, elevations of troponin I or troponin T are diagnostic of a myocardial infarction. Several thrombolytic or fibrinolytic therapies have been developed which either dissolve the clot within the vessel or work with the body’s own clotting factors to dissolve it. These include tissue plasminogen activator (tPA), streptokinase, and urokinase.
Another option is for the patient to have a treadmill exercise stress test and to be referred for a cardiac catheterization.
Catheterization. Cardiac catheterization was invented in 1929 by a physician named Werner Forssmann, who first tested the procedure by catheterizing his own heart. Over the years it has progressed from a simple investigative technique to a powerful diagnostic and therapeutic procedure.
The patient is premedicated and taken to the catheterization laboratory. A puncture is made in the groin and a catheter is fed up into the heart. If the blood supply to the legs is poor, the catheter is inserted through a brachial cutdown in the arm, a small incision in the upper part of the arm which is later sutured closed. In some cases, the catheter may be threaded through the radial artery beginning at the wrist. The catheter is properly positioned and radiopaque dye injected. While the dye is being injected and coursing through the vessels, it is recorded digitally and shows where the blockages are in the coronary arteries, how the valves and heart muscle are functioning, and different pressures in these arteries. This film is called a cineangiogram (like cinema), or cine (“sin‑ee”) for short.
Although the catheterization is quite straightforward, the terminology is technical and specialized. Terms such as aortic gradient, LVEDP, pigtail catheter, PCWP, assumed Fick method, and ejection fraction might seem quite alien. Your reference sources should include a personal word list and equipment list.
Catheters are referred to by size and name. A 7 French JL4 catheter is translated 7 French Judkins left 4 cm curve catheter. The word French refers to the French scale for sizing catheters and is often abbreviated F; thus, 7F means 7 French. The catheters are named for shape, size, inventor, manufacturer, or have a trade name.
Angioplasty. When your neighbor’s cardiac evaluation is completed, she may be told she has blockage of only one coronary artery. One of her options at this point is to have a PTCA (percutaneous transluminal coronary angioplasty). This procedure is often done immediately following the injection of a drug such as streptokinase or urokinase to lyse (break up) the clot. It can, however, be scheduled electively.
A catheter with a tiny balloon on the tip (4 or 5 mm) is placed at the site of the narrowing of the artery and the balloon is inflated by means of a hand pump, to compress or squeeze the plaque back against the artery wall and open the blood flow through the vessel.
The advantage of this procedure is that it does not involve open heart surgery. The disadvantage is that this narrowing can recur, especially in those carrying inherited (familial) diseases. For these patients, stents may be placed, some of which are coated with special substances to prevent the development of clots. An angioplasty must be done in a hospital setting that provides surgery. When an artery dissects (tears open), the patient is taken to surgery for repair of the artery.
Terminology
The cardiology transcriptionist should know the names of the coronary arteries and branches which are frequently mentioned in cardiac catheterization reports, coronary artery bypass grafting, and all the tests and procedures regarding the heart.
The major vessels are the left main coronary artery, the left anterior descending (LAD) coronary artery, the right coronary artery (RCA), and the circumflex coronary artery (sometimes referred to as the circ, pronounced “serk”). There are branches of these that take on additions, such as the left anterior descending diagonal (LADD). Other vessels to remember are the circumflex marginal, distal branches, and the posterior descendings. The major conduits are the aorta and pulmonary artery. The valves are aortic, mitral, pulmonary, and tricuspid.
Abbreviations. Although abbreviations are frequently dictated, the transcriptionist should exercise discretion when transcribing abbreviations in medical reports. When you are required to type abbreviations, use only those abbreviations that will not be misinterpreted; if you drop one letter of an abbreviation, you change the medical meaning and location. The posterior descending artery is abbreviated PDA, which also stands for the congenital heart defect of patent ductus arteriosus. When you translate abbreviations, be sure to transcribe the correct meaning as indicated by the context of the report.
A patient with multiple occlusions may opt for open heart surgery, or coronary artery bypass graft (CABG, pronounced cabbage). Open heart procedures occur in two ways—opening the chest down the middle (median sternotomy), or, less usual, spreading the ribs and entering through this area (thoracotomy). Bypasses are named for the number of vessels reconnected—single, double, triple, quadruple, etc.
In interpreting the dictation, the transcriptionist must become familiar with many abbreviations and eponyms. If a baby has a B‑T shunt, it is the procedure named after the famous Blalock-Taussig blue baby operation first performed by those two physicians. Favalaro, Bovie, St. Jude, Carpentier‑Edwards, and Bjork-Shiley are all proper names (eponyms). If an eponym is the name of one person (Johns Hopkins, Austin Flint), it is not hyphenated, and one must learn which compound terms are which.
Pediatric surgery. Pediatric surgery is exciting and ever changing. Congenital heart defects, often discovered at birth, are both open and closed heart procedures. These include PDA (patent ductus arteriosus), coarc (coarctation of the aorta), VSD (ventricular septal defect), ASD (atrial septal defect), AV (arteriovenous) canal, and “tet baby” which refers to a tetralogy of Fallot repair.
In instructing new transcriptionists, I tell them when I encounter a new word in dictation and cannot verify its correct spelling, my personal preference is to attach a note to the report with a phonetic spelling of the word in question. I have found that the sounds like note makes it easier to later identify the correct word and fill in the blank spot in the dictation, without having to listen to half the tape to find the questionable dictation spot. For example, dismorfick easily turns into dysmorphic, frenic to phrenic.
Occasionally we do not realize that we are not hearing a word correctly. I remember when a certain new medical transcriptionist transcribed patent foraminal valley in a cardiac catheterization report. After much kidding, she was told about the defect of patent foramen ovale (PFO). We all have our favorite stories about transcribing the first time, but can you guess who gave the patient a foraminal valley instead of foramen ovale? Well, it was me, and I'll never misspell that term again.
Medications. Other nonsurgical problems include both diseases and malfunctions. Diseases can be treated by diet and medications. The medications listed are innumerable. I like to describe the method of typing these as though they were green beans. A green bean is a green bean, right? But there are different brand names for green beans, e.g., Del Monte and Libby. The generic name (green bean) is not capitalized; however, the trade/brand name is. Therefore, nitroglycerin is not capitalized, but Nitro‑Dur is.
It is also important to recognize when a physician is dictating a category of drugs. For example, if a patient is placed on nitrate therapy or antagonists, those are drug categories, not drugs, and will therefore not be listed in a drug reference.
A minor confusing problem for transcriptionists is references to digoxin in dictation. Patients with congestive heart failure are commonly given digoxin (Lanoxin) which comes in two doses, 0.25 mg and 0.125 mg. (Note: Always place the zero before the decimal point.) Digitalis is the powdered leaf of the digitalis plant or foxglove, which is seldom used. Refined forms include digoxin (Lanoxin) and digitoxin (Crystodigin). If a physician says the patient had a laboratory “didj level” drawn, you can assume that this slang means “digoxin level” rather than digitoxin. Digitoxin is used infrequently but can be helpful in patients with kidney failure. Digoxin is excreted unchanged by the kidneys and can build up to toxic levels if the kidneys are not functioning well. Digitoxin, however, is metabolized to an inactive form by the liver first so that it is a much safer choice for patients with kidney failure. For the majority of patients in congestive heart failure, however, digoxin is prescribed.
Another confusing term is pro time which stands for prothrombin time (PT). This is a measure of the blood-thinning effect of coumadin. Because the test result is adjusted according to a standard computed for each batch of reagent, the result may be called the international normalized ratio (INR). Unusual units of measure include torr (pressure), joule (electric power), and met (metabolic unit, used in treadmill scoring).
Pacemakers. Other areas in which proper names are used are in treadmill protocols (Bruce, Naughton) and pacemakers, which are identified by company and product names, e.g., Medtronic, Pacesetter. The pacemaker is usually inserted in the cardiac catheterization laboratory but may also be inserted in a room set up to do electrophysiology studies.
Pacemakers are identified by a three‑letter code system, such as DDD or VVI, which need not be translated. The first letter indicates the chamber that is paced; the second letter denotes the chamber that is sensed; the third letter indicates whether the pacemaker is inhibited or triggered by the heart’s own electrical activity. For example, a DDD pacemaker serves the electrical activity of both the atrium and ventricle, paces (stimulates) both the atrium and ventricle to beat, and may cause (trigger) the atrium to contract while sending no signal (inhibited) to the ventricle, depending on what natural electrical activity is occurring in the heart at that time.
Of course, as soon as you have most of the common words down, you could be introduced to the exciting field of the AICD (automatic implantable cardioverter defibrillator). The AICD is used for patients who are candidates for what we call sudden death, which is just what it sounds like—boom, your heart stops.
In an AICD operation, a patch is placed on the heart and sewn on, with leads extending to a box (in the stomach area) which, like some types of pacemakers, can monitor the rhythm of the heart. When there is an arrhythmia (irregular rhythm), the generator box senses this, fires a jolt to the heart, and starts it back up again.