bennieyoung
Guru
I am trying to decide the best way to code the following report. I am considering two options. First option: 93655 x 2, 93656, 93657 x 2. Second option: 93653, 93655 x 2, 93662, 93462, 93623.
My confusion or hesitation is the doctor states in the report that "pulmonary veins remained isolated from prior procedure. But in the comments the doctor states "Ongoing" pulmonary vein isolation from prior ablation.
I would love for someone to look at this and give me their opinion. I would like to know someone else's thoughts. Any help at all would be greatly appreciated.
PreProcedure Dx: Paroxysmal atrial fibrillation and atrial flutter
PostProcedure Dx: Paroxysmal atrial fibrillation and atrial flutter
Procedures:
General Anesthesia
Transesophageal echo
Esophageal cooling
Ultrasound guided access
Intracardiac ultrasound
RF ablation cardiac
-Left atrial roof ablation
-Left atrial floor ablation
-Anterior mitral valve isthmus ablation
-Posterior mitral valve isthmus ablation
-Ablation ridge between LSPV and LAA
-Focal ablation anterior wall near LAA base
-Cavotricuspid isthmus ablation
PerClose venous closure x3
Clinical Hx: 62yo m two prior afib ablations with recurrent afib and flutter
Procedure:
Consent was obtained. A time out performed.
Sheaths:
RFV 8Fr to Versacross sheath to right atrium then for transeptal using Versacross pigtail wire. Octaray then Smart Touch D/F catheter advanced into right atrium and left atrium
RFV 7Fr decapolar to CS
LFV 8Fr for intracardiac echo
Procedure:
The patient entered the lab in sinus rhythm. He entered atrial fibrillation and variable atrial flutter repeatedly. Most episodes broke without intervention, but DC CV 300J was required three times.
After intubation, a transesophageal echo was performed and found no left atrial appendage thrombus. Then an esophageal cooling catheter was advanced guided by ICE so that the tip was in the stomach. The cooling temperature was lowered to 4-6 degrees C. Heparin was given to an ACT of 350-400 seconds.
Intracardiac echo was used to gather anatomy and assure there was no baseline pericardial effusion. The Octaray was advanced to the IVC, RA, and SVC to gather anatomy. The decapolar catheter was advanced into the CS using the collected matrix.
The right atrial flutter ablation was performed. At baseline, the transisthmus conduction time was 45ms. Lesions were placed using 30-35W to goal tag index 350-400 from the tricuspid isthmus to the inferior vena cava. After all signals were ablated, the TICT rose to 115 with pacing from CS and with pacing from lateral to the CTI line. Bidirectional block was proven.
The long Versacross sheath was advanced to the SVC using ICE. The Versacross pigtail wire was advanced to the tip of the dilator. The assembly was withdrawn using ICE and seen to tent the interatrial septum in the plane of the left pulmonary veins. RF was applied to the wire and wire seen to enter the LA, followed by the dilator and sheath. The wire and dilator were removed. The Octaray catheter was advanced to the LA and anatomy gathered.
The four pulmonary veins remained isolated from the prior ablation. There was signal along the ridge between LSPV and LAA. Ablation was performed here 35W to goal index 450. All signal here was resolved.
Given ongoing variable flutter after CTI line, an anterior mitral valve isthmus line was placed with 30 W to 350 tag index. Block was proven using the Octaray.
The posterior wall of the LA was isolated using 30W to goal 350: a roof and floor line were placed. Entrance and exit block was proven.
Capture from the anterior wall at base of the LAA was still present despite block of the anterior MV isthmus line. Epicardial connection was suspect. Focal ablation at high frequency signal was placed here with resolution of capture of the CS with pacing here.
A posterior mitral valve isthmus ablation line was placed using 30W to goal 350. This line was blocked as well.
The ablation catheter was removed to the right atrium. ICE found no pericardial effusion. The heparin drip was stopped. Protamine 40mg was given. The three access sites were closed with Perclose.
The pt tolerated the procedure well with no complication.
Conclusion:
Ongoing pulmonary vein isolation from prior ablation
Variable atrial flutter and atrial fibrillation
Ablation with CTI line, LA posterior wall isolation, MV isthmus lines anterior and posterior, focal ablation at base of LAA at suspected insertion of Bachman's bundle, ridge ablation. All lines blocked.
My confusion or hesitation is the doctor states in the report that "pulmonary veins remained isolated from prior procedure. But in the comments the doctor states "Ongoing" pulmonary vein isolation from prior ablation.
I would love for someone to look at this and give me their opinion. I would like to know someone else's thoughts. Any help at all would be greatly appreciated.
PreProcedure Dx: Paroxysmal atrial fibrillation and atrial flutter
PostProcedure Dx: Paroxysmal atrial fibrillation and atrial flutter
Procedures:
General Anesthesia
Transesophageal echo
Esophageal cooling
Ultrasound guided access
Intracardiac ultrasound
RF ablation cardiac
-Left atrial roof ablation
-Left atrial floor ablation
-Anterior mitral valve isthmus ablation
-Posterior mitral valve isthmus ablation
-Ablation ridge between LSPV and LAA
-Focal ablation anterior wall near LAA base
-Cavotricuspid isthmus ablation
PerClose venous closure x3
Clinical Hx: 62yo m two prior afib ablations with recurrent afib and flutter
Procedure:
Consent was obtained. A time out performed.
Sheaths:
RFV 8Fr to Versacross sheath to right atrium then for transeptal using Versacross pigtail wire. Octaray then Smart Touch D/F catheter advanced into right atrium and left atrium
RFV 7Fr decapolar to CS
LFV 8Fr for intracardiac echo
Procedure:
The patient entered the lab in sinus rhythm. He entered atrial fibrillation and variable atrial flutter repeatedly. Most episodes broke without intervention, but DC CV 300J was required three times.
After intubation, a transesophageal echo was performed and found no left atrial appendage thrombus. Then an esophageal cooling catheter was advanced guided by ICE so that the tip was in the stomach. The cooling temperature was lowered to 4-6 degrees C. Heparin was given to an ACT of 350-400 seconds.
Intracardiac echo was used to gather anatomy and assure there was no baseline pericardial effusion. The Octaray was advanced to the IVC, RA, and SVC to gather anatomy. The decapolar catheter was advanced into the CS using the collected matrix.
The right atrial flutter ablation was performed. At baseline, the transisthmus conduction time was 45ms. Lesions were placed using 30-35W to goal tag index 350-400 from the tricuspid isthmus to the inferior vena cava. After all signals were ablated, the TICT rose to 115 with pacing from CS and with pacing from lateral to the CTI line. Bidirectional block was proven.
The long Versacross sheath was advanced to the SVC using ICE. The Versacross pigtail wire was advanced to the tip of the dilator. The assembly was withdrawn using ICE and seen to tent the interatrial septum in the plane of the left pulmonary veins. RF was applied to the wire and wire seen to enter the LA, followed by the dilator and sheath. The wire and dilator were removed. The Octaray catheter was advanced to the LA and anatomy gathered.
The four pulmonary veins remained isolated from the prior ablation. There was signal along the ridge between LSPV and LAA. Ablation was performed here 35W to goal index 450. All signal here was resolved.
Given ongoing variable flutter after CTI line, an anterior mitral valve isthmus line was placed with 30 W to 350 tag index. Block was proven using the Octaray.
The posterior wall of the LA was isolated using 30W to goal 350: a roof and floor line were placed. Entrance and exit block was proven.
Capture from the anterior wall at base of the LAA was still present despite block of the anterior MV isthmus line. Epicardial connection was suspect. Focal ablation at high frequency signal was placed here with resolution of capture of the CS with pacing here.
A posterior mitral valve isthmus ablation line was placed using 30W to goal 350. This line was blocked as well.
The ablation catheter was removed to the right atrium. ICE found no pericardial effusion. The heparin drip was stopped. Protamine 40mg was given. The three access sites were closed with Perclose.
The pt tolerated the procedure well with no complication.
Conclusion:
Ongoing pulmonary vein isolation from prior ablation
Variable atrial flutter and atrial fibrillation
Ablation with CTI line, LA posterior wall isolation, MV isthmus lines anterior and posterior, focal ablation at base of LAA at suspected insertion of Bachman's bundle, ridge ablation. All lines blocked.