I have a different situation here and not sure how to go about coding it. Basically the plan was to put in a single chamber ICD. Patient had a cardiac arrest on the table. The provider already had the ICD lead open so he put that in but then put in a pacemaker pulse generator. I can't use the 33207 because he only put in the pacemaker generator. I don't feel I can use 33212 because it wasn't an existing lead as he just inserted it in this session. Do I use 33249 with a -53 as that was what the original plan for the procedure was going to be? I would love to hear comments.
PROCEDURES PERFORMED:
1. RV ICD lead placement.
2. Single chamber pacemaker pulse generator placement.
PREOPERATIVE DIAGNOSES:
1. Ischemic cardiomyopathy.
2. Severe left ventricular dysfunction.
3. Diabetes.
POSTOPERATIVE DIAGNOSES:
1. Ischemic cardiomyopathy.
2. Severe left ventricular dysfunction.
3. Diabetes.
4. Asystolic cardiac arrest.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: Minimal.
ANESTHESIA: Initially, local Lidocaine and IV Versed and Fentanyl. The patient required management by the anesthesiology service in the middle of the procedure.
COMPLICATIONS: Asystolic cardiac arrest, as detailed below.
INDICATION FOR PROCEDURE: The patient is a 67-year-old man with ischemic cardiomyopathy and severe LV dysfunction on optimal medical therapy. He is admitted with acute decompensated heart failure. The patient has been improved after IV diuresis as inpatient. He underwent angiography which showed no new ischemic lesions immediately prior to this procedure. He was referred for ICD for sudden cardiac death prevention.
DESCRIPTION OF PROCEDURE: The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient. He provided informed written consent. The patient was already in the catheterization lab as he had undergone coronary angiography immediately prior to this procedure. Left upper extremity venography confirmed a patent left subclavian system.
The patient was prepped and draped in the usual sterile fashion. Lidocaine was used to anesthetize the left pectoral region. Using a scalpel, a 4 cm incision was made over the left deltopectoral groove. Using blunt dissection and brief bursts of electrocautery, a device pocket was developed superficial to the pectoralis fascia.
Left cephalic vein isolation was then performed under direct visualization using blunt dissection. The vein was isolated and 0 silk ties were placed. The vein was accessed under direct visualization with a 20-gauge Angiocath. A Terumo Glidewire was then able to be advanced to the level of the IVC.
The patient then became very agitated. His SpO2 remained stable, as did his blood pressure and heart rate. His rhythm was sinus bradycardia in the 50s as it had been throughout the case. The patient had continued agitation and had received a total of 2 mg IV Versed and 75 mcg IV Fentanyl. He was also given 25 mg IV Benadryl. Given his ongoing agitation and the nature of the procedure, with planned intracardiac lead placement, Anesthesiology was called for assistance with the procedure. After arrival of the anesthesiology service, the patient was stabilized with stable SpO2, blood pressure, and heart rate. His agitation had improved.
As the cephalic access had proven difficult in the setting of his agitation, the Terumo wire was removed and the cephalic vein ties were secured with 0 silk x2 total. The plan was for left subclavian venous access for placement of the ICD lead. As preparations were being made for subclavian access, the patient was noted to rapidly lose his heart rate, going from sinus bradycardia in the 50s immediately to asystole. He was given several rounds of Atropine and Epinephrine immediately. CPR was also started immediately. The patient was then intubated emergently by the anesthesiologist. Narcan 0.4 mg was given. As no endocardial leads had been placed, transcutaneous pacing was used for a short time.
The patient was able to regain a rhythm, with sinus tachycardia in the 130s after several rounds of medications. He had a present carotid pulse and was started on Dopamine at 20 mcg peripherally. The patient's initial blood pressure was then 180 systolic. The Dopamine was then weaned rapidly to off. The patient's SpO2 with then stabilized in the high 90s on the ventilator. His blood pressure was 130 systolic or better. His heart rate was 130s in sinus tachycardia.
As the pocket had already been created and the ICD lead had already been opened, we proceeded with implantation of that lead and a single-chamber pacemaker to prevent further bradyarrhythmias.
Left subclavian venous access was then obtained with an introducer needle and a wire advanced under fluoroscopic guidance. A 9-French sheath was then placed over the wire. The RV ICD lead was then advanced under fluoroscopic guidance to the RV apical septum. The active fixation mechanism was deployed. Appropriate sensing, threshold, and impedance values were obtained. The sheath was then split and removed. The lead was then secured to the underlying tissue with 0 silk x2.
The wound was irrigated with copious Bacitracin and saline solution. The single-chamber pacemaker pulse generator was then connected to the lead with the appropriate torque wrench. The shocking coil was capped. The device and lead assembly was then placed in the cleaned pocket. The device was secured to the underlying tissue with 0 silk x1. The wound was then closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material in the fascial, subcutaneous, and subcuticular layers, respectively. Steri-Strips and a Tegaderm dressing as well as a pressure dressing were placed.
The patient remained intubated and was transferred to the ICU in stable but critical condition. The ICU service was contacted regarding any recommendations regarding cooling protocol. Their recommendation thus far had been for observation of neurologic status prior to initiation.
The patient's family was updated of all these events. All their questions were answered.
IMPLANTED HARDWARE:
1. The pulse generator is a Medtronic SESR01, serial number NWR249046H.
2. The RV ICD lead is a Medtronic 6935, serial number TAU103895V.
LEAD PARAMETERS: The RV lead senses 12.5 mV, threshold 1.2 volts at 0.5 msec and impedance 680 ohms. The device is programmed VVIR 60 to 120.
Jessica CPC, CCC
PROCEDURES PERFORMED:
1. RV ICD lead placement.
2. Single chamber pacemaker pulse generator placement.
PREOPERATIVE DIAGNOSES:
1. Ischemic cardiomyopathy.
2. Severe left ventricular dysfunction.
3. Diabetes.
POSTOPERATIVE DIAGNOSES:
1. Ischemic cardiomyopathy.
2. Severe left ventricular dysfunction.
3. Diabetes.
4. Asystolic cardiac arrest.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: Minimal.
ANESTHESIA: Initially, local Lidocaine and IV Versed and Fentanyl. The patient required management by the anesthesiology service in the middle of the procedure.
COMPLICATIONS: Asystolic cardiac arrest, as detailed below.
INDICATION FOR PROCEDURE: The patient is a 67-year-old man with ischemic cardiomyopathy and severe LV dysfunction on optimal medical therapy. He is admitted with acute decompensated heart failure. The patient has been improved after IV diuresis as inpatient. He underwent angiography which showed no new ischemic lesions immediately prior to this procedure. He was referred for ICD for sudden cardiac death prevention.
DESCRIPTION OF PROCEDURE: The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient. He provided informed written consent. The patient was already in the catheterization lab as he had undergone coronary angiography immediately prior to this procedure. Left upper extremity venography confirmed a patent left subclavian system.
The patient was prepped and draped in the usual sterile fashion. Lidocaine was used to anesthetize the left pectoral region. Using a scalpel, a 4 cm incision was made over the left deltopectoral groove. Using blunt dissection and brief bursts of electrocautery, a device pocket was developed superficial to the pectoralis fascia.
Left cephalic vein isolation was then performed under direct visualization using blunt dissection. The vein was isolated and 0 silk ties were placed. The vein was accessed under direct visualization with a 20-gauge Angiocath. A Terumo Glidewire was then able to be advanced to the level of the IVC.
The patient then became very agitated. His SpO2 remained stable, as did his blood pressure and heart rate. His rhythm was sinus bradycardia in the 50s as it had been throughout the case. The patient had continued agitation and had received a total of 2 mg IV Versed and 75 mcg IV Fentanyl. He was also given 25 mg IV Benadryl. Given his ongoing agitation and the nature of the procedure, with planned intracardiac lead placement, Anesthesiology was called for assistance with the procedure. After arrival of the anesthesiology service, the patient was stabilized with stable SpO2, blood pressure, and heart rate. His agitation had improved.
As the cephalic access had proven difficult in the setting of his agitation, the Terumo wire was removed and the cephalic vein ties were secured with 0 silk x2 total. The plan was for left subclavian venous access for placement of the ICD lead. As preparations were being made for subclavian access, the patient was noted to rapidly lose his heart rate, going from sinus bradycardia in the 50s immediately to asystole. He was given several rounds of Atropine and Epinephrine immediately. CPR was also started immediately. The patient was then intubated emergently by the anesthesiologist. Narcan 0.4 mg was given. As no endocardial leads had been placed, transcutaneous pacing was used for a short time.
The patient was able to regain a rhythm, with sinus tachycardia in the 130s after several rounds of medications. He had a present carotid pulse and was started on Dopamine at 20 mcg peripherally. The patient's initial blood pressure was then 180 systolic. The Dopamine was then weaned rapidly to off. The patient's SpO2 with then stabilized in the high 90s on the ventilator. His blood pressure was 130 systolic or better. His heart rate was 130s in sinus tachycardia.
As the pocket had already been created and the ICD lead had already been opened, we proceeded with implantation of that lead and a single-chamber pacemaker to prevent further bradyarrhythmias.
Left subclavian venous access was then obtained with an introducer needle and a wire advanced under fluoroscopic guidance. A 9-French sheath was then placed over the wire. The RV ICD lead was then advanced under fluoroscopic guidance to the RV apical septum. The active fixation mechanism was deployed. Appropriate sensing, threshold, and impedance values were obtained. The sheath was then split and removed. The lead was then secured to the underlying tissue with 0 silk x2.
The wound was irrigated with copious Bacitracin and saline solution. The single-chamber pacemaker pulse generator was then connected to the lead with the appropriate torque wrench. The shocking coil was capped. The device and lead assembly was then placed in the cleaned pocket. The device was secured to the underlying tissue with 0 silk x1. The wound was then closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material in the fascial, subcutaneous, and subcuticular layers, respectively. Steri-Strips and a Tegaderm dressing as well as a pressure dressing were placed.
The patient remained intubated and was transferred to the ICU in stable but critical condition. The ICU service was contacted regarding any recommendations regarding cooling protocol. Their recommendation thus far had been for observation of neurologic status prior to initiation.
The patient's family was updated of all these events. All their questions were answered.
IMPLANTED HARDWARE:
1. The pulse generator is a Medtronic SESR01, serial number NWR249046H.
2. The RV ICD lead is a Medtronic 6935, serial number TAU103895V.
LEAD PARAMETERS: The RV lead senses 12.5 mV, threshold 1.2 volts at 0.5 msec and impedance 680 ohms. The device is programmed VVIR 60 to 120.
Jessica CPC, CCC