# Complete EP study and Venogram



## MandyFlagg (Mar 19, 2012)

Could someone please help me....... This was coded 93620, 93621, 93613, 93662, 75820-26, 36005-59, & 93651.....I know it is long and I know some codes are not right I am just looking for a second opinion. 
Thanks....

     PROCEDURE PERFORMED:  Electrophysiology study.

     HISTORY:  The patient is a 60-year-old female with past medical
     history of obstructive sleep apnea, hypertension,
     persistent/permanent atrial fibrillation and diabetes mellitus.
     We have tried a variety of rhythm control treatment options
     including p.o. amiodarone as the patient has had difficulties
     with increasing shortness of breath since the prevalence of her
     atrial fibrillation has increased.  She underwent cardioversion
     with early recurrence of atrial fibrillation, was not able to
     maintain sinus rhythm more than one minute.  Despite multiple
     rhythm control attempts and continued symptomatic atrial
     fibrillation, the patient has made the decision to move forward
     with a catheter based ablative procedure.  Prior to the
     procedure, the patient was bridged off her Pradaxa with Lovenox.
     She underwent a transesophageal echocardiogram yesterday,
     demonstrating left atrial enlargement but no evidence of a left
     atrial appendage thrombus.

     PROCEDURE DETAILS:  Following informed consent, the patient was
     brought to the EP lab in the fasting post-absorptive state.
     Anesthesia was provided via the anesthesia service.  Using the
     standard sterile technique, both groins were prepped and draped
     in the usual fashion.  Using 1% lidocaine for local anesthesia,
     access into the right and left femoral veins were performed
     utilizing the modified Seldinger technique and the micropuncture
     kit.  Wires were confirmed in the inferior vena cava.  Over these
     wires, two 8-French short sheaths and one 7-French short sheath
     were placed in the right femoral vein and one 9-French sheath was
     placed in the left femoral vein.  All sheaths were flushed with
     heparinized saline.  Through the French sheath in the left
     femoral vein, an Acuson 8-1/2 French catheter was maneuvered into
     the area of the right atrial appendage for visualization of the
     fossa ovalis.  A CS EZ Steer FJ curve CS catheter was maneuvered
     through the 7-French sheath into the coronary sinus.  The two
     8-French short sheaths were then exchanged out for SL0 long
     sheaths and we were able to cross into the left atrium with the
     wire.  Right atrial pressure was then recorded at 12/3.  We then
     visualized fossa ovalis with the ultrasound catheter.  We
     advanced the dilator and sheath over the wire into the subclavian
     system and in a standard LAO pull down, we were able to easily
     cross into the left atrium  The wire was advanced the sheath over
     the dilator and wire into the left atrium.  Three stable blood
     pressures were seen and half the initial heparin bolus was given.
      We then used a FF curve ThermoCool catheters through the second
     SL0 sheath and again were easily able to cross in an LAO
     traditional transseptal pull down into the left atrium.  The
     remaining heparin bolus was given.  An OmniFlush catheter was
     then utilized to do pulmonary venogram on the left superior and
     right superior pulmonary veins.  An esophogram was then done with
     barium swallow, showing the esophagus located primarily over the
     right posterior veins.  Using the _____ mapping and the CARTO 3
     mapping system, we were able to create the geometry of the left
     atrium.  We did perform CARTO merge with the CT scan, which was
     performed.  The patient's anatomy was somewhat different in that
     she had several small right-sided veins and a large right-sided
     antrum.  There were two inferior veins which were smaller than 10
     mm, the right superior vein came off at an acute angle.  The left
     side had a common antra  of a large left superior vein and the
     inferior vein was also quite small.  The left atrium was clearly
     enlarged.  Antral circles were then performed using power and
     temperature limits of 30 watts in the anterior wall, 25 in the
     posterior wall.  Great care was taken not to ablate within the
     coronary ostia.  With antral circles, pulmonary vein isolation of
     the left superior and inferior veins were performed.  The
     patient's ablation was done during atrial fibrillation.  Then
     went to the right side.  The right superior vein after following
     an antral circle which could not be completed fully in the
     posterior wall due to the esophagus.  We did have clear isolation
     of the right superior vein.  In the ablation around the right
     superior vein in the anterior and superior portion, we did paste
     for phrenic nerve capture prior to ablation.  Any ablation done
     in the posterior wall was done for less than 10 seconds and we
     did not ablate in any area that we thought fluoroscopically was
     within 0.5-1 centimeters of the esophagus.  We then created a
     roof line adjoining the antral circles and then ablated, creating
     a mitral isthmus line with power limits of 35 watts.  We then
     cardioverted the patient to normal sinus rhythm.  Previously, she
     had not been able to maintain sinus rhythm, we were able at this
     time to maintain sinus rhythm, confirmed bidirectional block with
     pacing from both the coronary sinus as well as left atrial
     appendage.  Roof block could not be confirmed.  Additional
     ablation was done across the roof line, but we could not get a
     block across the roof line.  The right superior, left inferior
     and left superior veins all were confirmed to have isolation at
     the end of the case.  The electrophysiology catheters were then
     removed into the right atrium.  Baseline numbers showed the
     patient in sinus rhythm, pacing from the RV apex demonstrated no
     VA conduction at baseline.  The PR interval was 190, HV interval
     of 110, HV of 46, QRS of 120, QT of 390.  Sinus cycle length of
     720.  AV Wenckebach cycle length was 470 and AV nodal ERP was
     600/360.  The SL0 sheaths were then exchanged out for two
     9-French short sheaths.  All sheaths were flushed with
     heparinized saline and all were secured in place with 0 silk.  At
     conclusion of the study, the Acuson catheter was maneuvered into
     the RV.  There was a small pericardial fat pad which remained
     unchanged.  There is a trace pericardial effusion which remained
     unchanged from the beginning of the case.  This was documented.
     Closing blood pressure was 137/76 with a heart rate of 82.


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