em2177
Expert
NEED HELP CODING THIS REPORT. THANK YOU!! 
POSTPROCEDURE DIAGNOSES:
1. Successful implantation of automatic implantable
cardioverter-defibrillator St. Jude Medical pulse generator.
2. Successful explantation of old pacemaker, Medtronic.
3. Pocket revision.
4. Fluoroscopy.
5. Venogram.
INDICATION:
The patient is a very pleasant gentleman with episode of syncope
while driving a car, history of nonischemic dilated cardiomyopathy,
EF 35%.
Methods, risks, and benefits were explained to the patient including
risk of death, MI, stroke, bleeding, infection.
DESCRIPTION OF PROCEDURE:
Patient was taken to EP lab in fasting state, prepped and draped in a
usual sterile fashion. Xylocaine 1% was applied to the left chest
wall thus causing local sedation. A combination of blunt and sharp
dissection was created and opened up the pacemaker pocket. The
capsule was removed and redundant pocket was repositioned and
expanded to accommodate a new AICD. A venogram of the left
subclavian vein was made. Using a 19-gauge needle, the subclavian
vein was accessed. The J-wire could not pass through the subclavian
vein, therefore we ______ used a Glidewire. Initially we put an
8-French sheath into the subclavian vein, but we were unable to pass
leads through the subclavian vein. Thereafter, we had to upgrade to
long 7-French sheath that went through successfully, but had great
difficulty in manoeuvring the lead through the 7-French sheath.
Thereafter, it was upgraded to a 9-French long sheath. We were able
to do that successfully without complications. Thereafter using the
long 9-French sheath, we placed a RV lead and RV apex. The
appropriate thresholds and impedance were found. High output voltage
did not stimulate the diaphragm. This lead was sutured down to the
chest wall. Pocket was closed with antibiotic solution, the device
was removed and new device was inserted into the pocket. The device
was also sutured down to the chest wall and Ancef powder and FloSeal
was applied into pocket. We closed the pocket with running 2-0, 4-0
Monocryl. We did not do DFT testings since patient has not been
taking his Xarelto in consistent manner. We were concerned that he
might go and have a stroke during the cardioversion part of the DFT.
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
Less than 20 cc.
AICD DATA:
Patient's St. Jude Medical AICD.
Patient's RV lead St. Jude Medical.
Patient's ______ RA lead is Medtronic.
Patient's capped RV lead is Medtronic. Lead
measurements R waves of 9.8 millivolts, impedance of 710 ohms,
threshold 0.5 volts at 0.5 milliseconds. P waves are 5 millivolts,
patient has chronic atrial flutter. Impedance of 550 ohms.
Patient's pacing parameters set at DDDR 70, max rate of 110. VT's
are 162, VS's are 207. Patient will have stat chest x-ray and EKG.
We will observe overnight in telemetry. He will be placed on IV
antibiotics.
POSTPROCEDURE DIAGNOSES:
1. Successful implantation of automatic implantable
cardioverter-defibrillator St. Jude Medical pulse generator.
2. Successful explantation of old pacemaker, Medtronic.
3. Pocket revision.
4. Fluoroscopy.
5. Venogram.
INDICATION:
The patient is a very pleasant gentleman with episode of syncope
while driving a car, history of nonischemic dilated cardiomyopathy,
EF 35%.
Methods, risks, and benefits were explained to the patient including
risk of death, MI, stroke, bleeding, infection.
DESCRIPTION OF PROCEDURE:
Patient was taken to EP lab in fasting state, prepped and draped in a
usual sterile fashion. Xylocaine 1% was applied to the left chest
wall thus causing local sedation. A combination of blunt and sharp
dissection was created and opened up the pacemaker pocket. The
capsule was removed and redundant pocket was repositioned and
expanded to accommodate a new AICD. A venogram of the left
subclavian vein was made. Using a 19-gauge needle, the subclavian
vein was accessed. The J-wire could not pass through the subclavian
vein, therefore we ______ used a Glidewire. Initially we put an
8-French sheath into the subclavian vein, but we were unable to pass
leads through the subclavian vein. Thereafter, we had to upgrade to
long 7-French sheath that went through successfully, but had great
difficulty in manoeuvring the lead through the 7-French sheath.
Thereafter, it was upgraded to a 9-French long sheath. We were able
to do that successfully without complications. Thereafter using the
long 9-French sheath, we placed a RV lead and RV apex. The
appropriate thresholds and impedance were found. High output voltage
did not stimulate the diaphragm. This lead was sutured down to the
chest wall. Pocket was closed with antibiotic solution, the device
was removed and new device was inserted into the pocket. The device
was also sutured down to the chest wall and Ancef powder and FloSeal
was applied into pocket. We closed the pocket with running 2-0, 4-0
Monocryl. We did not do DFT testings since patient has not been
taking his Xarelto in consistent manner. We were concerned that he
might go and have a stroke during the cardioversion part of the DFT.
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
Less than 20 cc.
AICD DATA:
Patient's St. Jude Medical AICD.
Patient's RV lead St. Jude Medical.
Patient's ______ RA lead is Medtronic.
Patient's capped RV lead is Medtronic. Lead
measurements R waves of 9.8 millivolts, impedance of 710 ohms,
threshold 0.5 volts at 0.5 milliseconds. P waves are 5 millivolts,
patient has chronic atrial flutter. Impedance of 550 ohms.
Patient's pacing parameters set at DDDR 70, max rate of 110. VT's
are 162, VS's are 207. Patient will have stat chest x-ray and EKG.
We will observe overnight in telemetry. He will be placed on IV
antibiotics.