# Dual Pacemaker upgraded to Bi-V



## sslater (Nov 22, 2013)

I am needing help coding this upgrade from a Dual pacer to a Bi-ventricular ICD.  I've read this Op Note 3 times now and I'm very confused with these codes.  Thank you. 


OPERATIVE PROCEDURE:
*Placement of a left ventricular lead via the coronary sinus,
right ventricular pacemaker lead revision with capping of the RV
(right ventricular) lead, placement of a new right ventricular
pacemaker/ICD (implantable cardioverter-defibrillator) lead,
upgrade of a dual chamber pacemaker device to a biventricular ICD
(implantable cardioverter-defibrillator) generator*.

INDICATION:  Severe ischemic cardiomyopathy, left bundle branch
block with QRS duration greater than 150 milliseconds.  New York
Heart Association Class 3 heart failure.

PROCEDURE IN DETAIL:  The patient was brought to the cath lab in
normal fasting state.  This procedure was performed in the cath
lab using fluoroscopic guidance.  The patient's vital signs were
all monitored throughout the duration of the procedure including
his blood pressure, heart rate, heart rhythm, pulse oxygen
saturation, respirations.  The patient was prepped and draped in
normal sterile fashion and a time out was performed.  Local
anesthetic was administered in the left infraclavicular area over
the pacemaker generator using 2% Lidocaine.  A skin incision was
made using a #15 scalpel blade.  Blunt dissection down to the
pacemaker generator was performed with the assistance of the
Bovie electrocautery.  The pacemaker was removed from the
pacemaker pocket.  The leads were freed and removed from the
pacemaker pocket using Bovie electrocautery.  The pacemaker
pocket area was enlarged using blunt dissection.  Two wet laps
that were coated in antibiotic solution were placed into the
pacemaker pocket area.  Next, the left subclavian vein was
accessed with an access needle on the first attempt.  A wire was
placed through the needle into the left subclavian vein.  A
second introducer needle stick needle was inserted to gain a
second access to the left subclavian vein.  A sheath was placed
over the wire into the left subclavian vein.  The wire was
removed from the body.  First, the left ventricular lead was
placed.  This was a Quartet, model #XXXX, serial #XXXXXXXX.
The R wave amplitude was 11.4 millivolts.  Impedance was 1232
ohms.  Threshold was 1.5 volts.  Next, the RV lead was placed.
This was a Durata, model #xxxxxx, serial #xxxxxx.  the R
wave amplitude was 9.5 millivolts.  Impedance was 903 ohms.
Threshold was 1.0 volts.  The right atrial lead, which was
previously placed, this is XXXXXX, serial #XXXXXXXX.  This was
implanted on November 30, 2012.  P wave amplitude was 2.7
millivolts.  Impedance 410 ohms.  Threshold 0.75 volts.  All 3
leads were checked at 10 volts for diaphragmatic stimulation.
None was noted.  The RV and LV leads were sewn into place using 0
Ethibond.  All 3 leads were connected to the bi-V ICD generator
head.  This generator was a Quadra Assura, model #XXXXXXXXX,
serial #XXXXXX.  Each lead was screwed in tight to the
appropriate slot in the head and checked to be sure that they
were tightly secured.  The 2 laps in the pacemaker pocket area
were then removed from the body.  The pacemaker pocket area was
irrigated with antibiotic solution.  About 100 mL of antibiotic
solution was used for irrigation.  The generator was placed into
an AIGIS ICD pocket and the generator and the leads were placed
into the pacemaker pocket area.  The previously placed RV lead
was capped off.  This capped off lead is model #XXXXX, serial
#XXXXXXX.  Implant date was November 30, 2012.  The explanted
dual chamber pacemaker generator was model #2210, serial
#XXXXXX.  Implant date of the explanted pacemaker was November
30, 2012.  Repeat fluoroscopy of the generator head and the leads
was performed to insure they were all still in proper position.
The pacemaker generator was sewn to the pectoralis muscle with 0
Ethibond.  The deep tissue was closed with 2-0 Vicryl.  The skin
tissue was closed with 4-0 Vicryl.  Dermabond adhesive was
applied over the skin wound edges.  Defibrillator function
testing was performed.  There was one test.  The patient was
induced into ventricular fibrillation using DC fibber.  The
energy for defibrillation was 20 joules.  The charge time was 3.6
seconds.  Shock impedance was 44 ohms.  Result was a success with
restoration of normal sinus rhythm.  Sponge and needle counts
were correct.  Estimated blood loss was minimal.  There were no
drains.  Anesthesia was moderate sedation.  There were no
complications for this procedure.  Postop chest x-ray showed no
evidence of pneumothorax or other complications.

IMPRESSION:  Successful upgrade of a dual chamber permanent
pacemaker to a biventricular ICD, placement of a new left
ventricular lead, placement of a new right ventricular
pacemaker/ICD lead, capping off of a previously placed right
ventricular pacemaker lead, upgrade of device to a biventricular
ICD, successful defibrillator function testing.


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## twizzle (Nov 22, 2013)

*Pacer upgrade to Bi-v ICD*

33249, 33225, 93641-26, 33233


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