I need some other Cardiology experts out there to please weigh in on this procedure. I just need thoughts on if you would separately code for the arterial line and the Central venous cath placement??
Thanks in advance,
Melissa Bedford,CCS,CPC
Pre-procedure Diagnoses
1. NSTEMI (non-ST elevated myocardial infarction) (HCC) [410.70]
2. Cardiogenic shock [785.51]
3. Acute systolic heart failure [428.21]
Post-procedure Diagnoses
1. NSTEMI (non-ST elevated myocardial infarction) (HCC) [410.70]
2. Cardiogenic shock [785.51]
3. Acute systolic heart failure [428.21]
Procedures
1. LEFT HEART CATH [CATH27]
CATH LAB PROCEDURE SUMMARY
Procedures Performed:
Left Heart Catheterization
Selective Coronary Angiogram
Left Ventriculogram
Percutaneous placement of Impella Circulatory Assist Device
Triple Lumen Central Venous Catheter placement
Right Heart Catheterization
Placement of Swan-Ganz Catheter
Temporary transvenous pacemaker insertion
Arterial Line Placement
Abdominal Aortogram
Complications: None
Estimated Blood Loss: <20 mL
Contrast Used: 140cc Visipaque
Fluoro Time: 8.7 min
Procedure Details: Informed consent was obtained prior to the procedure. Patient was brought to the lab and prepped and draped in a sterile fashion. A time-out procedure was performed. Vascular access was obtained as documented below with fluoroscopic guidance using micropuncture system. A 6 Fr sheath was placed using modified Seldinger technique.
Coronary Angiogram: After access was obtained into the arterial system as documented above, coronary angiogram was performed in the standard fashion using JL4 and JR4 preformed catheters. The following findings were noted:
Dominance: Left
Coronary Territory:
Native Artery Grafts Supplying Coronary Territory
Percent Stenosis in vessels (equal to 2mm or greater) Percent Stenosis
Left Main 0
Prox LAD Bifid LAD with proximal occlusion in both vessels. 100% occluded LAD (lateral - gives off a septal branch) with TIMI1 flow. The larger medial LAD is 100% occluded with no visualized distal flow.
Mid/Distal LAD, Diag Branches See above
Circ, OMs, LPDA, LPL Branches 100% occluded OM1 with TIMI1 flow. Mid LCx has 95% stenosis
RCA, RPDA, RPL, AM Branches 100% - unclear anatomy of distal vessels. Probably co-dominant system
Ramus NA
At the end of diagnostic coronary angiogram, all catheters were removed in an atraumatic fashion over a wire.
LHC: Left heart catheterization was performed in the standard fashion using a 5F pig-tail catheter to gain access into the LV. The LVEDP was noted to be 48 mm of Hg. Left Ventriculogram was performed that showed a LVEF of 10% and akinetic anterior wall and mid-distal inferior wall, with hypokinetic basal anterior and basal inferior walls.Finally, the catheter was pulled back across the aortic valve, revealing a gradient of 0 mm Hg across the valve.
Abdominal Aortogram: Subsequently, using the 5F pigtail catheter, we performed abdominal aortogram with digital subtraction. This showed:
1. Moderate disease of L renal artery, with two right renal arteries, with severe stenosis of the superior right renal artery.
2. Moderate atherosclerosis of abdominal aorta with ectatic short segment below the renal arteries with eccentric plaque.
3. Patent bilateral iliac arteries.
At this point patient was noted to become more hypoxic and worse pulmonary edema. He began to go in and out of atrial fibrillation with long pauses at time of conversion. This persisted after atropine was given. He began to get hypotensive. Decision was made to place a temporary pacemaker.
Temporary Pacemaker Insertion: Using a modified Seldinger technique, a 6F sheath was placed in the L. CFV and a 6F TPM was advanced and positioned in the RV apex and tested. Thresholds were satisfactory. Backup pacing was initiated at 60 bpm at 5V. He was noted to be pacer dependent at this point.
Central Venous Line Placement: Using a modified Seldinger technique, access was obtained in the R. CFV and a triple lumen catheter was placed and all ports were flushed in the standard fashion. This was secured in place.
Insertion of Impella Percutaneous Left Ventricular Assist Device: The decision was made to place an impella for acute systolic heart failure with cardiogenic shock. At this point patient was in frank pulmonary edema, and concurrently, intubation was done for respiratory support (please see Dr. Nolans notes for details). The R. CFA access was upsized to a 35cm 8F sheath with serial dilations, and a Impella was advanced wireless, and positioned in the LV and positioned with fluoroscopic and echocardiographic confirmation. The device was secured in placed using sutures and StatLock. 95cm mark at entry point was noted.
Right heart Catheterization: RHC was done in the standard fashion using a R. IJV access that was obtained with a modified Seldinger technique in the standard fashion. A Swan-Ganz catheter was floated into the PA and measurements were obtained. The catheter was maintained and secured in the PA position.
RA: 13/14/13
RV: 54/11/18
PA:52/26/39
PCW: 29/26/26
Arterial Line Placement: a 4F arterial line was placed with a modified Seldinger technique using a 4F sheath in the right radial artery. Port was flushed and connected for continuous arterial pressure monitoring.
Findings were discussed with the family in detail.
CONCLUSIONS:
1. Acute systolic and diastolic heart failure with cardiogenic shock
2. Successful placement of an Impella Percutaneous Left Ventricular Assist Device for hemodynamic support
3. Successful placement of a central venous line for IV infusion of cardioactive agents, placement of an arterial line for invasive hemodynamic monitoring, placement of a temporary transvenous pacemaker for electrical support as well as a Swan-Ganz catheter for invasive hemodynamic monitoring.
4. Patient was intubated during the procedure due to pulmonary edema and respiratory failure.
RECOMMENDATIONS:
1. CCU monitoring
2. Further recommendations after discussion with his primary cardiologist and CV surgery team.
Thanks in advance,
Melissa Bedford,CCS,CPC
Pre-procedure Diagnoses
1. NSTEMI (non-ST elevated myocardial infarction) (HCC) [410.70]
2. Cardiogenic shock [785.51]
3. Acute systolic heart failure [428.21]
Post-procedure Diagnoses
1. NSTEMI (non-ST elevated myocardial infarction) (HCC) [410.70]
2. Cardiogenic shock [785.51]
3. Acute systolic heart failure [428.21]
Procedures
1. LEFT HEART CATH [CATH27]
CATH LAB PROCEDURE SUMMARY
Procedures Performed:
Left Heart Catheterization
Selective Coronary Angiogram
Left Ventriculogram
Percutaneous placement of Impella Circulatory Assist Device
Triple Lumen Central Venous Catheter placement
Right Heart Catheterization
Placement of Swan-Ganz Catheter
Temporary transvenous pacemaker insertion
Arterial Line Placement
Abdominal Aortogram
Complications: None
Estimated Blood Loss: <20 mL
Contrast Used: 140cc Visipaque
Fluoro Time: 8.7 min
Procedure Details: Informed consent was obtained prior to the procedure. Patient was brought to the lab and prepped and draped in a sterile fashion. A time-out procedure was performed. Vascular access was obtained as documented below with fluoroscopic guidance using micropuncture system. A 6 Fr sheath was placed using modified Seldinger technique.
Coronary Angiogram: After access was obtained into the arterial system as documented above, coronary angiogram was performed in the standard fashion using JL4 and JR4 preformed catheters. The following findings were noted:
Dominance: Left
Coronary Territory:
Native Artery Grafts Supplying Coronary Territory
Percent Stenosis in vessels (equal to 2mm or greater) Percent Stenosis
Left Main 0
Prox LAD Bifid LAD with proximal occlusion in both vessels. 100% occluded LAD (lateral - gives off a septal branch) with TIMI1 flow. The larger medial LAD is 100% occluded with no visualized distal flow.
Mid/Distal LAD, Diag Branches See above
Circ, OMs, LPDA, LPL Branches 100% occluded OM1 with TIMI1 flow. Mid LCx has 95% stenosis
RCA, RPDA, RPL, AM Branches 100% - unclear anatomy of distal vessels. Probably co-dominant system
Ramus NA
At the end of diagnostic coronary angiogram, all catheters were removed in an atraumatic fashion over a wire.
LHC: Left heart catheterization was performed in the standard fashion using a 5F pig-tail catheter to gain access into the LV. The LVEDP was noted to be 48 mm of Hg. Left Ventriculogram was performed that showed a LVEF of 10% and akinetic anterior wall and mid-distal inferior wall, with hypokinetic basal anterior and basal inferior walls.Finally, the catheter was pulled back across the aortic valve, revealing a gradient of 0 mm Hg across the valve.
Abdominal Aortogram: Subsequently, using the 5F pigtail catheter, we performed abdominal aortogram with digital subtraction. This showed:
1. Moderate disease of L renal artery, with two right renal arteries, with severe stenosis of the superior right renal artery.
2. Moderate atherosclerosis of abdominal aorta with ectatic short segment below the renal arteries with eccentric plaque.
3. Patent bilateral iliac arteries.
At this point patient was noted to become more hypoxic and worse pulmonary edema. He began to go in and out of atrial fibrillation with long pauses at time of conversion. This persisted after atropine was given. He began to get hypotensive. Decision was made to place a temporary pacemaker.
Temporary Pacemaker Insertion: Using a modified Seldinger technique, a 6F sheath was placed in the L. CFV and a 6F TPM was advanced and positioned in the RV apex and tested. Thresholds were satisfactory. Backup pacing was initiated at 60 bpm at 5V. He was noted to be pacer dependent at this point.
Central Venous Line Placement: Using a modified Seldinger technique, access was obtained in the R. CFV and a triple lumen catheter was placed and all ports were flushed in the standard fashion. This was secured in place.
Insertion of Impella Percutaneous Left Ventricular Assist Device: The decision was made to place an impella for acute systolic heart failure with cardiogenic shock. At this point patient was in frank pulmonary edema, and concurrently, intubation was done for respiratory support (please see Dr. Nolans notes for details). The R. CFA access was upsized to a 35cm 8F sheath with serial dilations, and a Impella was advanced wireless, and positioned in the LV and positioned with fluoroscopic and echocardiographic confirmation. The device was secured in placed using sutures and StatLock. 95cm mark at entry point was noted.
Right heart Catheterization: RHC was done in the standard fashion using a R. IJV access that was obtained with a modified Seldinger technique in the standard fashion. A Swan-Ganz catheter was floated into the PA and measurements were obtained. The catheter was maintained and secured in the PA position.
RA: 13/14/13
RV: 54/11/18
PA:52/26/39
PCW: 29/26/26
Arterial Line Placement: a 4F arterial line was placed with a modified Seldinger technique using a 4F sheath in the right radial artery. Port was flushed and connected for continuous arterial pressure monitoring.
Findings were discussed with the family in detail.
CONCLUSIONS:
1. Acute systolic and diastolic heart failure with cardiogenic shock
2. Successful placement of an Impella Percutaneous Left Ventricular Assist Device for hemodynamic support
3. Successful placement of a central venous line for IV infusion of cardioactive agents, placement of an arterial line for invasive hemodynamic monitoring, placement of a temporary transvenous pacemaker for electrical support as well as a Swan-Ganz catheter for invasive hemodynamic monitoring.
4. Patient was intubated during the procedure due to pulmonary edema and respiratory failure.
RECOMMENDATIONS:
1. CCU monitoring
2. Further recommendations after discussion with his primary cardiologist and CV surgery team.