sglamuzina
Guest
Can someone please provide some guidance on how to bill this ablation.....
PROCEDURE(S)
Atrial fibrillation catheter ablation: pulmonary vein isolation
Ablation of a right atrial tachycardia (base of the right atrial appendage)
Ablation of atypical right atrial flutter (first atrial flutter, AFL1)
Ablation of a CTI flutter rotating clockwise around the tricuspid valve (second separate atrial flutter, AFL2)
Limited Trans-esophageal echocardiogram
Transseptal access
Intracardiac echocardiography
3-D mapping with CARTO mapping system
LA pacing and recording
Ultrasound guided vascular access
Vascular closure with the Vascade closure devices
External electrical cardioversion
PRE-PROCEDURE DIAGNOSES:
Symptomatic atrial fibrillation and atrial flutter
POST-PROCEDURE DIAGNOSES:
Same as above
ANESTHESIA:
General anesthesia administered by the Anesthesia Department. Local with 1% lidocaine.
COMPLICATIONS:
No in-lab complications.
ESTIMATED BLOOD LOSS:
Minimal
INDICATIONS FOR PROCEDURE:
Gary Mark Sills is a 70 y.o.-old male with the above PMH. The patient has symptomatic paroxysmal atrial fibrillation and atrial flutter for which they prefer a rhythm control approach including cardiac ablation.
PROCEDURE DESCRIPTION
The indications, risks, benefits, alternatives, and details of the procedure were reviewed with the patient. The risks included but were not limited to bleeding, infection, vascular injury, pericardial effusion/cardiac tamponade, phrenic nerve injury, heart block and need for permanent pacemaker, pulmonary vein stenosis, atrioesophageal fistula, stroke, heart attack and death. After all questions were answered, the patient provided informed, written consent.
The patient was brought to the Electrophysiology Laboratory in the fasting and unsedated state. A peripheral IV was placed and the patient was connected to an external defibrillator and an EP recording system.
The patient was intubated, placed under general anesthesia, and monitored by the Anesthesiology service for the duration of the procedure. Blood pressure, heart rate, oxygen saturation, and cardiac rhythm were continuously monitored.
A pre-procedure transesophageal echocardiogram was performed and demonstrated no left atrial or left atrial appendage thrombus (reported in detail separately).
An esophageal cooling probe was placed.
The presenting rhythm was sinus rhythm.
The patient was prepped and draped in the usual sterile fashion. The right inguinal region was infiltrated with 1% lidocaine. Right femoral venous access x 3 was obtained using the modified Seldinger technique, under ultrasound guidance, with 8.5, 8.5, and 9-French short sheaths on the right. Through the 9-French right sided sheath, a diagnostic ultrasound catheter was advanced to the right atrium. Baseline ICE survey showed no pericardial effusion. A deflectable decapolar catheter was inserted into an 8.5-French sheath on the right and positioned under fluoroscopic guidance in the coronary sinus for LA pacing and recording.
The patient was anticoagulated with heparin bolus and infusion to maintain a goal ACT greater than 350 seconds for the remainder of the procedure.
The Octaray catheter was used to create a 3D electroanatomical map of the right atrium.
During mapping of the RA, the patient entered multiple different atrial arrhythmias which consistently degenerated into atrial fibrillation making mapping challenging.
With frequent attempts at re-mapping, we first mapped an atrial tachycardia with a proximal to distal CS activaiton pattern and CL of 260 msec to the lateral base of the right atrial appendage. Mapping was made difficult by incessent deterioration of the AT into afib requring multiple DCCV’s at 200 J and subsequent re-induction with burst pacing. Ablation was performed at the site of earliest atrial activation at the lateral base of the RA appendage at which point the signal was greater 45 msec prior to the P wave. Ablation was performed at 35 W with a goal Surepoint value of 400.
After ablation of the AT, the patient had recurrent atrial arrhythmias with 2:1 conduction and prox to distal CS activation with cylce lengths varying from 240 msec - 500 msec. These arrythmias also deteriorated into afib with mapping attempts.
An STSF D/F ablation catheter was then advanced through the Vizigo sheath into the right atrium and positioned at the distal cavotricuspid isthmus. Multiple RF lesions were then delivered along the CTI as guided by fluoroscopy, electrograms, and 3-D mapping visualization to create an ablation line extending from the distal to proximal CTI. RF lesions were applied until medial to lateral CTI block was observed with proximal CS pacing. This CTI line was performed however without a significant change in the frequency of the atrial arrythmias.
The Vizigo sheath was then was advanced over a guidewire to the SVC. The wire was removed and replaced with a VersaCross wire. Using fluoroscopic and ultrasound guidance, the sheath was withdrawn to the mid-portion of the interatrial septum and guided toward the LSPV. The wire was extended, with the assistance of Bovie electrocautery, and the sheath advanced into the left atrium, confirmed on ultrasound and fluoroscopy. The sheath was confirmed to be advanced into the left atrium and the wire and dilator were removed. The sheath was connected to continuous saline infusion.
Next, the Octaray catheter was advanced into the left atrium, through the Vizigo sheath, and was used to construct a 3-dimensional left atrial map with the Carto mapping system. A 3.5 mm ThermoCool Smart touch D/F ablation catheter was then advanced into the left atrium through the Vizigo sheath.
Using fluoroscopic, electrogram and ICE guidance, pulmonary vein isolation was performed with delivery of RF lesions around the left and right sided pulmonary veins using wide area circumferential ablation. Care was taken to avoid the phrenic nerve by high output pacing along the anterior portion of the right pulmonary veins prior to ablation. Ablation was performed at 50 W with goal Surepoint values of 400 for the posterior wall, 450 for the roof and floor of the PV's, 500 for the anterior portion of the PV's, and 550 for the endocardial ridge. The esophageal cooling probe reached goal temperature before posterior LA wall ablation was performed. After delivery of RF lesions, entrance block was confirmed in all four pulmonary veins.
During ablation of the PVI the patient entered two separate stable atrial flutters: atrial flutter 1 (AFL1) and atrial flutter 2 (AFL2).
Repeat mapping of the left and right atrium for AFL1 demonstrated a CL of 500 msec and a prox to distal CS actvation. Of note, after PVI was performed, the atrial flutters were much more stable with less deterioration into afib. Mapping of the RA for AFL1 demonstrated a re-entrent circuit around a lateral RA scar. Ablation was therefore performed from the lateral portion of the RA scar to the IVC with termination of AFL1 with catheter manipulation in this region. Right atrial ablation was performed at an output ranging from 35-40W and surepoint values of 400-450.
After the lateral RA to IVC line, repeat burst pacing was performed with induction of a stable second flutter with CL of 290 and a proximal to distal CS activation. Mapping demonstrated a clockwise CTI dependent flutter with a likely epicardial bridge jumping approximately 3 cm lateral to the previously ablated CTI line. Ablation at this epicardial connection terminated AFL2. Ablation of the CTI line was performed at 40 W with goal surepoint values of 500. Measurement of the trans-isthmus time for the CTI was 183 msec.
Repeat atrial burst pacing down to a CL of 220 msec was unable to induce any recurrent prolonged atrial arrhythmias at this point in the case.
At the conclusion of the procedure, heparin was discontinued, repeat ICE survey post-ablation confirmed no pericardial effusion, and catheters were removed from the heart. Protamine was administered, and after the ACT fell below 200 seconds, catheters and sheaths were removed and hemostasis was achieved with deployment of Vascade closure devices as well as manual compression. At procedure conclusion the patient was in sinus rhythm. The patient tolerated the entire procedure well with no evidence of any immediate complications.
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
Minimal.
PROCEDURE SUMMARY:
Radiofrequency catheter ablation for atrial fibrillation with pulmonary vein isolation
Ablation of an RA atrial tachycardia (AT located at the lateral base of the right atrial appendage)
Ablation of atypical right atrial flutter (first atrial flutter, AFL1, rotating around a lateral RA scar)
Ablation of a CTI flutter rotating clockwise around the tricuspid valve (second separate atrial flutter, AFL2, which required ablation an an epicardial CTI connection)
RECCOMENDATIONS:
Continue oral anticoagulation at 6 hours post procedure
Patient to lay flat for 3 hours
PROCEDURE(S)
Atrial fibrillation catheter ablation: pulmonary vein isolation
Ablation of a right atrial tachycardia (base of the right atrial appendage)
Ablation of atypical right atrial flutter (first atrial flutter, AFL1)
Ablation of a CTI flutter rotating clockwise around the tricuspid valve (second separate atrial flutter, AFL2)
Limited Trans-esophageal echocardiogram
Transseptal access
Intracardiac echocardiography
3-D mapping with CARTO mapping system
LA pacing and recording
Ultrasound guided vascular access
Vascular closure with the Vascade closure devices
External electrical cardioversion
PRE-PROCEDURE DIAGNOSES:
Symptomatic atrial fibrillation and atrial flutter
POST-PROCEDURE DIAGNOSES:
Same as above
ANESTHESIA:
General anesthesia administered by the Anesthesia Department. Local with 1% lidocaine.
COMPLICATIONS:
No in-lab complications.
ESTIMATED BLOOD LOSS:
Minimal
INDICATIONS FOR PROCEDURE:
Gary Mark Sills is a 70 y.o.-old male with the above PMH. The patient has symptomatic paroxysmal atrial fibrillation and atrial flutter for which they prefer a rhythm control approach including cardiac ablation.
PROCEDURE DESCRIPTION
The indications, risks, benefits, alternatives, and details of the procedure were reviewed with the patient. The risks included but were not limited to bleeding, infection, vascular injury, pericardial effusion/cardiac tamponade, phrenic nerve injury, heart block and need for permanent pacemaker, pulmonary vein stenosis, atrioesophageal fistula, stroke, heart attack and death. After all questions were answered, the patient provided informed, written consent.
The patient was brought to the Electrophysiology Laboratory in the fasting and unsedated state. A peripheral IV was placed and the patient was connected to an external defibrillator and an EP recording system.
The patient was intubated, placed under general anesthesia, and monitored by the Anesthesiology service for the duration of the procedure. Blood pressure, heart rate, oxygen saturation, and cardiac rhythm were continuously monitored.
A pre-procedure transesophageal echocardiogram was performed and demonstrated no left atrial or left atrial appendage thrombus (reported in detail separately).
An esophageal cooling probe was placed.
The presenting rhythm was sinus rhythm.
The patient was prepped and draped in the usual sterile fashion. The right inguinal region was infiltrated with 1% lidocaine. Right femoral venous access x 3 was obtained using the modified Seldinger technique, under ultrasound guidance, with 8.5, 8.5, and 9-French short sheaths on the right. Through the 9-French right sided sheath, a diagnostic ultrasound catheter was advanced to the right atrium. Baseline ICE survey showed no pericardial effusion. A deflectable decapolar catheter was inserted into an 8.5-French sheath on the right and positioned under fluoroscopic guidance in the coronary sinus for LA pacing and recording.
The patient was anticoagulated with heparin bolus and infusion to maintain a goal ACT greater than 350 seconds for the remainder of the procedure.
The Octaray catheter was used to create a 3D electroanatomical map of the right atrium.
During mapping of the RA, the patient entered multiple different atrial arrhythmias which consistently degenerated into atrial fibrillation making mapping challenging.
With frequent attempts at re-mapping, we first mapped an atrial tachycardia with a proximal to distal CS activaiton pattern and CL of 260 msec to the lateral base of the right atrial appendage. Mapping was made difficult by incessent deterioration of the AT into afib requring multiple DCCV’s at 200 J and subsequent re-induction with burst pacing. Ablation was performed at the site of earliest atrial activation at the lateral base of the RA appendage at which point the signal was greater 45 msec prior to the P wave. Ablation was performed at 35 W with a goal Surepoint value of 400.
After ablation of the AT, the patient had recurrent atrial arrhythmias with 2:1 conduction and prox to distal CS activation with cylce lengths varying from 240 msec - 500 msec. These arrythmias also deteriorated into afib with mapping attempts.
An STSF D/F ablation catheter was then advanced through the Vizigo sheath into the right atrium and positioned at the distal cavotricuspid isthmus. Multiple RF lesions were then delivered along the CTI as guided by fluoroscopy, electrograms, and 3-D mapping visualization to create an ablation line extending from the distal to proximal CTI. RF lesions were applied until medial to lateral CTI block was observed with proximal CS pacing. This CTI line was performed however without a significant change in the frequency of the atrial arrythmias.
The Vizigo sheath was then was advanced over a guidewire to the SVC. The wire was removed and replaced with a VersaCross wire. Using fluoroscopic and ultrasound guidance, the sheath was withdrawn to the mid-portion of the interatrial septum and guided toward the LSPV. The wire was extended, with the assistance of Bovie electrocautery, and the sheath advanced into the left atrium, confirmed on ultrasound and fluoroscopy. The sheath was confirmed to be advanced into the left atrium and the wire and dilator were removed. The sheath was connected to continuous saline infusion.
Next, the Octaray catheter was advanced into the left atrium, through the Vizigo sheath, and was used to construct a 3-dimensional left atrial map with the Carto mapping system. A 3.5 mm ThermoCool Smart touch D/F ablation catheter was then advanced into the left atrium through the Vizigo sheath.
Using fluoroscopic, electrogram and ICE guidance, pulmonary vein isolation was performed with delivery of RF lesions around the left and right sided pulmonary veins using wide area circumferential ablation. Care was taken to avoid the phrenic nerve by high output pacing along the anterior portion of the right pulmonary veins prior to ablation. Ablation was performed at 50 W with goal Surepoint values of 400 for the posterior wall, 450 for the roof and floor of the PV's, 500 for the anterior portion of the PV's, and 550 for the endocardial ridge. The esophageal cooling probe reached goal temperature before posterior LA wall ablation was performed. After delivery of RF lesions, entrance block was confirmed in all four pulmonary veins.
During ablation of the PVI the patient entered two separate stable atrial flutters: atrial flutter 1 (AFL1) and atrial flutter 2 (AFL2).
Repeat mapping of the left and right atrium for AFL1 demonstrated a CL of 500 msec and a prox to distal CS actvation. Of note, after PVI was performed, the atrial flutters were much more stable with less deterioration into afib. Mapping of the RA for AFL1 demonstrated a re-entrent circuit around a lateral RA scar. Ablation was therefore performed from the lateral portion of the RA scar to the IVC with termination of AFL1 with catheter manipulation in this region. Right atrial ablation was performed at an output ranging from 35-40W and surepoint values of 400-450.
After the lateral RA to IVC line, repeat burst pacing was performed with induction of a stable second flutter with CL of 290 and a proximal to distal CS activation. Mapping demonstrated a clockwise CTI dependent flutter with a likely epicardial bridge jumping approximately 3 cm lateral to the previously ablated CTI line. Ablation at this epicardial connection terminated AFL2. Ablation of the CTI line was performed at 40 W with goal surepoint values of 500. Measurement of the trans-isthmus time for the CTI was 183 msec.
Repeat atrial burst pacing down to a CL of 220 msec was unable to induce any recurrent prolonged atrial arrhythmias at this point in the case.
At the conclusion of the procedure, heparin was discontinued, repeat ICE survey post-ablation confirmed no pericardial effusion, and catheters were removed from the heart. Protamine was administered, and after the ACT fell below 200 seconds, catheters and sheaths were removed and hemostasis was achieved with deployment of Vascade closure devices as well as manual compression. At procedure conclusion the patient was in sinus rhythm. The patient tolerated the entire procedure well with no evidence of any immediate complications.
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
Minimal.
PROCEDURE SUMMARY:
Radiofrequency catheter ablation for atrial fibrillation with pulmonary vein isolation
Ablation of an RA atrial tachycardia (AT located at the lateral base of the right atrial appendage)
Ablation of atypical right atrial flutter (first atrial flutter, AFL1, rotating around a lateral RA scar)
Ablation of a CTI flutter rotating clockwise around the tricuspid valve (second separate atrial flutter, AFL2, which required ablation an an epicardial CTI connection)
RECCOMENDATIONS:
Continue oral anticoagulation at 6 hours post procedure
Patient to lay flat for 3 hours