Garden Grove, CA
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Can someone please assist me with coding this EP Report.......

Atrial fibrillation catheter ablation: pulmonary vein isolation
Additional ablation for atrial fibrillation with a posterior box lesion set
Ablation of cavotricuspid isthmus for typical CTI-dependent flutter
Ablation of likely roof dependent atrial flutter with a roof line
Ablation of another separate atrial flutter circuit with generation of an anterior left atrial line from the mitral valve to the roof line
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

#Paroxysmal symptomatic afib, not tolerating AADs previously (CCB/BB/sotalol/propafenone/amiodarone due to significant SOB). S/p multiple DCCV, first 6/2016
#Shortness of breath, undergoing workup by pulm but uncertain etiology after 2 CT scans
#Tobacco use in her 50s for 8 years 10 month

-10/2016 afib ablation
-3/8/23: patient reports she has had 2 cardioversions during this year and feels better in sinus rhythm. Tolerating Eliquis without any issues with bleeding, denies falls and syncope.

Same as above, additionally the patient demonstrated an RA CTI dependent flutter, as well as other unstable likely left atrial flutters. Patient's LA had extensive scarring on the initial LA map

General anesthesia administered by the Anesthesia Department. Local with 1% lidocaine.

No in-lab complications.


Jonnye Bierwirth Forsch is a 77 y.o.-old female with the above PMH. The patient has symptomatic paroxysmal afib, she presents for an outpatient TEE and afib ablation.

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 temperature monitoring probe was placed.

The presenting rhythm was sinus rhythm with a PR interval of 192, a QRS duration 80 msec msec, a QT interval 420 msec, and an RR interval of 964 msec.

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 11-French short sheaths on the right. Through the 11-French left 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 RA mapping the patient entered atrial flutter with a proximal to distal CS activation pattern and a cycle length of 304 msec.

At this point one of the 8.5-French sheaths on the right was exchanged for an 8.5-French Vizigo sheath and an ablation catheter was advanced through it 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. The measured trans-isthmus time with proximal CS pacing was 210 msec. Of note, the patient's AFL terminated during CTI line generation.

The Vizigo sheath 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 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.

Mapping of the left atrium demonstrated re-connections of both the left and right pulmonary veins.

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'ss, and 550 for the endocardial ridge. Careful monitoring of the esophageal temperature was performed and ablation was stopped with the esophagus temperature rose and then restarted in the corresponding area once the temperature had cooled.

After delivery of RF lesions, entrance/exit block was confirmed in all four pulmonary veins.

Of note, the anterior wall as well of the roof of the LA was markedly scarred. Therefore burst pacing of the posterior LA wall was performed with induction of at least two different atrial flutters which consistently degenerated into afib. Given the scarring on the anterior LA wall and along the LA roof, the decision was made to perform an LA roof line (ablation from the LSPV to the RSPV), as well as perform an anterior mitral line (ablation from the mitral valve to the LA roof line). Ablation in these regions was performed at 50 W. After creation of these lines the patient was still consistently inducible into afib (requiring DCCV for conversion to sinus rhythm). Therefore a posterior box lesion set was performed (ablation at 50 W). After ablation in these regions the patient could be induced into afib with rapid atrial pacing but was not inducible for sustained atrial flutter.

CTI block was then confirmed with pacing maneuvers and this block had persisted >60 minutes minute waiting period. The measured trans-isthmus time with proximal CS pacing was confirmed to still be 210 msec.

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 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.



Atrial fibrillation catheter ablation: pulmonary vein isolation
Additional ablation for atrial fibrillation with a posterior box lesion set
Ablation of cavotricuspid isthmus for typical CTI-dependent flutter (confirmation of persistent CTI block with a trans-isthmus of 210 msec)
Ablation of likely roof dependent atrial flutter with a roof line
Ablation of another separate atrial flutter circuit with generation of an anterior atrial line from the mitral valve to the roof line (additionally to help with control of patient's afiib)

Continue oral anticoagulation at 6 hours post procedure
Patient to lay flat for 3 hours
Of note, patient re-entered afib in PACU possibly due to inflammation from ablation and so was started on IV amiodarone and discharged with 400 mg PO amiodarone dai