aforsythe
Networker
We can't seem to agree on codes for this procedure in our office.
Any help is greatly appreciated.
Thanks.
PREOPERATIVE DIAGNOSIS: Atrial fibrillation, cardiomyopathy, congestive
heart failure and coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Atrial fibrillation, cardiomyopathy, congestive
heart failure and coronary artery disease plus atrial flutter.
OPERATION: AV node ablation, reprogramming of
biventricular ICD, electrophysiologic study, coronary sinus
catheterization, stimulation on isoproterenol, ablation of atrial flutter
and cardioversion at time of study.
HISTORY: The patient is a 69-year-old gentleman with a history of
ischemic cardiomyopathy, hypertension, ejection fraction of 25% and
coronary artery disease who has a biventricular ICD, atrial fibrillation
with difficulty to control rates who is referred for an AV node ablation.
During the course of the procedure, the patient was noted to have isthmus
then atrial flutter which was also approached.
PROCEDURE: The patient was brought to the Electrophysiology Laboratory
in a fasting state and an 8-French sheath was initially placed in the right
femoral vein. The patient's biventricular ICD was disabled for tachy
detections and an 8-mm catheter was advanced to the His
bundle region. Mapping was performed and three RF lesions were delivered
and at the of the RF delivery, the patient had complete heart block and was
paced at 30 beats per minute. It was noted that the patient did organized
from an atrial fibrillation initially to an atrial flutter rhythm and it
was decided to map this utilizing a duodeca catheter. This was placed in
the right atrium and it was noted that the patient had isthmus then atrial
flutter. After discussing this with the patient's wife, we obtained
consent to perform RF energy in the tricuspid IVC isthmus to attempt to
terminate the patient's atrial flutter. The patient's INR was noted to be
2.1 at the time of the procedure. This was performed and after a total of
six additional lesions, the atrial flutter terminated which was initially
at a cycle length of 254 milliseconds and pacing from the proximal coronary
sinus demonstrated that there was no evidence of isthmus conduction.
Electrophysiologic evaluation was then performed and pacing from the
coronary sinus was noted that the patient's sinus node recovery time was
1128. Drive cycle length of 600 milliseconds. AV node Wenckebach could
not be achieved due to created heart block. HV interval was previously
looked at during mapping of the AV node and was noted to be 80
milliseconds.
VENTRICULAR STIMULATION: The right ventricular apex was stimulated twice
to outside threshold of 0.5 mA. VA conduction was not present at baseline.
Burst pacing in the ventricle did not produce any VT.
IMPRESSION:
1. Baseline trial fibrillation and atrial flutter with atrial flutter
cycle length of 254 milliseconds.
2. Normal sinus node function and complete heart block after creation of AV
node ablation.
3. No evidence of VA conduction or bypass tract.
4. No inducible VT or VF.
5. Successful AV node ablation.
6. Successful atrial flutter ablation.
RECOMMENDATIONS:
1. Reinitiation of amiodarone for management of the patient's atrial
fibrillation.
2. Continuation of current anticoagulation regimen with Coumadin.
3. Followup appointment in two weeks' time to check the patient's device.
Thank you for allowing us to participate in the care of this patient.
Please do not hesitate to contact us if you have questions regarding the
above.
Any help is greatly appreciated.
Thanks.
PREOPERATIVE DIAGNOSIS: Atrial fibrillation, cardiomyopathy, congestive
heart failure and coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Atrial fibrillation, cardiomyopathy, congestive
heart failure and coronary artery disease plus atrial flutter.
OPERATION: AV node ablation, reprogramming of
biventricular ICD, electrophysiologic study, coronary sinus
catheterization, stimulation on isoproterenol, ablation of atrial flutter
and cardioversion at time of study.
HISTORY: The patient is a 69-year-old gentleman with a history of
ischemic cardiomyopathy, hypertension, ejection fraction of 25% and
coronary artery disease who has a biventricular ICD, atrial fibrillation
with difficulty to control rates who is referred for an AV node ablation.
During the course of the procedure, the patient was noted to have isthmus
then atrial flutter which was also approached.
PROCEDURE: The patient was brought to the Electrophysiology Laboratory
in a fasting state and an 8-French sheath was initially placed in the right
femoral vein. The patient's biventricular ICD was disabled for tachy
detections and an 8-mm catheter was advanced to the His
bundle region. Mapping was performed and three RF lesions were delivered
and at the of the RF delivery, the patient had complete heart block and was
paced at 30 beats per minute. It was noted that the patient did organized
from an atrial fibrillation initially to an atrial flutter rhythm and it
was decided to map this utilizing a duodeca catheter. This was placed in
the right atrium and it was noted that the patient had isthmus then atrial
flutter. After discussing this with the patient's wife, we obtained
consent to perform RF energy in the tricuspid IVC isthmus to attempt to
terminate the patient's atrial flutter. The patient's INR was noted to be
2.1 at the time of the procedure. This was performed and after a total of
six additional lesions, the atrial flutter terminated which was initially
at a cycle length of 254 milliseconds and pacing from the proximal coronary
sinus demonstrated that there was no evidence of isthmus conduction.
Electrophysiologic evaluation was then performed and pacing from the
coronary sinus was noted that the patient's sinus node recovery time was
1128. Drive cycle length of 600 milliseconds. AV node Wenckebach could
not be achieved due to created heart block. HV interval was previously
looked at during mapping of the AV node and was noted to be 80
milliseconds.
VENTRICULAR STIMULATION: The right ventricular apex was stimulated twice
to outside threshold of 0.5 mA. VA conduction was not present at baseline.
Burst pacing in the ventricle did not produce any VT.
IMPRESSION:
1. Baseline trial fibrillation and atrial flutter with atrial flutter
cycle length of 254 milliseconds.
2. Normal sinus node function and complete heart block after creation of AV
node ablation.
3. No evidence of VA conduction or bypass tract.
4. No inducible VT or VF.
5. Successful AV node ablation.
6. Successful atrial flutter ablation.
RECOMMENDATIONS:
1. Reinitiation of amiodarone for management of the patient's atrial
fibrillation.
2. Continuation of current anticoagulation regimen with Coumadin.
3. Followup appointment in two weeks' time to check the patient's device.
Thank you for allowing us to participate in the care of this patient.
Please do not hesitate to contact us if you have questions regarding the
above.