bhargavi
Guru
do i add modifer FB due to fidelis lead recall as a facility coder, or i am thinking of 33249,33241
OPERATION PERFORMED
1. Biventricular pacing implantable cardioverter-defibrillator pulse
generator explantation and replacement.
2. Right ventricular implantable cardioverter-defibrillator replacement
cutting and capping the old Fidelis recalled right ventricular lead and
placement of a new right ventricular implantable
cardioverter-defibrillator lead.
ANESTHESIA
MAC
COMPLICATION(S)
None.
ESTIMATED BLOOD LOSS
5 ml.
Defibrillator threshold testing not performed due to the presence of atrial
fibrillation with a subtherapeutic INR of 1.8.
HARDWARE IMPLANTED
1. Medtronic Viva XT biventricular pacing implantable
cardioverter-defibrillator pulse generator model number DTBA1D4, serial
number BLE212089 H.
2. Medtronic active fixation right ventricular lead model number 6935M-55,
serial number TDL123337V.
Hardware cut, capped and abandoned Medtronic Fidelis lead model number 6949-65,
serial number LFJ186618V implanted on 5/19/2006.
OPERATIVE NOTE
The patient brought to the electrophysiology laboratory in the postabsorptive
state. She was prepped, draped in usual sterile fashion. Left upper chest was
anesthetized with 10 ml of a 50/50 mixture of 0.25% Marcaine. She says
lidocaine. An incision was made over the old scar and this and dissection
performed down to the pocket where the pocket was incised, generator delivered.
Subclavian access was obtained. A tearaway sheath followed by placement of the
right ventricular lead and superior vena cava and fluoroscopic guidance
assisted placement the right ventricular lead into the right ventricular apex.
Multiple right ventricular sites were tested and the R-wave was rather
diminutive diffusely in the 1.5 to 5 range. Ultimately an adequate spot was
obtained. The right ventricular lead was anchored to the pectoralis fascia
using Ethibond. The old left ventricular lead was tested. The atrial lead
showed persistent atrial fibrillation. The left ventricular lead had an
impedance of 532 ohms, pacing threshold 1.0 volts at 0.6 milliseconds pulse
width. The new right ventricular lead had an R wave of 5 mV, impedance 550
ohms with a threshold of 0.5 volts of 0.5 milliseconds pulse width. The atrial
lead showed a 0.5 mV atrial fibrillation wave impedance 342 ohms and pacing was
not obtainable. Defibrillator threshold testing was not performed due to
subtherapeutic INR. The new right ventricular lead is a single coil lead
placed on the septum just above the old right ventricular lead. No leads are
secured to the device placed in the pocket. The inferomedial aspect of the
pocket was expanded to accommodate the new device. The pocket was irrigated
with antibiotic solution and hemostasis was assisted with placement arrest in
the pocket. The incision was closed in three layers, the lower two with
running 2-0 Vicryl and cutaneous with 4-0 Vicryl. Steri-Strips and dry sterile
dressing were placed over the wound. The patient was transferred to the
Postanesthesia Care Unit in stable condition for recovery from anesthesia. The
device was left programmed as previously VVIR 75-120. The device was by
atrioventricular pacing consistently.
OPERATION PERFORMED
1. Biventricular pacing implantable cardioverter-defibrillator pulse
generator explantation and replacement.
2. Right ventricular implantable cardioverter-defibrillator replacement
cutting and capping the old Fidelis recalled right ventricular lead and
placement of a new right ventricular implantable
cardioverter-defibrillator lead.
ANESTHESIA
MAC
COMPLICATION(S)
None.
ESTIMATED BLOOD LOSS
5 ml.
Defibrillator threshold testing not performed due to the presence of atrial
fibrillation with a subtherapeutic INR of 1.8.
HARDWARE IMPLANTED
1. Medtronic Viva XT biventricular pacing implantable
cardioverter-defibrillator pulse generator model number DTBA1D4, serial
number BLE212089 H.
2. Medtronic active fixation right ventricular lead model number 6935M-55,
serial number TDL123337V.
Hardware cut, capped and abandoned Medtronic Fidelis lead model number 6949-65,
serial number LFJ186618V implanted on 5/19/2006.
OPERATIVE NOTE
The patient brought to the electrophysiology laboratory in the postabsorptive
state. She was prepped, draped in usual sterile fashion. Left upper chest was
anesthetized with 10 ml of a 50/50 mixture of 0.25% Marcaine. She says
lidocaine. An incision was made over the old scar and this and dissection
performed down to the pocket where the pocket was incised, generator delivered.
Subclavian access was obtained. A tearaway sheath followed by placement of the
right ventricular lead and superior vena cava and fluoroscopic guidance
assisted placement the right ventricular lead into the right ventricular apex.
Multiple right ventricular sites were tested and the R-wave was rather
diminutive diffusely in the 1.5 to 5 range. Ultimately an adequate spot was
obtained. The right ventricular lead was anchored to the pectoralis fascia
using Ethibond. The old left ventricular lead was tested. The atrial lead
showed persistent atrial fibrillation. The left ventricular lead had an
impedance of 532 ohms, pacing threshold 1.0 volts at 0.6 milliseconds pulse
width. The new right ventricular lead had an R wave of 5 mV, impedance 550
ohms with a threshold of 0.5 volts of 0.5 milliseconds pulse width. The atrial
lead showed a 0.5 mV atrial fibrillation wave impedance 342 ohms and pacing was
not obtainable. Defibrillator threshold testing was not performed due to
subtherapeutic INR. The new right ventricular lead is a single coil lead
placed on the septum just above the old right ventricular lead. No leads are
secured to the device placed in the pocket. The inferomedial aspect of the
pocket was expanded to accommodate the new device. The pocket was irrigated
with antibiotic solution and hemostasis was assisted with placement arrest in
the pocket. The incision was closed in three layers, the lower two with
running 2-0 Vicryl and cutaneous with 4-0 Vicryl. Steri-Strips and dry sterile
dressing were placed over the wound. The patient was transferred to the
Postanesthesia Care Unit in stable condition for recovery from anesthesia. The
device was left programmed as previously VVIR 75-120. The device was by
atrioventricular pacing consistently.