jthahn@tds.net
Contributor
Good morning,
Any help with this I am only coming up with CPT 33225, 76000
Procedure:
The patient was brought to the electrophysiology laboratory in a post absorptive state. Informed consent was given by the patient prior to the procedure and confirmed. Intravenous prophylactic antibiotics were administered prior to the procedure. After the site of implantation was prepped and draped in the usual sterile fashion and after adequate anesthesia was given, the skin was infiltrated with 1% lidocaine and 0.5% bupivicaine. The skin was incised with a #10 scalpel. Blunt and electrosurgical dissection was carried out to the level of the pre pectoral fascia with careful attention paid to hemostasis. A pocket to house the pulse generator was formed between the pre pectoral fascia and subcutaneous fat with blunt and electrosurgical dissection. The pocket was copiously irrigated with antibiotic containing normal saline and subsequently observed. Once adequate hemostasis was confirmed within the pocket, venous access was obtained. The axillar vein was accessed via a contrast guided Seldinger technique with 2 separate sticks. J tip 0.035 inch guide wires were introduced and their course through the venous system was confirmed by their presence under fluoroscopy in the inferior vena.
LV lead Implant
A 9.0 French sheath was then passed over the guide wire and the guide wire removed. a multi purpose guiding catheter was introduced and engaged with the coronary sinus. Engaging the CS with a wire was relatively easy, once this accomplished a venogram was done. A balloon tip catheter was used to perform coronary sinus angiogram and identify posterior lateral baranch. There was a good posterolateral branch arising from the CS.
The left ventricular lead was advanced through the sheath into the posterior lateral branch under fluoroscopic guidance. The acute pacing and sensing thresholds were measured and found to be satisfactory. No diaphragmatic capture
RA Lead Implant:
The old right atrial lead had poor sensing and does not capture. We proceeded with placement of a new RA lead. A peel away sheath was brought to the field and placed into the venous system via over the wire technique.
Multiple areas on the right atrium were tried for placement of the new right atrial lead. There was poor sensing all over the right atrium. In areas where the P-wave is 1.0 mv, there was no capture despite using maximum output.
Given the lack of any viable tissue on the right atrium, placement of a new RA lead was abundant. The old RA lead was connected to the biventricular pacemaker.
Generator:
The implanted leads were attached to the biventricular pacemaker device using the setscrews. The pocket was irrigated with antibiotic solution. The pulse generator and leads were coiled and placed in the pocket. Fluoroscopy was used to verify the final placement of the pacemaker and leads. The pocket was closed using multiple layers of suture and a dry sterile dressing was applied.
There were no complications, patient tolerated the procedure well. The patient left the EP lab in stable condition.
Impression / Device:
1) Successful Implantation of biventricular pacemaker via left axillary vein. Adequate sensing and pacing threshold.
2) The old right atrial lead has poor sensing and pacing parameters, attempt at implanting a new right atrial lead had the same problem. It appears there is no viable tissue in the right atrium and the whole chamber is effectively replaced by scar
Any help with this I am only coming up with CPT 33225, 76000
Procedure:
The patient was brought to the electrophysiology laboratory in a post absorptive state. Informed consent was given by the patient prior to the procedure and confirmed. Intravenous prophylactic antibiotics were administered prior to the procedure. After the site of implantation was prepped and draped in the usual sterile fashion and after adequate anesthesia was given, the skin was infiltrated with 1% lidocaine and 0.5% bupivicaine. The skin was incised with a #10 scalpel. Blunt and electrosurgical dissection was carried out to the level of the pre pectoral fascia with careful attention paid to hemostasis. A pocket to house the pulse generator was formed between the pre pectoral fascia and subcutaneous fat with blunt and electrosurgical dissection. The pocket was copiously irrigated with antibiotic containing normal saline and subsequently observed. Once adequate hemostasis was confirmed within the pocket, venous access was obtained. The axillar vein was accessed via a contrast guided Seldinger technique with 2 separate sticks. J tip 0.035 inch guide wires were introduced and their course through the venous system was confirmed by their presence under fluoroscopy in the inferior vena.
LV lead Implant
A 9.0 French sheath was then passed over the guide wire and the guide wire removed. a multi purpose guiding catheter was introduced and engaged with the coronary sinus. Engaging the CS with a wire was relatively easy, once this accomplished a venogram was done. A balloon tip catheter was used to perform coronary sinus angiogram and identify posterior lateral baranch. There was a good posterolateral branch arising from the CS.
The left ventricular lead was advanced through the sheath into the posterior lateral branch under fluoroscopic guidance. The acute pacing and sensing thresholds were measured and found to be satisfactory. No diaphragmatic capture
RA Lead Implant:
The old right atrial lead had poor sensing and does not capture. We proceeded with placement of a new RA lead. A peel away sheath was brought to the field and placed into the venous system via over the wire technique.
Multiple areas on the right atrium were tried for placement of the new right atrial lead. There was poor sensing all over the right atrium. In areas where the P-wave is 1.0 mv, there was no capture despite using maximum output.
Given the lack of any viable tissue on the right atrium, placement of a new RA lead was abundant. The old RA lead was connected to the biventricular pacemaker.
Generator:
The implanted leads were attached to the biventricular pacemaker device using the setscrews. The pocket was irrigated with antibiotic solution. The pulse generator and leads were coiled and placed in the pocket. Fluoroscopy was used to verify the final placement of the pacemaker and leads. The pocket was closed using multiple layers of suture and a dry sterile dressing was applied.
There were no complications, patient tolerated the procedure well. The patient left the EP lab in stable condition.
Impression / Device:
1) Successful Implantation of biventricular pacemaker via left axillary vein. Adequate sensing and pacing threshold.
2) The old right atrial lead has poor sensing and pacing parameters, attempt at implanting a new right atrial lead had the same problem. It appears there is no viable tissue in the right atrium and the whole chamber is effectively replaced by scar