bhargavi
Guru
Attempted dual-chamber biventricular implantable cardioverter defibrillator
implant.
INDICATION
A 73-year-old white female with anxiety, depression, coronary artery disease
status post coronary artery bypass graft in 1988 and again in 2000, previous
percutaneous coronary intervention to the saphenous vein graft to the right
coronary artery on September 2014, myocardial infarction, triple-vessel
disease, ischemic cardiomyopathy with left ventricular dysfunction, diabetes
mellitus type 2, chronic kidney disease, stage III, hypertension,
hyperlipidemia, peripheral artery disease, with subclavian artery stenosis
status post percutaneous coronary intervention to the left subclavian on
January 19, 2014, with stent placement, cerebrovascular accident, chronic left
bundle branch block, hyperlipidemia, obesity, chronic obstructive pulmonary
disease on home O2, chronic kidney disease, limited ambulation, lower extremity
edema with gait instability, equilibrium problem, now admitted for DDD
biventricular implantable cardioverter defibrillator implantation.
Previous echocardiogram on May 20, 2014 noted the ejection fraction of 30 to 35
percent, with left bundle branch block at that time. The patient's repeat echo
on December 9, 2014 shows an ejection fraction of 25 to 30 percent with no
significant change post recent percutaneous coronary intervention subclavian on
September 9, 2014, and a last right coronary artery stent placement to the vein
graft on September 2014.
The patient this time fills MADIT-II criteria for implantable cardioverter
defibrillator implantation, criteria for depressed ejection fraction, New York
Heart Association Class 2 symptoms with systolic dysfunction, but not fills
MADIT-II criteria but also criteria for upgrade to a biventricular implantable
cardioverter defibrillator system in light of chronic left bundle branch block
with QRS duration in excess of 120 milliseconds in addition.
Risks and benefits were explained to the patient preoperatively. Risks
including, "bleeding, infection, irregular heartbeat, chest pain, heart attack,
death, hole in the heart, hole in the lungs, stroke, as well as potential
contrast reaction and renal failure with a long-standing history of diabetes
mellitus, with a creatinine of 2.1".
Risks and benefits reviewed. The patient signed informed consent. Preoperative
and antibiotic vancomycin was given as per routine. Due to his
immunocompromised patient with protected long procedure as well as conscious
sedation as administered per anesthesia.
PROCEDURE IN DETAIL
The bilateral groins were prepped and draped in usual sterile fashion. Two
percent lidocaine solutions were infiltrated the right groin. At this point in
time, I placed a right femoral venous line for central venous access, which is
a 6-French sheath in right femoral vein. A right femoral arterial line,
5-French sheath was placed in a right femoral artery to allow for hemodynamic
monitoring perioperatively.
At this point in time, I moved to the chest region. The left chest was prepped
and draped in usual sterile fashion. 0.25 percent Sensorcaine and 2 percent
lidocaine solutions were infiltrated into the left prepectoral space.
At this point, a left axillary/subclavian venogram was performed to visualize
the central circulation.
I developed a left prepectoral pocket after I made an incision
infraclavicularly. A 8 pocket was then developed using blunt and sharp
dissection.
At this point, in Trendelenburg position, I used the venogram for roadmap to
allow for central venous access. Two subclavian punctures were then performed
with access to the central venous system.
I was able to use a micropuncture kit with subsequent upgrade using
sheath/guidewire technique to place two 85 centimeter Terumo guidewires into
the central circulation.
At this point, I used a 9 and 6-French sheath to insert both right femoral,
right-sided implantable cardioverter defibrillator lead as well as right atrial
lead into the central circulation using sheath/guidewire technique. The right
ventricular lead was placed in a right ventricular apical septal region. The
right atrial lead was placed in a right anterolateral atrial appendage atrial
wall region. Satisfactory positioning was confirmed. This was confirmed with
fluoroscopic electrogram and threshold data. Upon completion, I introduced a
10-French sheath using the second guidewire into the central circulation. I did
use a Medtronic Attain guiding sheath which was a 50-S sheath that was shaped
into a curve. I was able to use a 4 pole Mariner steerable catheter, and tried
to access the coronary sinus.
I was having great difficulty accessing the coronary sinus. Nevertheless, I did
manage to place the guiding catheter into what I felt was the ostium of a
seemingly occluded coronary sinus. I was able to obtain satisfactory
electrograms confirming that I was in the coronary sinus. However, this
coronary sinus had nothing more than a stump. I as not able to insert a sheath.
I was able to actually place a guiding sheath for venogram to confirm total
occlusion, however, on multiple attempts, I was never able to get into the
coronary sinus. On one episode had an amputated the coronary sinus, probably
about a 0.5 centimeter in length. I did note that there were multiple vascular
clips in the posterior aspect of the heart which I suspect probably did manage
to clamp off the coronary sinus during one of her two coronary artery bypass
grafting surgeries.
After a long process of trying to confirm an occluded coronary sinus, I finally
abandoned the course of the venous access with some transient venography.
At this point in time, I did abandon the CS lead placement.
Both right atrial and ventricular leads were then re-evaluated and fixed to the
fascial plane using 2-0 Ethibond suture.
The pocket was irrigated with antibiotic solution. Electrocautery along with
Arista powder was used x2 for hemostasis. The patient has been on aspirin and
Plavix which is favored significant venous oozing and generalized oozing in the
pocket site.
The lead tips of the acute right atrial and right ventricular leads were then
cleaned and dried and placed into the new implantable
cardioverter-defibrillator header. The patient received a dual-chamber
implantable cardioverter defibrillator generator.
There were no future plans to insert an epicardial left ventricular lead as the
patient had two previous bypass surgeries, and we would not be able to easily
access the myocardium in light of these surgeries and also for fear of
disrupting her existing epicardial grafts and favoring more quickly
complications.
At this point, the patient was downgraded from a biventricular implantable
cardioverter defibrillator to a dual-chamber implantable cardioverter
defibrillator system.
At this point, the lead tips were cleaned and dried and placed into the
implantable cardioverter-defibrillator header. The implantable cardioverter
defibrillator leads were then inserted into the prepectoral pocket.
The implantable cardioverter defibrillator generator was tacked to the fascial
plane using 2-0 Ethibond sutures to prevent it from migrating inferiorly.
The wound was then closed in three layers. The first two layers were closed
using 0 Vicryl suture in running stitch configuration. The subcuticular layer
was closed using 4-0 Monocryl suture.
The wound was then dressed using Mastisol, half-inch Steri-Strips, plain white
gauze, and Tegaderm dressing. The patient tolerated the procedure well without
complication.
Acute thresholds measured the PSA at time of implant noted a P-wave to be 2.4
millivolts. The atrial pacing threshold was 0.5 milliseconds at 1.4 volts with
impedance of 520 ohms. The mA was 2.1. The slew rate in the atrium is 0.4
volts/second. The right ventricle R-wave was 20.0 millivolts. The right
ventricle impedance 680 ohms. The right ventricle pacing threshold was 0.5
milliseconds at 0.5 volts with an mA of 0.6. The slew rate was 2.7 volts/second.
Repeat threshold testing through the device once attached now noted a P-wave to
be 2.5 millivolts. The atrial pacing threshold was 0.5 millisecond. 0.75 volts
with impedance of 490 ohms. The right ventricle R-wave was 12.0 millivolts. The
right ventricle pacing threshold was 0.5 milliseconds at 0.5 volts with
impedance of 660 ohms.
The noninvasive HV impedance was 42 ohms.
The patient underwent defibrillation threshold testing as per routine. The
patient induced with a "DC fibber" induction. The patient was induced into
ventricular fibrillation. Patient had 1 1 sensing at least sensitive
sensitivity. The patient received a 25 joule shock with a shock impedance of 42
ohms and a charge time of 5.6 seconds with prompt restoration of sinus rhythm.
After a 5 minute interval we repeated the induction. Again we induced with a
"DC fibber" induction. Ventricular fibrillation was induced. We had 1 1 sensing
at least sensitive sensitivity. The patient received a 25 joule shock with a
shock impedance of 41 ohms and a charge time of 5.4 seconds.
Implanted hardware at this time includes a Saint Jude device model CD 2411-36Q,
serial number 7138002 device. The right atrial lead is a Saint Jude model 208
TC-46 centimeter bipolar active fixation lead, serial number CNX 037851. The RV
lead is a Saint Jude, model 7120Q-58 centimeter bipolar active fixation lead,
serial number BNP 044978.
CONCLUSION
1. Successful DDD implantable cardioverter defibrillator implantation.
2. Successful left axillary/subclavian venogram to visualize the central
circulation and provide a roadmap for central venous access.
3. Central venous access for an attempt to cannulate the coronary sinus. I did
place an Attain guide sheath in there and shoot multiple attempts at
venography, as well as multiple mapping of an aborted stump of the coronary
sinus. However, the coronary sinus was occluded and the LV lead placement
was abandoned.
4. Defibrillation threshold testing was performed.
5. The patient also had a right femoral central venous line inserted as well as
a right femoral arterial line inserted as per routine in these patients with
compromise cardiac function.
6. Defibrillation threshold was also performed as per routine to confirm
satisfactory implantable cardioverter defibrillator function at the time of
implant.
thanks for all your help in advance
i had used 33249,93641,75820.
pl advise. i got denial from medicare
implant.
INDICATION
A 73-year-old white female with anxiety, depression, coronary artery disease
status post coronary artery bypass graft in 1988 and again in 2000, previous
percutaneous coronary intervention to the saphenous vein graft to the right
coronary artery on September 2014, myocardial infarction, triple-vessel
disease, ischemic cardiomyopathy with left ventricular dysfunction, diabetes
mellitus type 2, chronic kidney disease, stage III, hypertension,
hyperlipidemia, peripheral artery disease, with subclavian artery stenosis
status post percutaneous coronary intervention to the left subclavian on
January 19, 2014, with stent placement, cerebrovascular accident, chronic left
bundle branch block, hyperlipidemia, obesity, chronic obstructive pulmonary
disease on home O2, chronic kidney disease, limited ambulation, lower extremity
edema with gait instability, equilibrium problem, now admitted for DDD
biventricular implantable cardioverter defibrillator implantation.
Previous echocardiogram on May 20, 2014 noted the ejection fraction of 30 to 35
percent, with left bundle branch block at that time. The patient's repeat echo
on December 9, 2014 shows an ejection fraction of 25 to 30 percent with no
significant change post recent percutaneous coronary intervention subclavian on
September 9, 2014, and a last right coronary artery stent placement to the vein
graft on September 2014.
The patient this time fills MADIT-II criteria for implantable cardioverter
defibrillator implantation, criteria for depressed ejection fraction, New York
Heart Association Class 2 symptoms with systolic dysfunction, but not fills
MADIT-II criteria but also criteria for upgrade to a biventricular implantable
cardioverter defibrillator system in light of chronic left bundle branch block
with QRS duration in excess of 120 milliseconds in addition.
Risks and benefits were explained to the patient preoperatively. Risks
including, "bleeding, infection, irregular heartbeat, chest pain, heart attack,
death, hole in the heart, hole in the lungs, stroke, as well as potential
contrast reaction and renal failure with a long-standing history of diabetes
mellitus, with a creatinine of 2.1".
Risks and benefits reviewed. The patient signed informed consent. Preoperative
and antibiotic vancomycin was given as per routine. Due to his
immunocompromised patient with protected long procedure as well as conscious
sedation as administered per anesthesia.
PROCEDURE IN DETAIL
The bilateral groins were prepped and draped in usual sterile fashion. Two
percent lidocaine solutions were infiltrated the right groin. At this point in
time, I placed a right femoral venous line for central venous access, which is
a 6-French sheath in right femoral vein. A right femoral arterial line,
5-French sheath was placed in a right femoral artery to allow for hemodynamic
monitoring perioperatively.
At this point in time, I moved to the chest region. The left chest was prepped
and draped in usual sterile fashion. 0.25 percent Sensorcaine and 2 percent
lidocaine solutions were infiltrated into the left prepectoral space.
At this point, a left axillary/subclavian venogram was performed to visualize
the central circulation.
I developed a left prepectoral pocket after I made an incision
infraclavicularly. A 8 pocket was then developed using blunt and sharp
dissection.
At this point, in Trendelenburg position, I used the venogram for roadmap to
allow for central venous access. Two subclavian punctures were then performed
with access to the central venous system.
I was able to use a micropuncture kit with subsequent upgrade using
sheath/guidewire technique to place two 85 centimeter Terumo guidewires into
the central circulation.
At this point, I used a 9 and 6-French sheath to insert both right femoral,
right-sided implantable cardioverter defibrillator lead as well as right atrial
lead into the central circulation using sheath/guidewire technique. The right
ventricular lead was placed in a right ventricular apical septal region. The
right atrial lead was placed in a right anterolateral atrial appendage atrial
wall region. Satisfactory positioning was confirmed. This was confirmed with
fluoroscopic electrogram and threshold data. Upon completion, I introduced a
10-French sheath using the second guidewire into the central circulation. I did
use a Medtronic Attain guiding sheath which was a 50-S sheath that was shaped
into a curve. I was able to use a 4 pole Mariner steerable catheter, and tried
to access the coronary sinus.
I was having great difficulty accessing the coronary sinus. Nevertheless, I did
manage to place the guiding catheter into what I felt was the ostium of a
seemingly occluded coronary sinus. I was able to obtain satisfactory
electrograms confirming that I was in the coronary sinus. However, this
coronary sinus had nothing more than a stump. I as not able to insert a sheath.
I was able to actually place a guiding sheath for venogram to confirm total
occlusion, however, on multiple attempts, I was never able to get into the
coronary sinus. On one episode had an amputated the coronary sinus, probably
about a 0.5 centimeter in length. I did note that there were multiple vascular
clips in the posterior aspect of the heart which I suspect probably did manage
to clamp off the coronary sinus during one of her two coronary artery bypass
grafting surgeries.
After a long process of trying to confirm an occluded coronary sinus, I finally
abandoned the course of the venous access with some transient venography.
At this point in time, I did abandon the CS lead placement.
Both right atrial and ventricular leads were then re-evaluated and fixed to the
fascial plane using 2-0 Ethibond suture.
The pocket was irrigated with antibiotic solution. Electrocautery along with
Arista powder was used x2 for hemostasis. The patient has been on aspirin and
Plavix which is favored significant venous oozing and generalized oozing in the
pocket site.
The lead tips of the acute right atrial and right ventricular leads were then
cleaned and dried and placed into the new implantable
cardioverter-defibrillator header. The patient received a dual-chamber
implantable cardioverter defibrillator generator.
There were no future plans to insert an epicardial left ventricular lead as the
patient had two previous bypass surgeries, and we would not be able to easily
access the myocardium in light of these surgeries and also for fear of
disrupting her existing epicardial grafts and favoring more quickly
complications.
At this point, the patient was downgraded from a biventricular implantable
cardioverter defibrillator to a dual-chamber implantable cardioverter
defibrillator system.
At this point, the lead tips were cleaned and dried and placed into the
implantable cardioverter-defibrillator header. The implantable cardioverter
defibrillator leads were then inserted into the prepectoral pocket.
The implantable cardioverter defibrillator generator was tacked to the fascial
plane using 2-0 Ethibond sutures to prevent it from migrating inferiorly.
The wound was then closed in three layers. The first two layers were closed
using 0 Vicryl suture in running stitch configuration. The subcuticular layer
was closed using 4-0 Monocryl suture.
The wound was then dressed using Mastisol, half-inch Steri-Strips, plain white
gauze, and Tegaderm dressing. The patient tolerated the procedure well without
complication.
Acute thresholds measured the PSA at time of implant noted a P-wave to be 2.4
millivolts. The atrial pacing threshold was 0.5 milliseconds at 1.4 volts with
impedance of 520 ohms. The mA was 2.1. The slew rate in the atrium is 0.4
volts/second. The right ventricle R-wave was 20.0 millivolts. The right
ventricle impedance 680 ohms. The right ventricle pacing threshold was 0.5
milliseconds at 0.5 volts with an mA of 0.6. The slew rate was 2.7 volts/second.
Repeat threshold testing through the device once attached now noted a P-wave to
be 2.5 millivolts. The atrial pacing threshold was 0.5 millisecond. 0.75 volts
with impedance of 490 ohms. The right ventricle R-wave was 12.0 millivolts. The
right ventricle pacing threshold was 0.5 milliseconds at 0.5 volts with
impedance of 660 ohms.
The noninvasive HV impedance was 42 ohms.
The patient underwent defibrillation threshold testing as per routine. The
patient induced with a "DC fibber" induction. The patient was induced into
ventricular fibrillation. Patient had 1 1 sensing at least sensitive
sensitivity. The patient received a 25 joule shock with a shock impedance of 42
ohms and a charge time of 5.6 seconds with prompt restoration of sinus rhythm.
After a 5 minute interval we repeated the induction. Again we induced with a
"DC fibber" induction. Ventricular fibrillation was induced. We had 1 1 sensing
at least sensitive sensitivity. The patient received a 25 joule shock with a
shock impedance of 41 ohms and a charge time of 5.4 seconds.
Implanted hardware at this time includes a Saint Jude device model CD 2411-36Q,
serial number 7138002 device. The right atrial lead is a Saint Jude model 208
TC-46 centimeter bipolar active fixation lead, serial number CNX 037851. The RV
lead is a Saint Jude, model 7120Q-58 centimeter bipolar active fixation lead,
serial number BNP 044978.
CONCLUSION
1. Successful DDD implantable cardioverter defibrillator implantation.
2. Successful left axillary/subclavian venogram to visualize the central
circulation and provide a roadmap for central venous access.
3. Central venous access for an attempt to cannulate the coronary sinus. I did
place an Attain guide sheath in there and shoot multiple attempts at
venography, as well as multiple mapping of an aborted stump of the coronary
sinus. However, the coronary sinus was occluded and the LV lead placement
was abandoned.
4. Defibrillation threshold testing was performed.
5. The patient also had a right femoral central venous line inserted as well as
a right femoral arterial line inserted as per routine in these patients with
compromise cardiac function.
6. Defibrillation threshold was also performed as per routine to confirm
satisfactory implantable cardioverter defibrillator function at the time of
implant.
thanks for all your help in advance
i had used 33249,93641,75820.
pl advise. i got denial from medicare