# Biventricular defibrillator implant attempt.



## amym (Feb 21, 2013)

Please help me code this.  

Procedure:  Permanent biventricular defibrillator implants. 

History: The patient received 1 gram 
of IV vancomycin prophylactically before the procedure. 

Procedure:  Opportunity 
for questions was provided and informed consent obtained.  After 
sterile preparation of the skin surrounding the left deltopectoral 
area with antiseptic scrub this area was carefully covered with a 
Steri-Drape followed by the application of sterile towels and a 
sterile laparotomy sheet.  Procedure was performed under general 
anesthesia, delivered by staff anesthesiologist.  Local anesthesia 
with 1% lidocaine was administered an approximately 2-inch incision 
across the left deltopectoral groove was made.  Before the incision 
was made, a nonselective venogram of the left upper extremity was 
performed given the patient's history of breast cancer on that side, 
we wanted to ensure that the venous anatomy is patent.  Nonselective 
venogram showed good patency of the left axillary, subclavian, as 
well as cephalic vein.  After the incision using blunt dissection 
with careful hemostasis the left cephalic vein was isolated and 
accessed between 2 silk ties.  Two glide wires were inserted under 
the guide of fluoroscopy and the left upper extremity venogram.  The 
left axillary access was also obtained and another guidewire was 
inserted. 

The patient was noted to have a venous stent from the right 
subclavian vein encroaching onto the superior vena cava.  However, 
the nonselective venogram did not confirmed the stent coming all the 
way to the superior vena cava. 

The right ventricular lead that was implanted was a Boston 
Scientific model ,  serial , that was advanced to the 
left cephalic vein, and positioned in the RV apex and active 
fixation mechanism deployed. 

At this point, the right atrial lead which was a Guidant , 
serial# was advanced through the left cephalic vein and 
brought to the level of the right atrium.  With advancement of the 
right atrial lead, there was some resistance underway, which was 
concerning for possibility of the leads crossing this struts of the 
of the venous stent that was coming from the right.  At this point, 
a 7-French sheath was introduced into the left axillary vein and a 
selective venogram of the superior vena cava was performed, which 
confirmed encroachment of the right-side of the stent all the way 
into the superior vena cava.  This proved that both leads had gone 
through the straddled had gone through the struts of the stent 
through the sidewalls of the stent crossing wall to wall before 
coming back into the superior vena cava and at finding their way to 
the right side of the heart.  At this point, the decision was to 
explant both leads given that the leads were crossing through the 
walls of the of the stent and the patient would have been at risk 
for superior vena cava syndrome as well as that face that this could 
have compromised the stent and also the face that the mechanical 
contact between the stent and the leads could have caused insulation 
breach and unnecessary and inappropriate shocks in future. 
Therefore, the active fixation mechanism was withdrawn again and RV 
lead and the right atrial lead were both removed from the heart. 
Proper hemostasis was achieved with 2-0 Vicryl sutures.  Pocket was 
irrigated with antibiotic solution and subcutaneous tissue closed 
with interrupted absorbable suture and skin was closed with 
continuous absorbable suture.  Steri-Strips were applied and a 
sterile occlusive dressing was applied on top of that.  The patient 
was transferred to monitoring area in stable condition. 

Comments: 
1. Attempt at CRT-D implant was aborted after selective venogram 
      confirmed that the right atrial and right ventricular leads 
      had crossed through the right subclavian vein, which had 
      encroached into the superior vena cava.  Right-sided implant 
      is not suitable given the presence of an active AV fistula for 
      hemodialysis and history of prior complication with vascular 
      anatomy in the right upper extremity. 
2. At this point, would recommend the options of either 
      subcutaneous ICD versus epicardial defibrillator and pacing 
      leads with the open thoracotomy.  We will discuss the options 
      with the patient, and will proceed as the patient as per 
      patient's wishes.


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## jewlz0879 (Feb 22, 2013)

You could consider 33249 - 53 given the problem with the leads as he clearly states the medical reason for explanting them and suggests open ICD placement by thoractomy. 75820-26 for the non-selective venogram prior to lead placement. 

HTH


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