# EP question



## Jess1125 (May 28, 2014)

Any idea on what code to use for non-invasive programmed stimulation portion of this procedure?

PROCEDURES PERFORMED:
1.  Noninvasive programmed stimulation (NIPS).
2.  Removal of a pacemaker generator.
3.  Placement of ICD lead and dual-chamber ICD generator.

PREOPERATIVE DIAGNOSES:
1.  Ventricular tachycardia.
2.  History of CABG and aortic valve replacement.
3.  High degree AV block, status post dual-chamber pacemaker.


POSTOPERATIVE DIAGNOSES:
1.  Ventricular tachycardia.
2.  History of CABG and aortic valve replacement.
3.  High degree AV block, status post dual-chamber pacemaker.


ANESTHESIA:  Local Lidocaine and moderate sedation with intravenous Versed and Fentanyl.


SPECIMENS:  Pacemaker pulse generator.


COMPLICATIONS:  None.


ESTIMATED BLOOD LOSS:  Minimal.


INDICATIONS FOR SURGERY:  The patient is a 74-year-old man with a history of bypass surgery as well as mechanical aortic valve replacement.  He had postoperative high degree AV block and has a permanent pacemaker in place.  He generally paces in the ventricle.  The patient has been noted on multiple pacemaker checks to have episodes of high ventricular rates with AV dissociation, concerning for ventricular tachycardia given his AV block.  He is referred for EP study and possible device upgrade.


DESCRIPTION OF PROCEDURE:  The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient, and he provided informed written consent.  The patient brought to the electrophysiology laboratory.  His device was interrogated.


His pacemaker showed multiple recent episodes of high ventricular rates with AV dissociation concerning for ventricular tachycardia.  He was also noted to have underlying sinus rhythm with AV Wenckebach, but generally intact AV conduction.


Noninvasive programmed stimulation was then performed.  The patient was administered sedation.  Ventricular extrastimulus testing at 600 and then 400 milliseconds pacing cycle length was performed through his pacemaker.  Single, double, and triple ventricular extrastimuli were delivered to the ventricular effective refractory period.  


With the 600 drive train, no inducible ventricular arrhythmias were seen with single, double, or triple ventricular extrastimuli.  This was then repeated with a 400 millisecond drive train.  At 400/240/200/200, the patient was inducible for a sustained monomorphic ventricular tachycardia.  The cycle length was 220 milliseconds.  It was of a right bundle, right inferior axis with a positive R-wave across the precordium.  The patient was having near loss of consciousness and an external rescue shock was delivered.  This led to change in the morphology to a right bundle, right inferior axis with an R-wave transition at V4, V5, and a cycle length of approximately 330 milliseconds.  A second shock then restored the patient's sinus tachycardia with intermittent ventricular pacing.


Given the patient's structural heart disease status post mechanical AVR, ventricular high rate episodes concerning for ventricular tachycardia in the setting of high degree AV block, and inducible monomorphic ventricular tachycardia, the device was then upgraded to an ICD.


The patient was fully reprepped for the device procedure.  Left upper extremity venography confirmed a patent left subclavian system.


Lidocaine 2% was used to anesthetize the left pectoral region.  Using a scalpel, a 4 cm incision was made over the left deltopectoral groove.  Using blunt dissection and brief bursts of electrocautery, the pocket was opened and the device and leads were freed from their adhesions.


Left subclavian venous access was then obtained with an introducer needle and wires were placed under fluoroscopic guidance.  A 9-French sheath was placed.  The RV ICD lead was then delivered to the RV apical septum under fluoroscopic guidance.  There was ample separation between the lead tip and the pacemaker lead.  The active fixation mechanism was deployed.  Appropriate sensing, threshold, and impedance values were obtained.  The sheath was split and removed.  The lead was secured to the underlying tissue with 0 silk x2.


The pacemaker pulse generator was then removed from the leads and removed from the field.  The RV lead was then capped and the cap secured with 0 silk x2.  The atrial lead was tested and found to have appropriate sensing, threshold, and impedance values.


Hemostasis was ensured in the pocket with further electrocautery.  The pocket was irrigated with copious Bacitracin and saline solution.  The ICD pulse generator was connected to the leads with the appropriate torque wrench.  The device and lead assembly were then placed in the cleaned pocket.  The RV pacing lead was buried under the device.  The pulse generator was secured to the underlying tissue with 0 silk x1.


The pocket was closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material.  Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.


The patient tolerated procedure well, and was transferred to a monitored bed in stable condition.


IMPLANTED HARDWARE:  The pulse generator is a Medtronic DDBB1D4, serial number BWB211294 H.  The RA lead is a Medtronic 4076, serial BBL862424 V from 12/11/12.  The RV lead is a Medtronic 6935M, serial number TDL001267 V.  The capped RV lead is a Medtronic 4092, serial number LEP477337 V from 12/11/12.


LEAD PARAMETERS:  The RA lead senses 2.1 millivolts, threshold 0.5 volts at 0.4 milliseconds, impedance 361 ohms.  RV lead senses 8.0 millivolts, threshold 0.75 volts at 0.4 milliseconds, impedance 475 ohms, shock impedance 81 ohms.  


DFT was deferred given the patient's mechanical valve off anticoagulation and need for shocks already today.


The device was programmed AAI-DDD 60-130, VF zone of 188 with max shocks, VT monitor zone at 150.


The explanted hardware was a Medtronic ADDR01 Adapta, serial number NWB219787 H from 12/11/12.


We will attempt to continue ongoing MVP mode pacing to minimize the right ventricular pacing burden.  This may also have some impact on his VT burden.  We will also be investigating med changes.  As he had not had frank syncope, antiarrhythmics will not be started at this point.

Provider says it isn't 93724-26 as he wasn't assessing an anti-tachycardia pacing system and pacemaker didn't have capability to do this.

Provider was thinking 93624-26 as essentially they were testing the efficacy of his meds in preventing ventricular tachycardia. 

Jessica CPC, CCC


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## Jennarw (May 28, 2014)

93642-26 is right for the NIPS


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## Jess1125 (May 28, 2014)

Thanks! Sounded good to me, too.

Jessica CPC, CCC


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