Hi. I am brand new to Cardiology coding and need help with a difficult (for me) case. Thanks in advance for your help!! 
Here goes.
The left subclavian site was infiltrated with 1% lidodaine. A 7French sheath was placed in the vein without difficulty. The pocket was created using sharp and blunt dissection. A second 7 French sheath was placed. Gauze soaked with tobramycin was placed in the pocket.
We attempted to place the pacemaker wire but it did not go in the expected course to the superior vena cava. It was removed. A venogram showed persistent left superior vena cava going into a markedly dilated coronary sinus and then into the atrium. I felt that we would not be able to negotiate these angles to place wires into the right ventricle and so the sheaths were pulled. Hemostasis obtained by manual pressure. Gauze was removed from the pocket. The pocket was closed with 2-0 Vicryl and Steri-Strips.
The right subclavian site was then infiltrated with 2% lidocaine. Two sheaths were placed in the vein and a pocket was created as on the left. Prior to doing this we performed a venogram on the right confirming patency through the superior vena cava into the right atrium. We then tried to place a right ventricular lead into the right ventricle. The majority of the time it would go into the dilated coronary sinus and vena cava. At times we did enter the right ventricle, but the wire would not go into the apex no matter how we tried. We had significant ventricular ectopy during this time. The wire would go out the pulmonary artery. After multiple wires, we then tried to get a wire placed into the right ventricular apex using a 6 French JR-4 coronary diagnostic catheter. This was unsuccessful. Again, anytime we entered the right ventricle the wire would not go into the apex but would be deflected upward into the pulmonary artery or out into the coronary sinus again. We also tried a multipurpose catheter.
We decided to terminate the case.
The sheaths were pulled with hemostasis by manual pressure. The gauze was removed from the pocket. It was thoroughly irrigated with saline and tobramycin solution. The pocket was closed with 2-0 Vicryl. This gave a good skin closure which was reinforced with Steri-Strips.
Here goes.The left subclavian site was infiltrated with 1% lidodaine. A 7French sheath was placed in the vein without difficulty. The pocket was created using sharp and blunt dissection. A second 7 French sheath was placed. Gauze soaked with tobramycin was placed in the pocket.
We attempted to place the pacemaker wire but it did not go in the expected course to the superior vena cava. It was removed. A venogram showed persistent left superior vena cava going into a markedly dilated coronary sinus and then into the atrium. I felt that we would not be able to negotiate these angles to place wires into the right ventricle and so the sheaths were pulled. Hemostasis obtained by manual pressure. Gauze was removed from the pocket. The pocket was closed with 2-0 Vicryl and Steri-Strips.
The right subclavian site was then infiltrated with 2% lidocaine. Two sheaths were placed in the vein and a pocket was created as on the left. Prior to doing this we performed a venogram on the right confirming patency through the superior vena cava into the right atrium. We then tried to place a right ventricular lead into the right ventricle. The majority of the time it would go into the dilated coronary sinus and vena cava. At times we did enter the right ventricle, but the wire would not go into the apex no matter how we tried. We had significant ventricular ectopy during this time. The wire would go out the pulmonary artery. After multiple wires, we then tried to get a wire placed into the right ventricular apex using a 6 French JR-4 coronary diagnostic catheter. This was unsuccessful. Again, anytime we entered the right ventricle the wire would not go into the apex but would be deflected upward into the pulmonary artery or out into the coronary sinus again. We also tried a multipurpose catheter.
We decided to terminate the case.
The sheaths were pulled with hemostasis by manual pressure. The gauze was removed from the pocket. It was thoroughly irrigated with saline and tobramycin solution. The pocket was closed with 2-0 Vicryl. This gave a good skin closure which was reinforced with Steri-Strips.