bennieyoung
Guru
I first thought to code this 93656, 93655, 93655, 93623 but I am now considering using 93657 instead of 93655. Can anyone tell me how they would code this?
Procedures:
Ablation Atrial Fibrillation RF
Intracardiac echocardiography (ICE)
Ultrasound guided femoral vein access
Transseptal puncture
Pulmonary vein isolation
Drug study
Procedure:
TEE was performed to rule out LAA thrombus
Bilateral Femoral vein access was obtained using the micropuncture needle kit under ultrasound guidance x 3. The below mentioned sheaths were placed for introduction of the below catheters.
ICE was used to obtain LA geometry and identify the intraatrial septum and pulmonary veins.
The enso esophageal cooling device was placed into the esophagus and the tip guided to the desired location using ICE guidance.
Differential atrial pacing was performed which confirmed bidirectional block along the prior CTI line.
IV Heparin was given to target an ACT of > 320 seconds.
Transseptal puncture was performed guided by ICE. This was performed using RF Wire. The deflectable sheath was placed over the wire into the LA and wire and dilator were removed. A multipolar mapping catheter was used to obtain 3D geometry and voltage of the left atrium.
The enso esophageal cooling device was cooled to 4 degrees celsius before ablation on the LA posterior wall was performed.
The multipolar catheter was then exchanged for the ablation catheter mentioned below. The right phrenic nerve was mapped by pacing to ensure that areas to be ablated on the anterior aspect of the RSPV did not have phrenic nerve capture. It was ensured that this was performed prior to institution of full paralysis.
A detailed voltage map was performed which did reveal that the right inferior pulmonary vein was reconnected along with reconnection localized to the anterior aspect of the left superior and left inferior pulmonary veins. The patient did go into atrial fibrillation at this time.
Pulmonary vein re-isolation was performed using radiofrequency energy targeting the pulmonary veins antrally. Ablation was first delivered to the right inferior pulmonary vein along its posterior aspect and along the carina. Ablation was extended to the septal aspect of the right inferior pulmonary vein as well. Atrial fibrillation continued. Ablation was then delivered to the anterior aspect of the left superior pulmonary vein targeting the ridge along the left atrial appendage. Ablation was extended down the ridge anterior to the left inferior pulmonary vein. The patient did convert to sinus rhythm. High output pacing was confirmed and demonstrated lack of capture all along the left atrial appendage ridge.
IV Adenosine was administered to look for dormant conduction. Isoproterenol at 20 mics per minute was administered to assess for non-PV triggers.
With programmed atrial stimulation and during isoproterenol washout the patient spontaneously went into atrial fibrillation. Atrial fibrillation appeared to initiate with a proximal to distal activation sequence on the coronary sinus. Left atrial posterior wall was healthy when the voltage was evaluated in sinus rhythm. Decision was made to pull the catheter to the right atrium and mapped the superior vena cava. Paralysis was reversed and the phrenic nerve was mapped along the superior vena cava. The SVC was then isolated with a circumferential ablation lesion set performed and a point by point fashion. Patient did continue in atrial fibrillation. The voltage map did reveal a area of scar between the SVC and the IVC along the lateral right atrial wall. There were some prolonged high-frequency low amplitude electrograms notable throughout this area of scar. This area was homogenized with ablation connecting the SVC to the IVC. It was noticed that when the catheter was taken out of the right atrium and pulled into the IVC atrial fibrillation with terminate spontaneously. A-fib did not recur at this time.
ICE confirmed absence of pericardial effusion at the end of the case
The catheter and sheath was removed and the femoral vein access sites were closed with Perclose
Hemostasis was achieved.
Catheter Sheath
RFV Multipolar mapping catheter (Octaray) exchanged for
Ablation catheter Versacross bidirectional sheath
LFV Decapolar Long 8F
RFV Intracardiac echo Long 9F
Procedure data:
Power: 40w
Number of ablations: 62
Ablation time: 1010s
LA Volume: 77cc
Voltage: As above
Fluoro Time: 0
Intervals:
Rythm CL PR QRS QT AH HV
Baseline NSR 700 222 84 396 178 70
Post Procedure NSR 792 180 90 418 136 75
Left atrial and ventricular pacing and recording were performed (no sustained atrial arrhythmias could be induced):
AVBCL:680
Drug Study:
Isoproterenol 20 mcg/min
Adenosine 24mg IV
EBL
20cc
Heparin
27,000 units
Protamine
30
Conclusion:
-Successful ablation of atrial fibrillation by reisolation of the right inferior pulmonary vein and left pulmonary veins
-SVC isolation
Procedures:
Ablation Atrial Fibrillation RF
Intracardiac echocardiography (ICE)
Ultrasound guided femoral vein access
Transseptal puncture
Pulmonary vein isolation
Drug study
Procedure:
TEE was performed to rule out LAA thrombus
Bilateral Femoral vein access was obtained using the micropuncture needle kit under ultrasound guidance x 3. The below mentioned sheaths were placed for introduction of the below catheters.
ICE was used to obtain LA geometry and identify the intraatrial septum and pulmonary veins.
The enso esophageal cooling device was placed into the esophagus and the tip guided to the desired location using ICE guidance.
Differential atrial pacing was performed which confirmed bidirectional block along the prior CTI line.
IV Heparin was given to target an ACT of > 320 seconds.
Transseptal puncture was performed guided by ICE. This was performed using RF Wire. The deflectable sheath was placed over the wire into the LA and wire and dilator were removed. A multipolar mapping catheter was used to obtain 3D geometry and voltage of the left atrium.
The enso esophageal cooling device was cooled to 4 degrees celsius before ablation on the LA posterior wall was performed.
The multipolar catheter was then exchanged for the ablation catheter mentioned below. The right phrenic nerve was mapped by pacing to ensure that areas to be ablated on the anterior aspect of the RSPV did not have phrenic nerve capture. It was ensured that this was performed prior to institution of full paralysis.
A detailed voltage map was performed which did reveal that the right inferior pulmonary vein was reconnected along with reconnection localized to the anterior aspect of the left superior and left inferior pulmonary veins. The patient did go into atrial fibrillation at this time.
Pulmonary vein re-isolation was performed using radiofrequency energy targeting the pulmonary veins antrally. Ablation was first delivered to the right inferior pulmonary vein along its posterior aspect and along the carina. Ablation was extended to the septal aspect of the right inferior pulmonary vein as well. Atrial fibrillation continued. Ablation was then delivered to the anterior aspect of the left superior pulmonary vein targeting the ridge along the left atrial appendage. Ablation was extended down the ridge anterior to the left inferior pulmonary vein. The patient did convert to sinus rhythm. High output pacing was confirmed and demonstrated lack of capture all along the left atrial appendage ridge.
IV Adenosine was administered to look for dormant conduction. Isoproterenol at 20 mics per minute was administered to assess for non-PV triggers.
With programmed atrial stimulation and during isoproterenol washout the patient spontaneously went into atrial fibrillation. Atrial fibrillation appeared to initiate with a proximal to distal activation sequence on the coronary sinus. Left atrial posterior wall was healthy when the voltage was evaluated in sinus rhythm. Decision was made to pull the catheter to the right atrium and mapped the superior vena cava. Paralysis was reversed and the phrenic nerve was mapped along the superior vena cava. The SVC was then isolated with a circumferential ablation lesion set performed and a point by point fashion. Patient did continue in atrial fibrillation. The voltage map did reveal a area of scar between the SVC and the IVC along the lateral right atrial wall. There were some prolonged high-frequency low amplitude electrograms notable throughout this area of scar. This area was homogenized with ablation connecting the SVC to the IVC. It was noticed that when the catheter was taken out of the right atrium and pulled into the IVC atrial fibrillation with terminate spontaneously. A-fib did not recur at this time.
ICE confirmed absence of pericardial effusion at the end of the case
The catheter and sheath was removed and the femoral vein access sites were closed with Perclose
Hemostasis was achieved.
Catheter Sheath
RFV Multipolar mapping catheter (Octaray) exchanged for
Ablation catheter Versacross bidirectional sheath
LFV Decapolar Long 8F
RFV Intracardiac echo Long 9F
Procedure data:
Power: 40w
Number of ablations: 62
Ablation time: 1010s
LA Volume: 77cc
Voltage: As above
Fluoro Time: 0
Intervals:
Rythm CL PR QRS QT AH HV
Baseline NSR 700 222 84 396 178 70
Post Procedure NSR 792 180 90 418 136 75
Left atrial and ventricular pacing and recording were performed (no sustained atrial arrhythmias could be induced):
AVBCL:680
Drug Study:
Isoproterenol 20 mcg/min
Adenosine 24mg IV
EBL
20cc
Heparin
27,000 units
Protamine
30
Conclusion:
-Successful ablation of atrial fibrillation by reisolation of the right inferior pulmonary vein and left pulmonary veins
-SVC isolation