# Removal w/reimplantation of pacer



## lcouto (Feb 6, 2014)

Can anyone help with this please.... I'd appreciate any help... Thank you

Pre-procedure Diagnoses 
  1. SSS (sick sinus syndrome)   
  Post-procedure Diagnoses 
  1. SSS (sick sinus syndrome)   
  Procedures 
  1. HC PACEMAKER DDDR DUAL SYSTEM   
  BRIEF OPERATIVE NOTE


Pre-operative Diagnosis:  
SSS
Breast CA


Procedure Performed :
Removal of Permanent Pacemaker from left side and reimplantation of Permanent Pacemaker on right side
Venogram




Implants and Procedure Description:  
After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken.  Was performed from the right forearm with visualization of the right axillary and subclavian veins.  After demonstration of the patency of these vessels  the patient was placed in Trendelenburg position and percutaneous was obtained a fluoroscopic guidance in the right axillary vein and an .035 wire was advanced into the right atrium and then secured to the drape with a hemostat while we removed the pacemaker from the left chest.


Attention was then turned to the pacemaker in the left chest.The skin and subcutaneous tissue overlying the pacemaker was infiltrated with lidocaine.  Sharp incision was made in the skin.  Utilizing a combination of sharp sharp and blunt dissection.  The prep prepectoral fascia a was separated.  I then carefully separated the pectoralis muscle overlying the pacemaker and carefully dissected the leads from the pacer pocket.  Pacemaker was removed intact and placed in antibiotic solution.  The the retention sutures from the pacing leads were removed.  I then advanced a stylette into the atrial lead and directly under fluoroscopic guidance retracted the set helix freeing the atrial lead from its attachment to the right atrium.  The lead fell free and was removed from the body and placed in antibiotic solution.  I advanced a second stylette into the ventricular lead and retracted the stylette until the lead again was freed from its attachment.  This lead also was easily retrieved from the body and placed in antibiotic solution.  The pocket was irrigated with antibiotic solution and the muscle layer and subcutaneous tissue was closed with 3-0 Vicryl suture.  The skin layer was closed with subcuticular 4-0 Vicryl suture.




ACCESS and POCKET FORMATION:
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the right pectoralis muscle.  Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, a pocket was formed in the prepectoral fascia incorporating 035 wire.  

VENTRICULAR LEAD:
Over the .035 wire, an 8 French peel-away sheath was advanced. The dilator was removed, and a second .035 wire was placed through the sheath. The sheath was removed and then reintroduced over one of the .035 wires. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was the active fixation lead from the left chest. Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 9.1 mV, impedance 891 ohms, threshold was 0.6 volts. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.


ATRIAL LEAD:  
Attention was then turned to the atrial lead. Over the second .035 wire a second dilator and sheath were placed. The wire and dilator were exchanged then for the atrial pacing lead. The lead was an active fixation lead . Utilizing curved and straight stylettes, the lead was positioned and secured in the right atrial appendage. It was tested and found to have P waves of 1.9 mV, impedance 607 ohms, threshold was 1.2 volts. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with an output of 10 V and did not stimulate the diaphragm. 


CLOSURE:
The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator . The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated. The subcutaneous fascia was closed with interrupted Vicryl suture. The skin layer was closed with staples.   Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.


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## nesha2566 (Feb 6, 2014)

This sounds like CPT code 33228 to me. Check out that code.


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## lcouto (Feb 6, 2014)

Thank you


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