# Operative note help..tricky one



## 1073358 (Dec 18, 2008)

CPT's this far:
33223
33244
33215
33202
33255
77001-26
93631-26
93641-26

I think I need more codes for the right atrial lead extraction and the insertion of a new one, but I am stuck...

PREOPERATIVE DIAGNOSES
1. Nonischemic cardiomyopathy with need for left ventricular epicardial lead. 
2. Paroxysmal atrial fibrillation. 

POSTOPERATIVE DIAGNOSES
1. Nonischemic cardiomyopathy with need for left ventricular epicardial lead. 
2. Paroxysmal atrial fibrillation. 
3. Lead migration of previously placed automatic implantable cardiac
defibrillator in the right infraclavicular location (both atrial and RV
leads). 

PROCEDURE PERFORMED
1. AICD pocket revision with placement subpectoral. 
2. Left ventricular coronary sinus endocardial lead extraction. 
3. Right atrial lead extraction. 
4. Insertion of new right atrial lead. 
5. Reposition and replacement of right ventricular lead. 
6. Median sternotomy and placement of left ventricular epicardial leads. 
7. Atrial fibrillation ablation with bilateral pulmonary vein encircling
lesions, and a GP mapping and ablation. 
8. Removal of left atrial appendage. 
9. Fluoroscopic guidance for axillary access and lead placement.

SURGEON
Dr. R

ASSISTANT SURGEON
Dr. J

ASSISTANT
Dr. L

CLINICAL HISTORY
This is a very complicated gentleman with a non-ischemic cardiomyopathy. At
one point in time he had a biventricular automatic implantable cardiac
defibrillator in his left infraclavicular location and it actually had done
quite well with an ejection fraction that had gone from 10 to 35% clinically,
he had obtained a great benefit. Unfortunately this site eroded through the
skin and that whole AICD had to be removed and extracted. He subsequently had
attempts at automatic implantable cardiac defibrillator through the right
side. This included left ventricular lead in the coronary sinus. However they
were unable to really get that particularly to work. He has decompensated and
gone down hill. He newly developed as well atrial fibrillation which is
paroxysmal. Given all of these issues, it was really felt that he would best
be served by upgrade to an epicardial LV lead. Unfortunately, given the
right-sided device there was no way to do this other than a median
sternotomy. We felt that if we were going to do that it would make sense to
attempt to ablate his atrial fibrillation. He was brought to the operating
room electively. 
DESCRIPTIVE PROCEDURE
After uneventful induction and intubation he was prepped and draped. During
the device interrogation we realize that there were problems with both the
atrial and ventricular lead. When you look at his preop, his x-ray, both
leads seem to have pulled back a substantial amount. I felt that it made
absolutely no sense to embark on the bigger procedure if we did not have
automatic implantable cardiac defibrillator that was intact and working. Thus
I initially undertook what had been an unanticipated procedure, that being
complete revision of the AICD in place. Through the pocket and the right
infraclavicular area I opened. I defined the capsule, removed the device, and
felt that it was already much thinner than I would have liked. For this
reason I created a subpectoral pocket. Once this was performed, under
fluoroscopic guidance after freeing up all the leads, I defined the coronary
sinus lead. This was very easily removed and not scarred in in any fashion
with the other lead. The atrial lead seemed to move pretty freely and I
initially made attempts to just try to reposition it. I could get it up into
the atrial appendage, with utilizing preformed J to do so. However, I could
never get it to fix in the wall where concern that there may actually be
tissue on the tendril tip. After finding that we really could not plug the
lead in, I removed the lead under fluoroscopic guidance. In fact we did find
there was a healthy in growth of tissue on the tendril tip. At this point I
could cannulate the subclavian vein, but could not pass traditional wire. I
asked Dr. L to come up, and utilizing some cath laboratory wires, we
are able to get by the scar tissue, and dilate a track so that we could get a
more traditional wire in place. It took quite a long time, and it was all
done under fluoroscopic guidance. I then repositioned the right ventricular
lead. This was very easily repositioned into the apex of the right ventricle.
This was easily screwed into place, and we had very good numbers. Through the
wire that we had placed utilizing modified Seldinger technique I then was
able to get an atrial lead in, and positioned it into the atrial appendage.
It was pretty difficult given all the scar tissue and I had a hard time with
mobility of this lead. Finally, we were able to get it in place in a fashion
where we had reasonable numbers to use it. Having completed all of this, and
frankly taking about 2 1/2 hours to do so, I then felt we could safely
undertake what we had come to this operation to do. A standard median
sternotomy was performed. I opened the pericardium and created a well. I
encircled both the right and left pulmonary veins. I then utilized the
AtriCure bipolar RF clamps to undertake bilateral pulmonary vein isolation.
Before this was done, however, I mapped A, B, and C on both sides, and could
actually pace and also measure P waves. A couple of times he did go into
atrial fibrillation and then he was shocked back into sinus. After we had
done the initial measurements I placed the clamps, created three burns of
tissue on the right side. We had not mapped GPs. The only GP that had a
positive autonomic response was R7 and R10. These were then burned with the
pen. We retested and had ablated the response. I then mapped for both
entrance and exit block, and found we had this. I then turned my attention to
the left side. Similarly we mapped for entrance and exit P-waves. We had
them. The clamp was then apply. Three firings were undertaken. The GPs were
mapped, and the only GP that had a positive autonomic response was L10. This
was ablated and retested and the response had abated. We mapped again for
entrance and exit block. We still had in the B position evidence of P-waves
that we could measure. I replaced the pen, burned two more times, and we
remeasured and the P-waves had completely dissipated. The atrial appendage
which had been visualized with transesophageal echocardiogram to be free of
clot was then easily exposed and removed. This was done with a pericardial
reinforced EndoGIA stapler. Everything looked quite good at this point. The
epicardial leads were both screwed into place between the diagonal and ramus
on muscular issue. They seated very nicely. Initial testing of both leads was
excellent. The leads were both model numbers 5071. These were subsequently,
after testing and I was happy with them, tunneled and passed directly into
the pocket through the chest wall on the right leaving redundancy of the
leads themselves. The lead that was capped was serial number LAQC76961V. The
lead that was utilized was LAQ076760V. This had a measurable R-wave of 8 mv,
an impedance of 595 ohms, and a pacing threshold of 0.5 volts. I had the RV
lead with a P-wave of 8.2 mv, a slew of 2.8 volts per seconds, an impedance
of 590 ohms, and a pacing threshold of 0.4 volts at 0.5 milliseconds. The new
atrial lead had a measurable P-wave of 3.4 mV, a slew of 0.9 volts per
second, an impedance of 604 ohms, and a threshold of 0.8 volts at 0.5 ms. I
should note that the new atrial lead was a Medtronic 5076 52 cm lead, serial
number PJN1754975. The system seemed to test out reasonably well at this
point; however, under fluoroscopy we had found that there was problems with
the atrial lead and it had migrated with the manipulations during the atrial
fibrillation ablation. With this, I had to reposition the atrial lead once
again. The above numbers referenced are the final numbers that we had after
we did so under fluoroscopy. However, rather than positioning the lead in the
atrial appendage, it was positioned in the left lateral free wall as I was
having a difficult time getting it back into the atrial appendage. Given his
previous issues we had worked very hard to position both the RV and LV lead
with a lot of slack. Although the leads were then attached to the ICD this
had been removed and wrapped in antibiotic cloth. This was delivered into the
pocket and then we undertook device phase testing. We initiated VF will shock
on T on two occasions. On both occasions at 25 joules had satisfactory V
fibrillation with the device. At that point we felt we had finally completed
what we had come to do. I delivered powdered antibiotics into the pocket,
closed the pocket in layers with running absorbable suture. I placed two
chest tubes, opened up both pleural spaces, and reapproximate the majority of
the pericardium. Again, I made every effort to make the LV leads redundant.
The sternum was closed in the usual fashion after the application of
vancomycin paste. Soft tissue was closed in layers with running absorbable
suture. Antibiotics were also will placed in the wound. All counts were
correct. He required no blood products. Hemodynamically he was very stable.
He left the operative room in critical but stable condition. All counts were
were correct. He remained intubated.


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