Second opinion- how would you code this ?
Procedures: Electrophysiologic Testing with Induction of Arrhythmia
with drug stimulation
with left atrial pacing and recording
Standard Mapping
With left ventricular pacing and recording
LV pacing and mapping
3D Mapping
Standard mapping
Intracardiac Echocardiography
Indication: Ventricular Tachycardia
Ischemic Cardiomyopathy
Medications: Heparin 20000 units
Isuprel 12 Micrograms/min
Epinephrine 15 micrograms/min
Dopamine 10 micrograms/min
Input/output: 2400 / 400 cc
PROCEDURE DESCRIPTION:
The patient was prepared and draped in sterile fashion. Following local anesthesia with 1% xylocaine, sheaths were inserted percutaneously into the right femoral vein and the left femoral vein and femoral artery for administration of IV fluids and introduction of catheters.
A 10.5 F phased array ultrasound catheter was inserted through the left femoral vein and positioned in the right atrium for imaging. Intracardiac Echocardiography was performed. The left ventricul, right ventricle, RVOT, Aortic valve and pulmonic valve were mapped. Multipolar catheters were positioned at the right ventricular apex, right ventricular outflow tracts, His bundle and high right atrium for pacing and recording. Programmed atrial stimulation was performed to assess the EP properties of the atrium and AV conduction system, and for arrhythmia induction. Programmed ventricular stimulation was performed to assess the electrophysiologic properties of the ventricul, and for arrhythmia induction. Stimulation during cathecholamine infusion was performed. These results are reported below.
Following induction of ventricular tachycardia. Activation mapping and pacemapping were performed using 3.5 mm Thermacool Navistar D Cure Mapping was performed in SR to delineate the scar. Detailed results of mapping are reported below.
Ablation was not done given the fact we could only induce NSVT and the scar and fractinoated signals are very close to the HIS bundle. We attempted induction by pacing in the RV apex and RVOT with two cycle lenghts and up to 3 extra stimuli. We did that on isuprel at 12 mcgm / min, with epinephrine at 15 mcg/min and on dopamine 10 mcg/ min. During the entrie prior of left heart catheterization, intravenous heparin was administered to maintain ACT at > 320 seconds.
At the end of the procedure. The catheters and sheaths were removed and hemostasis obtained by manual compression.
PROCEDURAL DATA:
Cardiac Intervals :
Rhythm CL PR QRS QT AH HV
Baseline : Sinus 915 138 101 431 114 63
Post procedure : Sinus 794 149 101 427
Access Catheter
LFV 11F Siemens Sound Star
RFV 7F Bidirectional FJ Decapolar catheter
RFA 3.5 mm Thermacool
Spontaneous or Induced Arrhythmias: NSVT.
Refractory periods
Baseline Isuprel Dopamine Epinephrine
HRA
AVN
RV 600/270
400/250 400/250 (apex)
400/230 (RVOT 400/230 (apex)
400/220 (RVOT) 400/240 (apex)
400/230 (RVOT)
Mapping Results: The scar is near the mitral annulus and most of the fractionated signals are near the HIS bundle
Total Procedure Time: 245 min
Total Fluoroscopy Time: 17.8 min
Complications: none
SUMMARY
1. Comprehensive EP study with attempted induction of VT. We could only induce NSVT despite aggressive PES on isuprel, epinephrine and dopamine.
2. 3 D mapping with scar mapping, ICE and Drug study. The scar is near the mitral annulus and most of the fractionated signals are near the HIS bundle. Given the location we elected not to deliver RF on the fractionated signals unless we induce and study the VT
Procedures: Electrophysiologic Testing with Induction of Arrhythmia
with drug stimulation
with left atrial pacing and recording
Standard Mapping
With left ventricular pacing and recording
LV pacing and mapping
3D Mapping
Standard mapping
Intracardiac Echocardiography
Indication: Ventricular Tachycardia
Ischemic Cardiomyopathy
Medications: Heparin 20000 units
Isuprel 12 Micrograms/min
Epinephrine 15 micrograms/min
Dopamine 10 micrograms/min
Input/output: 2400 / 400 cc
PROCEDURE DESCRIPTION:
The patient was prepared and draped in sterile fashion. Following local anesthesia with 1% xylocaine, sheaths were inserted percutaneously into the right femoral vein and the left femoral vein and femoral artery for administration of IV fluids and introduction of catheters.
A 10.5 F phased array ultrasound catheter was inserted through the left femoral vein and positioned in the right atrium for imaging. Intracardiac Echocardiography was performed. The left ventricul, right ventricle, RVOT, Aortic valve and pulmonic valve were mapped. Multipolar catheters were positioned at the right ventricular apex, right ventricular outflow tracts, His bundle and high right atrium for pacing and recording. Programmed atrial stimulation was performed to assess the EP properties of the atrium and AV conduction system, and for arrhythmia induction. Programmed ventricular stimulation was performed to assess the electrophysiologic properties of the ventricul, and for arrhythmia induction. Stimulation during cathecholamine infusion was performed. These results are reported below.
Following induction of ventricular tachycardia. Activation mapping and pacemapping were performed using 3.5 mm Thermacool Navistar D Cure Mapping was performed in SR to delineate the scar. Detailed results of mapping are reported below.
Ablation was not done given the fact we could only induce NSVT and the scar and fractinoated signals are very close to the HIS bundle. We attempted induction by pacing in the RV apex and RVOT with two cycle lenghts and up to 3 extra stimuli. We did that on isuprel at 12 mcgm / min, with epinephrine at 15 mcg/min and on dopamine 10 mcg/ min. During the entrie prior of left heart catheterization, intravenous heparin was administered to maintain ACT at > 320 seconds.
At the end of the procedure. The catheters and sheaths were removed and hemostasis obtained by manual compression.
PROCEDURAL DATA:
Cardiac Intervals :
Rhythm CL PR QRS QT AH HV
Baseline : Sinus 915 138 101 431 114 63
Post procedure : Sinus 794 149 101 427
Access Catheter
LFV 11F Siemens Sound Star
RFV 7F Bidirectional FJ Decapolar catheter
RFA 3.5 mm Thermacool
Spontaneous or Induced Arrhythmias: NSVT.
Refractory periods
Baseline Isuprel Dopamine Epinephrine
HRA
AVN
RV 600/270
400/250 400/250 (apex)
400/230 (RVOT 400/230 (apex)
400/220 (RVOT) 400/240 (apex)
400/230 (RVOT)
Mapping Results: The scar is near the mitral annulus and most of the fractionated signals are near the HIS bundle
Total Procedure Time: 245 min
Total Fluoroscopy Time: 17.8 min
Complications: none
SUMMARY
1. Comprehensive EP study with attempted induction of VT. We could only induce NSVT despite aggressive PES on isuprel, epinephrine and dopamine.
2. 3 D mapping with scar mapping, ICE and Drug study. The scar is near the mitral annulus and most of the fractionated signals are near the HIS bundle. Given the location we elected not to deliver RF on the fractionated signals unless we induce and study the VT
