TWilliam2019
Guru
STATEMENT OF MEDICAL NECESSITY
Mr. Patient is a 60-year-old gentleman with persistent atrial fibrillation. He has filled 1C antiarrhythmic. He has significant functional impairment with his atrial fibrillation, and he presents today for a pulmonary vein isolation procedure.
Procedure Note
The patient was brought to the electrophysiology lab in fasting state after signing informed consent. The patient was initially in the nonsedated state. The procedure was performed under general anesthesia. After intubation, local anesthetic was used with 1% lidocaine solution in the right femoral and left femoral veins. Using modified Seldinger technique, access was obtained in the left and right femoral veins. Two 8-French sheaths were placed in the right femoral vein, and a 5-French and a 6-French sheath were placed in the right femoral vein. A 9-French sheath was placed in the left femoral vein. A St.Jude tripolar His catheter was placed across the tricuspid vale and maneuvered to record a large His deflection. A St. Jude 6-French decapolar catheter with lumen was placed in the coronary sinus os. The patient's atrium appeared to be enlarged, and we could not advance the decapolar catheter into the body of the coronary sinus. We used an angioplasty wire which cannulated the coronary sinus, and using a railroad technique, we advanced the decapolar catheter over the angioplasty wire. Venography revealed a moderate –sized coronary sinus. There were no diverticula or aneurysms. Through the left femoral vein, an ACUSON 110 cm intracardiac echocardiographic catheter was placed in the right atrium. There appeared to be a baseline small pericardial effusion. The atrial septum was visualized. There was a very small patent foramen ovale. The patient was presented to the lab in atrial fibrillation, and a transesophageal echocardiogram was performed which revealed normal left ventricular systolic function. He had a very large atrial appendage, and there was no clot formation in the appendage. The intracardiac echocardiographic catheter was used for guidelines and the transseptal puncture. Surface electrograms were then recorded. The patient was in atrial fibrillation. The ventricular response was approximately 100 ms. The QRS duration was 90 ms and the QT interval was 510 ms. Intracardiac intervals revealed HV interval of 52 ms.
Ablation
An 8-French sheath in the right groin was then exchanged for a long Swartz SL1 sheath. This was continuously flushed with heparinized saline. A Brockenbrough needle was used for the transseptal puncture. The puncture site was guided by both intracardiac echocardiography and also, was guided by both intracardiac echocardiography and also, RAO and LAO fluoroscopy. The right atrial pressure was 2 and the left atrial pressure was 3. After the transseptal was performed, left atrial venography revealed appropriate position of the catheter. Continuous hemodynamics was monitored throught an arterial sheath. The second 8-French sheath in the right groin was then exchanged from another Swartz SL1 sheath. A second transseptal was then performed using a brockenbrough needle under both intracardiac echocardiography guidance and also, LAO and RAO visualization. Again, contrast revealed left atrial positioning of both catheters. A decapolar Lasso catheter was then advanced via the Swartz SL1 sheath to the left atrium. A St. Jude Safire Duo irrigated ablation catheter was advanced into the left atrium over an Agilis steerable sheath. This was positioned in the left atrium. A 3-dimensional map of the left atrium was made using St Jude NavX cardiac mapping system. After entire shell was made of the left atrium, separate venography was performed in all 4 pulmonary veins. Venography of all 4 pulmonary veins was performed using Agilis catheter. An irrigated ablation catheter was then positioned in the atrium of each individual coronary vein, and energy to a maximum of 30 watts was given after the Halo catheter was placed in the veins. The patient remained in atrial fibrillation during the entire process. Ablation was performed with continuous transesophageal echocardiography temperate monitoring, and after the transseptal was performed, 7000 units of heparin was given and heparin was re-bolused intermittently to achieve and ACT of greater than 300. Both the left upper pulmonary vein, the left lower pulmonary vein and the right upper pulmonary vein were electrically isolated after the Halo was placed in each vein. The right lower pulmonary vein was small and we could not place the Halo catheter into the body of the vein itself. An anatomic ablation was performed in this area the using irrigated catheter and then the ablation catheter was positioned inside the vein to prove exit block. Ultimately, all 4 veins were electrically isolated. To prove isolation, the patient was electrically cardioverted to sinus rhythm and both right atrial appendage. Left atrial appendage and coronary sinus pacing was performed. This revealed entrance block in all 4 veins. Postablation, the PR interval was 198 ms, the QRS duration was 94 ms and the QT interval was 510 ms. The sinus cycle length was 1080 ms. Intracardiac intervals revealed an AH interval of 120 ms and HV interval of 52 ms. The antegrade Wenckebach cycle length was 526 ms; the block was proximal. The antegrade AV node effective refractory period at a 600-ms drive was 440 ms; the block was proximal. The ablation catheter was then palced in the right ventricular apex. Ventricular pacing revealed no retrograde conduction. Intracardiac echocardiography was then performed which revealed a small, but stable pericardial effusion. Right ventricular and left ventricular function remained stable. All catheters were then removed from the heart. The patient returned to telemetry in stable condition with the sheath sutured in place. The patient received a total of 4 L of fluid during the procedure, and he was give 20 mg of IV Lasix at termation of the procedure. The fluoroscopy time was 68.5 minutes and total contrast was 45 mL.
WHAT CODES WOULD I USE? THANKS
Mr. Patient is a 60-year-old gentleman with persistent atrial fibrillation. He has filled 1C antiarrhythmic. He has significant functional impairment with his atrial fibrillation, and he presents today for a pulmonary vein isolation procedure.
Procedure Note
The patient was brought to the electrophysiology lab in fasting state after signing informed consent. The patient was initially in the nonsedated state. The procedure was performed under general anesthesia. After intubation, local anesthetic was used with 1% lidocaine solution in the right femoral and left femoral veins. Using modified Seldinger technique, access was obtained in the left and right femoral veins. Two 8-French sheaths were placed in the right femoral vein, and a 5-French and a 6-French sheath were placed in the right femoral vein. A 9-French sheath was placed in the left femoral vein. A St.Jude tripolar His catheter was placed across the tricuspid vale and maneuvered to record a large His deflection. A St. Jude 6-French decapolar catheter with lumen was placed in the coronary sinus os. The patient's atrium appeared to be enlarged, and we could not advance the decapolar catheter into the body of the coronary sinus. We used an angioplasty wire which cannulated the coronary sinus, and using a railroad technique, we advanced the decapolar catheter over the angioplasty wire. Venography revealed a moderate –sized coronary sinus. There were no diverticula or aneurysms. Through the left femoral vein, an ACUSON 110 cm intracardiac echocardiographic catheter was placed in the right atrium. There appeared to be a baseline small pericardial effusion. The atrial septum was visualized. There was a very small patent foramen ovale. The patient was presented to the lab in atrial fibrillation, and a transesophageal echocardiogram was performed which revealed normal left ventricular systolic function. He had a very large atrial appendage, and there was no clot formation in the appendage. The intracardiac echocardiographic catheter was used for guidelines and the transseptal puncture. Surface electrograms were then recorded. The patient was in atrial fibrillation. The ventricular response was approximately 100 ms. The QRS duration was 90 ms and the QT interval was 510 ms. Intracardiac intervals revealed HV interval of 52 ms.
Ablation
An 8-French sheath in the right groin was then exchanged for a long Swartz SL1 sheath. This was continuously flushed with heparinized saline. A Brockenbrough needle was used for the transseptal puncture. The puncture site was guided by both intracardiac echocardiography and also, was guided by both intracardiac echocardiography and also, RAO and LAO fluoroscopy. The right atrial pressure was 2 and the left atrial pressure was 3. After the transseptal was performed, left atrial venography revealed appropriate position of the catheter. Continuous hemodynamics was monitored throught an arterial sheath. The second 8-French sheath in the right groin was then exchanged from another Swartz SL1 sheath. A second transseptal was then performed using a brockenbrough needle under both intracardiac echocardiography guidance and also, LAO and RAO visualization. Again, contrast revealed left atrial positioning of both catheters. A decapolar Lasso catheter was then advanced via the Swartz SL1 sheath to the left atrium. A St. Jude Safire Duo irrigated ablation catheter was advanced into the left atrium over an Agilis steerable sheath. This was positioned in the left atrium. A 3-dimensional map of the left atrium was made using St Jude NavX cardiac mapping system. After entire shell was made of the left atrium, separate venography was performed in all 4 pulmonary veins. Venography of all 4 pulmonary veins was performed using Agilis catheter. An irrigated ablation catheter was then positioned in the atrium of each individual coronary vein, and energy to a maximum of 30 watts was given after the Halo catheter was placed in the veins. The patient remained in atrial fibrillation during the entire process. Ablation was performed with continuous transesophageal echocardiography temperate monitoring, and after the transseptal was performed, 7000 units of heparin was given and heparin was re-bolused intermittently to achieve and ACT of greater than 300. Both the left upper pulmonary vein, the left lower pulmonary vein and the right upper pulmonary vein were electrically isolated after the Halo was placed in each vein. The right lower pulmonary vein was small and we could not place the Halo catheter into the body of the vein itself. An anatomic ablation was performed in this area the using irrigated catheter and then the ablation catheter was positioned inside the vein to prove exit block. Ultimately, all 4 veins were electrically isolated. To prove isolation, the patient was electrically cardioverted to sinus rhythm and both right atrial appendage. Left atrial appendage and coronary sinus pacing was performed. This revealed entrance block in all 4 veins. Postablation, the PR interval was 198 ms, the QRS duration was 94 ms and the QT interval was 510 ms. The sinus cycle length was 1080 ms. Intracardiac intervals revealed an AH interval of 120 ms and HV interval of 52 ms. The antegrade Wenckebach cycle length was 526 ms; the block was proximal. The antegrade AV node effective refractory period at a 600-ms drive was 440 ms; the block was proximal. The ablation catheter was then palced in the right ventricular apex. Ventricular pacing revealed no retrograde conduction. Intracardiac echocardiography was then performed which revealed a small, but stable pericardial effusion. Right ventricular and left ventricular function remained stable. All catheters were then removed from the heart. The patient returned to telemetry in stable condition with the sheath sutured in place. The patient received a total of 4 L of fluid during the procedure, and he was give 20 mg of IV Lasix at termation of the procedure. The fluoroscopy time was 68.5 minutes and total contrast was 45 mL.
WHAT CODES WOULD I USE? THANKS