# Upgrade to Biventricular ICD



## OPENSHAW (Mar 25, 2014)

INDICATION:
This patient has a history of complete heart block requiring a pacemaker about 18 months ago. Since then he has suffered a Type III aortic dissection which was repaired with a stent. In the succeeding months he has developed atrial fibrillation and progressive deterioration in LV function which has not responded to medical therapy while on a Life Vest. 

He is being admitted for an upgrade to a Biventricular ICD.

PROCEDURE: 
Subclavian venogram.
Implantation of RV pace/shock lead and CS lead for Bi V pacing.
Implantation of a new PG.
Removal of old pacemaker PG.
Capping of functional RV pacing lead.
DFT testing at implant.

NARRATIVE:
Following premedication with IV and PO antibiotics, the patient was taken to the laboratory and the left pectoral area prepared and draped.40 cc's of 1% lidocaine were infiltrated and a 4 cm incision was made along the strap line beginning at the junction of the mid and lateral third of the clavicle. Dissection was carried down to the pectoralis fascia and bleeding was controlled with cautery. A pocket of sufficient size to contain the pulse generator and leads was developed with blunt and sharp dissection. The patient was then placed in the Trendelenberg position and an 18G thin walled needle was inserted into the subclavian vein which had been previously identified and found suitable for implant with the injection of 20cc's of iodinated contrast. A J-wire was passed to the right atrium. A double wire technique was used to insert the second wire using a 7F sheath. A 9F peel-away valved sheath was inserted over the short J guide wire. A bipolar positive fixation pace/shock lead was inserted and with the use of curved and straight stylets was positioned in the RV where good sensing and pacing parameters were obtained and no abnormal stimulation was noted at a maximum output of 10 volts. The second wire was used to insert a second 9 F valved peel-away sheath. A CS sheath inside of which was a short AL2 catheter was advanced tor the low RA over the long wire. The CS was located and a Wholey wire was passed to the anterior cardiac vein allowing advancement of the AL2 an the CS sheath. Following removal of the AL2 and wire, a bipolar CS lead was advanced over a whisper wire. We were unable to engage a lateral vein which had been previously outlined with a CS injection of half-strength contrast. We removed the lead and wire and inserted an inner cannula with a 90 degree curver at the tip. We were able to engage the lateral branch and passed the wire and lead distally into the vein where good pacing parameters were obtained and no abnormal stimulation was noted at the maximum output of 10V. During the process of removing the sheaths, the RV lead was dislodged requiring it to be re positioned and fixed to the distal RV septum with good parameters. There was some increase in the slack of the CS lead noted during this procedure which was corrected with gentle traction. The leads were then firmly attached to the pectoralis fascia with 0 silk and the pocked was flushed with antibiotic solution. The pacemaker PG was disconnected and the RV lead capped. We attached the RA lead to the new PG. After firmly attaching the leads to the pulse generator, the pulse generator and leads were carefully placed in the pocket. Following a final flouroscopic check, the wound was closed with interrupted 2.0 Vicryl, continuous 2.0 Vicryl, and stainless steel staples.
The patient was then given deep sedation with 9mg of IV etomidate. Ventricular fibrillation was induced with a T shock. It was promptly sensed without dropout and converted with 20J. The patient was converted to NSR. Chest wall stimulation was noted post cardioversion, but fluoroscopy showed no change in lead position. This was corrected by changing the output and pacing vector. A sterile dressing was applied. The patient was allowed to regain consciousness and was taken to the recovery area.

EP DATA:

Right Atrium    Bipolar  Threshold (AF) Impedance@5V: 361Ohms             P wave: 2.0mV
Right Ventricle: Bipolar Threshold @ PW 0.4ms: 0,5V Impedance @5V: 665 Ohms            R wave: 3.0mV
High Energy Impedance: 54 Ohms delivering 20J via an B>AX pathway

IMPLANTED DATA:
Pulse Generator: Medtronic   Model no: Serial no: Date of implant: 3/24/2014
Atrial Lead: Medtronic  Model no: Serial no:  Date of implant: 8/10/2012
LV lead: Location: CS  Medtronic Model no: Date of Implant: 03/24/2014    RV Lead Serial no: Medtronic Model no:Serial no: Date of implant: 3/24/2014
RV pacing lead (capped usable): Medtronic Model no: Serial no: Date of implant: 3/24/2014

COMPLICATIONS: None

SPECIMEN: 
Old Pacemaker PG Model no: Serial no: Date of implant: 8/10/2012
ESTIMATED BLOOD LOSS: <25cc.

FLOUROSCOPIC DOSE: Please see lab protocol.

Would this be coded as:
33228, 33225, and 93641
Please help!!!!!


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## Jim Pawloski (Mar 26, 2014)

OPENSHAW said:


> INDICATION:
> This patient has a history of complete heart block requiring a pacemaker about 18 months ago. Since then he has suffered a Type III aortic dissection which was repaired with a stent. In the succeeding months he has developed atrial fibrillation and progressive deterioration in LV function which has not responded to medical therapy while on a Life Vest.
> 
> He is being admitted for an upgrade to a Biventricular ICD.
> ...



AS the old song goes, two out of three ain't bad.  You need 33249, 33223 to 33225 and 93641.


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