Would someone care to look at this report with me and help me decipher this note? I am new to coding for cath lab procedures and am struggling with this note. I have 37211 for the EKOS. I'm thinking 93452 and 93462 for the heart cath. I am having trouble finding something to cover the repair of the mitral valve. I appreciate any help!
PROCEDURES PERFORMED
1. Trans-septal left heart catheterization.
2. Retrograde left heart catheterization.
3. Left atrial angiography.
4. Transcatheter repair of thrombosed prosthetic mitral valve.
5. Placement of left atrial thrombolytic infusion catheter (EKOS) with
thrombolytic infusion.
INDICATION: Thrombosed mechanical mitral valve prosthesis.
DESCRIPTION OF PROCEDURE: The procedure, risks, and alternatives were
explained in detail to the patient's family. This procedure was performed
on an emergency basis. The patient had severe heart failure with a high
likelihood of death within minutes. All decisions were made by a
multidisciplinary team including ICU Cardiology, imaging, and
interventional. The patient was felt to be inoperable. The risks of
stroke and death were clearly explained to the patient's family and the
family requested that we proceed with any possible life-saving
intervention. The patient was taken to the catheterization laboratory
where transesophageal echocardiography was performed. A St. Jude mitral
valve mechanical prosthesis was identified and both of the leaflets were
involved. One leaflet was completely immobile in the closed position, and
the other leaflet was partially closed and nearly immobile. The right
femoral artery and vein were accessed and sheaths were placed. A
trans-septal puncture was performed under TEE guidance and simultaneous
LA/LV pressure data were recorded. A left atrial pressure of approximately
50 mmHg was recorded, along with a transmitral gradient of approximately 30
mmHg. The valve was approached with an Agilis catheter and the rigid end
of an Amplatz Super Stiff guidewire fashioned into a hook. The hinge
points on the mitral prosthesis were manipulated with the tip of the hook
until the leaflets moved freely. Pressure data were followed and the left
atrial pressure dropped abruptly with mobilization of the leaflets. The
transmitral gradient dropped to nearly 0.
At that point, an EKOS catheter was placed in the left atrium around the
mitral valve and the Agilis catheter was withdrawn to the right atrium.
The catheters were sutured in place and a thrombolytic infusion was begun.
Sterile dressings were applied. The patient was given intravenous heparin
to achieve a therapeutic ACT, and rocuronium to avoid any movement that
might dislodge the catheter. The patient was returned to her ICU bed in
stable condition with no apparent complications.
RESULTS AND CONCLUSIONS
1. Thrombosed St. Jude mitral valve prosthesis with extremely high
transmitral pressure gradient.
2. Successful mechanical mobilization of both mitral valve occluder
leaflets.
RECOMMENDATIONS
1. Six to twelve hours of ultrasound-assisted thrombolysis.
2. Follow-up transesophageal echocardiography.
PROCEDURES PERFORMED
1. Trans-septal left heart catheterization.
2. Retrograde left heart catheterization.
3. Left atrial angiography.
4. Transcatheter repair of thrombosed prosthetic mitral valve.
5. Placement of left atrial thrombolytic infusion catheter (EKOS) with
thrombolytic infusion.
INDICATION: Thrombosed mechanical mitral valve prosthesis.
DESCRIPTION OF PROCEDURE: The procedure, risks, and alternatives were
explained in detail to the patient's family. This procedure was performed
on an emergency basis. The patient had severe heart failure with a high
likelihood of death within minutes. All decisions were made by a
multidisciplinary team including ICU Cardiology, imaging, and
interventional. The patient was felt to be inoperable. The risks of
stroke and death were clearly explained to the patient's family and the
family requested that we proceed with any possible life-saving
intervention. The patient was taken to the catheterization laboratory
where transesophageal echocardiography was performed. A St. Jude mitral
valve mechanical prosthesis was identified and both of the leaflets were
involved. One leaflet was completely immobile in the closed position, and
the other leaflet was partially closed and nearly immobile. The right
femoral artery and vein were accessed and sheaths were placed. A
trans-septal puncture was performed under TEE guidance and simultaneous
LA/LV pressure data were recorded. A left atrial pressure of approximately
50 mmHg was recorded, along with a transmitral gradient of approximately 30
mmHg. The valve was approached with an Agilis catheter and the rigid end
of an Amplatz Super Stiff guidewire fashioned into a hook. The hinge
points on the mitral prosthesis were manipulated with the tip of the hook
until the leaflets moved freely. Pressure data were followed and the left
atrial pressure dropped abruptly with mobilization of the leaflets. The
transmitral gradient dropped to nearly 0.
At that point, an EKOS catheter was placed in the left atrium around the
mitral valve and the Agilis catheter was withdrawn to the right atrium.
The catheters were sutured in place and a thrombolytic infusion was begun.
Sterile dressings were applied. The patient was given intravenous heparin
to achieve a therapeutic ACT, and rocuronium to avoid any movement that
might dislodge the catheter. The patient was returned to her ICU bed in
stable condition with no apparent complications.
RESULTS AND CONCLUSIONS
1. Thrombosed St. Jude mitral valve prosthesis with extremely high
transmitral pressure gradient.
2. Successful mechanical mobilization of both mitral valve occluder
leaflets.
RECOMMENDATIONS
1. Six to twelve hours of ultrasound-assisted thrombolysis.
2. Follow-up transesophageal echocardiography.