# need help downgrade from biv to dual chamber icd



## bhargavi (May 4, 2015)

Attempted dual-chamber biventricular implantable cardioverter defibrillator     
implant.                                                                        

INDICATION                                                                      
A 73-year-old white female with anxiety, depression, coronary artery disease    
status post coronary artery bypass graft in 1988 and again in 2000, previous    
percutaneous coronary intervention to the saphenous vein graft to the right     
coronary artery on September 2014, myocardial infarction, triple-vessel         
disease, ischemic cardiomyopathy with left ventricular dysfunction, diabetes    
mellitus type 2, chronic kidney disease, stage III, hypertension,               
hyperlipidemia, peripheral artery disease, with subclavian artery stenosis      
status post percutaneous coronary intervention to the left subclavian on        
January 19, 2014, with stent placement, cerebrovascular accident, chronic left  
bundle branch block, hyperlipidemia, obesity, chronic obstructive pulmonary     
disease on home O2, chronic kidney disease, limited ambulation, lower extremity 
edema with gait instability, equilibrium problem, now admitted for DDD          
biventricular implantable cardioverter defibrillator implantation.              

Previous echocardiogram on May 20, 2014 noted the ejection fraction of 30 to 35 
percent, with left bundle branch block at that time. The patient's repeat echo  
on December 9, 2014 shows an ejection fraction of 25 to 30 percent with no      
significant change post recent percutaneous coronary intervention subclavian on 
September 9, 2014, and a last right coronary artery stent placement to the vein 
graft on September 2014.                                                        

The patient this time fills MADIT-II criteria for implantable cardioverter      
defibrillator implantation, criteria for depressed ejection fraction, New York  
Heart Association Class 2 symptoms with systolic dysfunction, but not fills     
MADIT-II criteria but also criteria for upgrade to a biventricular implantable  
cardioverter defibrillator system in light of chronic left bundle branch block  
with QRS duration in excess of 120 milliseconds in addition.                    

Risks and benefits were explained to the patient preoperatively. Risks          
including, "bleeding, infection, irregular heartbeat, chest pain, heart attack, 
death, hole in the heart, hole in the lungs, stroke, as well as potential       
contrast reaction and renal failure with a long-standing history of diabetes    
mellitus, with a creatinine of 2.1".                                            

Risks and benefits reviewed. The patient signed informed consent. Preoperative  
and antibiotic vancomycin was given as per routine. Due to his                  
immunocompromised patient with protected long procedure as well as conscious    
sedation as administered per anesthesia.                                        

PROCEDURE IN DETAIL                                                             
The bilateral groins were prepped and draped in usual sterile fashion. Two      
percent lidocaine solutions were infiltrated the right groin. At this point in  
time, I placed a right femoral venous line for central venous access, which is  
a 6-French sheath in right femoral vein. A right femoral arterial line,         
5-French sheath was placed in a right femoral artery to allow for hemodynamic   
monitoring perioperatively.                                                     

At this point in time, I moved to the chest region. The left chest was prepped  
and draped in usual sterile fashion. 0.25 percent Sensorcaine and 2 percent     
lidocaine solutions were infiltrated into the left prepectoral space.           

At this point, a left axillary/subclavian venogram was performed to visualize   
the central circulation.                                                        

I developed a left prepectoral pocket after I made an incision                  
infraclavicularly. A 8 pocket was then developed using blunt and sharp          
dissection.                                                                     

At this point, in Trendelenburg position, I used the venogram for roadmap to    
allow for central venous access. Two subclavian punctures were then performed   
with access to the central venous system.                                       

I was able to use a micropuncture kit with subsequent upgrade using             
sheath/guidewire technique to place two 85 centimeter Terumo guidewires into    
the central circulation.                                                        

At this point, I used a 9 and 6-French sheath to insert both right femoral,     
right-sided implantable cardioverter defibrillator lead as well as right atrial 
lead into the central circulation using sheath/guidewire technique. The right   
ventricular lead was placed in a right ventricular apical septal region. The    
right atrial lead was placed in a right anterolateral atrial appendage atrial   
wall region. Satisfactory positioning was confirmed. This was confirmed with    
fluoroscopic electrogram and threshold data. Upon completion, I introduced a    
10-French sheath using the second guidewire into the central circulation. I did 
use a Medtronic Attain guiding sheath which was a 50-S sheath that was shaped   
into a curve. I was able to use a 4 pole Mariner steerable catheter, and tried  
to access the coronary sinus.                                                   

I was having great difficulty accessing the coronary sinus. Nevertheless, I did 
manage to place the guiding catheter into what I felt was the ostium of a       
seemingly occluded coronary sinus. I was able to obtain satisfactory            
electrograms confirming that I was in the coronary sinus. However, this         
coronary sinus had nothing more than a stump. I as not able to insert a sheath. 
I was able to actually place a guiding sheath for venogram to confirm total     
occlusion, however, on multiple attempts, I was never able to get into the      
coronary sinus. On one episode had an amputated the coronary sinus, probably    
about a 0.5 centimeter in length. I did note that there were multiple vascular  
clips in the posterior aspect of the heart which I suspect probably did manage  
to clamp off the coronary sinus during one of her two coronary artery bypass    
grafting surgeries.                                                             

After a long process of trying to confirm an occluded coronary sinus, I finally 
abandoned the course of the venous access with some transient venography.       

At this point in time, I did abandon the CS lead placement.                     

Both right atrial and ventricular leads were then re-evaluated and fixed to the 
fascial plane using 2-0 Ethibond suture.                                        

The pocket was irrigated with antibiotic solution. Electrocautery along with    
Arista powder was used x2 for hemostasis. The patient has been on aspirin and   
Plavix which is favored significant venous oozing and generalized oozing in the 
pocket site.                                                                    

The lead tips of the acute right atrial and right ventricular leads were then   
cleaned and dried and placed into the new implantable                           
cardioverter-defibrillator header. The patient received a dual-chamber          
implantable cardioverter defibrillator generator.                               

There were no future plans to insert an epicardial left ventricular lead as the 
patient had two previous bypass surgeries, and we would not be able to easily   
access the  myocardium in light of these surgeries and also for fear of         
disrupting her existing epicardial grafts and favoring more quickly             
complications.                                                                  

At this point, the patient was downgraded from a biventricular implantable      
cardioverter defibrillator to a dual-chamber implantable cardioverter           
defibrillator system.                                                           

At this point, the lead tips were cleaned and dried and placed into the         
implantable cardioverter-defibrillator header. The implantable cardioverter     
defibrillator leads were then inserted into the prepectoral pocket.             

The implantable cardioverter defibrillator generator was tacked to the fascial  
plane using 2-0 Ethibond sutures to prevent it from migrating inferiorly.       

The wound was then closed in three layers. The first two layers were closed     
using 0 Vicryl suture in running stitch configuration. The subcuticular layer   
was closed using 4-0 Monocryl suture.                                           

The wound was then dressed using Mastisol, half-inch Steri-Strips, plain white  
gauze, and Tegaderm dressing. The patient tolerated the procedure well without  
complication.                                                                   

Acute thresholds measured the PSA at time of implant noted a P-wave to be 2.4   
millivolts. The atrial pacing threshold was 0.5 milliseconds at 1.4 volts with  
impedance of 520 ohms. The mA was 2.1. The slew rate in the atrium is 0.4       
volts/second. The right ventricle R-wave was 20.0 millivolts. The right         
ventricle impedance 680 ohms. The right ventricle pacing threshold was 0.5      
milliseconds at 0.5 volts with an mA of 0.6. The slew rate was 2.7 volts/second.

Repeat threshold testing through the device once attached now noted a P-wave to 
be 2.5 millivolts. The atrial pacing threshold was 0.5 millisecond. 0.75 volts  
with impedance of 490 ohms. The right ventricle R-wave was 12.0 millivolts. The 
right ventricle pacing threshold was 0.5 milliseconds at 0.5 volts with         
impedance of 660 ohms.                                                          

The noninvasive HV impedance was 42 ohms.                                       

The patient underwent defibrillation threshold testing as per routine. The      
patient induced with a "DC fibber" induction. The patient was induced into      
ventricular fibrillation. Patient had 1 1 sensing at least sensitive            
sensitivity. The patient received a 25 joule shock with a shock impedance of 42 
ohms and a charge time of 5.6 seconds with prompt restoration of sinus rhythm.  
After a 5 minute interval we repeated the induction. Again we induced with a    
"DC fibber" induction. Ventricular fibrillation was induced. We had 1 1 sensing 
at least sensitive sensitivity. The patient received a 25 joule shock with a    
shock impedance of 41 ohms and a charge time of 5.4 seconds.                    

Implanted hardware at this time includes a Saint Jude device model CD 2411-36Q, 
serial number 7138002 device. The right atrial lead is a Saint Jude model 208   
TC-46 centimeter bipolar active fixation lead, serial number CNX 037851. The RV 
lead is a Saint Jude, model 7120Q-58 centimeter bipolar active fixation lead,   
serial number BNP 044978.                                                       

CONCLUSION                                                                      
1. Successful DDD implantable cardioverter defibrillator implantation.          
2. Successful left axillary/subclavian venogram to visualize the central        
   circulation and provide a roadmap for central venous access.                 
3. Central venous access for an attempt to cannulate the coronary sinus. I did  
   place an Attain guide sheath in there and shoot multiple attempts at         
   venography, as well as multiple mapping of an aborted stump of the coronary  
   sinus. However, the coronary sinus was occluded and the LV lead placement    
   was abandoned.                                                               
4. Defibrillation threshold testing was performed.                              
5. The patient also had a right femoral central venous line inserted as well as 
   a right femoral arterial line inserted as per routine in these patients with 
   compromise cardiac function.                                                 
6. Defibrillation threshold was also performed as per routine to confirm        
   satisfactory implantable cardioverter defibrillator function at the time of  
   implant.                                                                     

   thanks for all your help in advance
i had used 33249,93641,75820.
pl advise. i got denial from medicare


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## Chlrtrep (May 4, 2015)

bhargavi said:


> Attempted dual-chamber biventricular implantable cardioverter defibrillator
> implant.
> 
> 
> ...



A quick observation here: You do not code for the venogram (75820) as this is included in the procedure for the implant. Unless there was a medical necessity that is well documented.  But you do not code this for roadmapping.


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