Any help is greatly appreciated. My codes 33220 and 93640. Not sure if I am missing anything or completely off track. The sternotomy part is making me overthink? Thank you.
PREOPERATIVE DIAGNOSES:
1. Prolonged QT syndrome/ventricular tachycardia.
2. Lead fracture.
POSTOPERATIVE DIAGNOSES:
1. Prolonged QT syndrome/ventricular tachycardia.
2. Lead fracture.
PROCEDURE PERFORMED:
1. Lead extraction times 2.
2. Lead insertion (RV-dual coil ICD; RA-pacing).
3. Electrophysiologic study.
4. Fluoroscopy.
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: The patient brought to the operating room and with
standard monitoring, general anesthesia was safely and uneventfully induced.
External defibrillator patches and SCD hose were in place and functioning. The
left chest was prepped and draped as a sterile field allowing sufficient drying
time to mitigate fire risk. Time-out precautions were observed.
The patient's implanting incisional scar in the left infraclavicular chest wall
was excised and the incision carried down to enter the ICD pocket. The patient
is morbidly obese. The device was delivered into the wound. There appeared to
be some fluid within the header of the device involving both of the leads
present. The leads were firmly secured to the header of the device. The leads
were disconnected from the device and the device moved to the back table. The
patient had an adequate intrinsic heart rate and rhythm. The suture fixation
stitches were removed from the leads as we mobilize them. It appeared that
there were several sutures that were in fact around the leads and unprotected
by the suture sleeve. This appeared to result in a fracture of the insulation
of the atrial lead. We could not discern any fractures of the RV dual-coil
electrode, although this lead had a considerable amount of noise recorded on
multiple locations requiring the device to be inactivated. Examination of this
lead under fluoroscopy failed to reveal any definitive breaks. Given the noise
observed, however, we elected to extract both leads.
Stylets were passed down each lead in turn and active fixation device was
withdrawn. Both leads were removed under constant fluoroscopic guidance using
gentle traction alone. Hemostasis was adequate.
We attempted to cannulate the left subclavian vein through the existing wound,
but were unsuccessful in this endeavor. We deepened the incision in the
deltopectoral groove and found a number of small branches leading to a triad of
larger vessels at the level of the subclavian vein. One of these larger
vessels was encircled proximally and distally and through a short transverse
sternotomy, we were able to pass the dual coil defibrillator electrode. It was
guided out the right ventricular outflow tract and then withdrawn and seated in
the apex of the right ventricle. The patient's heart was rather vertical in
orientation. Acceptable pacing thresholds for this lead were established as
follows: Stimulation threshold 0.9 V with a satisfactory impedance and R waves
14 mV.
Through another venotomy slightly more distally, we passed a bipolar atrial
pacing electrode. It was guided under fluoroscopy into the right atrium.
Here, it appeared to traverse an atrial septal defect or patent foramen into
the left atrium. It was withdrawn and rotated in counterclockwise become
established and what appears to be the atrial appendage. Care was actively
secured and the following pacing parameters measured: Stimulation threshold
1.7 V, impedance 930 ohms and P waves 3.5 mV. These data were acceptable. The
leads were secured to the chest wall and hemostasis was assured. The leads
were placed back in the header of the device, St. Jude model CD2231-40Q, serial
number 619178.
The device was returned to the pocket and secured to the chest wall using the
suture port provided. Electrophysiologic study was now performed to determine
the adequacy of defibrillation thresholds. The patient had ventricular
fibrillation induced on a single occasion and was successfully cardioverted at
15 joules of energy. The shocking impedance was 49 ohms and the charge 2.6
seconds.
Lead position was confirmed by fluoroscopy. Hemostasis was assured. Sponge,
instrument and needle counts were correct. Pacing and sensing were
appropriate. The device was programmed to DDDR with the lower rate of 60 and
upper rate of 110 with two zones of tachy therapy, one at a rate threshold of
181 pulses per minute with ATP to be delivered. A second zone rate threshold
of 214 pulses per minute with limited ATP and shocking was also programmed.
After closure of the wounds in multiple layers and establishing correct
sponges, needle counts and confirming lead position, the patient was reversed
and taken to PACU in satisfactory condition having tolerated the procedure
well. Local anesthetic agent was injected into the incision area to assist
with postoperative pain management prior to application of a sterile
compression dressing.
Thank you,
Brendan Bailey, CPC
PREOPERATIVE DIAGNOSES:
1. Prolonged QT syndrome/ventricular tachycardia.
2. Lead fracture.
POSTOPERATIVE DIAGNOSES:
1. Prolonged QT syndrome/ventricular tachycardia.
2. Lead fracture.
PROCEDURE PERFORMED:
1. Lead extraction times 2.
2. Lead insertion (RV-dual coil ICD; RA-pacing).
3. Electrophysiologic study.
4. Fluoroscopy.
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: The patient brought to the operating room and with
standard monitoring, general anesthesia was safely and uneventfully induced.
External defibrillator patches and SCD hose were in place and functioning. The
left chest was prepped and draped as a sterile field allowing sufficient drying
time to mitigate fire risk. Time-out precautions were observed.
The patient's implanting incisional scar in the left infraclavicular chest wall
was excised and the incision carried down to enter the ICD pocket. The patient
is morbidly obese. The device was delivered into the wound. There appeared to
be some fluid within the header of the device involving both of the leads
present. The leads were firmly secured to the header of the device. The leads
were disconnected from the device and the device moved to the back table. The
patient had an adequate intrinsic heart rate and rhythm. The suture fixation
stitches were removed from the leads as we mobilize them. It appeared that
there were several sutures that were in fact around the leads and unprotected
by the suture sleeve. This appeared to result in a fracture of the insulation
of the atrial lead. We could not discern any fractures of the RV dual-coil
electrode, although this lead had a considerable amount of noise recorded on
multiple locations requiring the device to be inactivated. Examination of this
lead under fluoroscopy failed to reveal any definitive breaks. Given the noise
observed, however, we elected to extract both leads.
Stylets were passed down each lead in turn and active fixation device was
withdrawn. Both leads were removed under constant fluoroscopic guidance using
gentle traction alone. Hemostasis was adequate.
We attempted to cannulate the left subclavian vein through the existing wound,
but were unsuccessful in this endeavor. We deepened the incision in the
deltopectoral groove and found a number of small branches leading to a triad of
larger vessels at the level of the subclavian vein. One of these larger
vessels was encircled proximally and distally and through a short transverse
sternotomy, we were able to pass the dual coil defibrillator electrode. It was
guided out the right ventricular outflow tract and then withdrawn and seated in
the apex of the right ventricle. The patient's heart was rather vertical in
orientation. Acceptable pacing thresholds for this lead were established as
follows: Stimulation threshold 0.9 V with a satisfactory impedance and R waves
14 mV.
Through another venotomy slightly more distally, we passed a bipolar atrial
pacing electrode. It was guided under fluoroscopy into the right atrium.
Here, it appeared to traverse an atrial septal defect or patent foramen into
the left atrium. It was withdrawn and rotated in counterclockwise become
established and what appears to be the atrial appendage. Care was actively
secured and the following pacing parameters measured: Stimulation threshold
1.7 V, impedance 930 ohms and P waves 3.5 mV. These data were acceptable. The
leads were secured to the chest wall and hemostasis was assured. The leads
were placed back in the header of the device, St. Jude model CD2231-40Q, serial
number 619178.
The device was returned to the pocket and secured to the chest wall using the
suture port provided. Electrophysiologic study was now performed to determine
the adequacy of defibrillation thresholds. The patient had ventricular
fibrillation induced on a single occasion and was successfully cardioverted at
15 joules of energy. The shocking impedance was 49 ohms and the charge 2.6
seconds.
Lead position was confirmed by fluoroscopy. Hemostasis was assured. Sponge,
instrument and needle counts were correct. Pacing and sensing were
appropriate. The device was programmed to DDDR with the lower rate of 60 and
upper rate of 110 with two zones of tachy therapy, one at a rate threshold of
181 pulses per minute with ATP to be delivered. A second zone rate threshold
of 214 pulses per minute with limited ATP and shocking was also programmed.
After closure of the wounds in multiple layers and establishing correct
sponges, needle counts and confirming lead position, the patient was reversed
and taken to PACU in satisfactory condition having tolerated the procedure
well. Local anesthetic agent was injected into the incision area to assist
with postoperative pain management prior to application of a sterile
compression dressing.
Thank you,
Brendan Bailey, CPC
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