Wiki Cardiac Ablation / Atrial Flutter and Afib. - How would this be coded?

sglamuzina

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Garden Grove, CA
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PROCEDURE(S)
Atrial fibrillation catheter ablation: posterior wall isolation and further ablation around the pulmonary veins
Left atrial flutter ablation (first independent flutter ablation): mapping demonstrating likely roof or anterior wall dependent flutter ablated with a roof line and anterior mitral line
Right atrial flutter (second independent flutter ablation) CTI dependent flutter with clockwise rotation around the TV: ablation along the CTI
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
Confirmation of CTI line of block with adenosine

PRE-PROCEDURE DIAGNOSES:
1. Persistent symptomatic afib with concern for tachycardia mediated cardiomyopathy w/depression in LVEF when he's had recurrent afib, tolerating Xarelto
2. HFrEF, LVEF 30% w/concern for tachy mediated CM
3. Prolonged QTc of 500msec while on amiodarone
4. CAD s/p stenting and 3V CABG 2016
5. DMII, HLD

-9/22/22 PVI with pre-procedure TEE
-10/11/22 Reports he still has fatigue but this is slowly improving. Denies presyncope/syncope, EKG shows NSR PR of 184, QRS of 128, and QTc 472
-Recurrent afib
-11/10/22 cardioversion with Dr. Eslami
-1/10/23 TTE LVEF 25-30% with basal inferior LV wall akinetic, mildly dilated LA, and RVSP 17
-1/17/23 f/u pt has continued fatigue and difficult sleeping and naps during the day. Increase to 400mg of amiodarone and plan for repeat DCCV
-1/24/23 TEE DCCV at Hoag, single 200 J shock
-2/7/23 f/u: pt reports symptoms of fatigue improved after the cardioversion by 30-40%, however he is now back in afib today.
-3/7/23 f/u: pt reports improved symptoms less SOB and fatigue after his cardioversion. After speaking with patient's primary cardiologist Dr. Eslami, he re-affirms that whenever patient has episodes of afib it causes HF exacerbations.

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:
PATIENT is a 78 y.o.-old male with the above PMH. The patient has symptomatic persistent atrial fibrillation. We have had extensive conversations regarding the options for afib management, including discussions of concern for tachycardia mediated cardiomyopathy. Options have been discussed with the patient's general cardiologist. Patient and family prefer to proceed with afib ablation for management of his atrial fibrillation.

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 temperature monitoring probe was placed.

The presenting rhythm was atrial fibrillation.

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, 8.5, and 9-French short sheaths on the right. Through the 8-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 9-French sheath on the right and positioned under fluoroscopic guidance in the coronary sinus for LA pacing and recording.

Of note, the patient's IVC lead into the RA at such an angle that the ICE views of the inter-atrial septal required care in order to maintain.

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 patient was cardioverted to sinus rhythm with a single shock at 200 J DCCV.

The Octaray catheter was used to create a 3D electroanatomical map of the right atrium.

The 8.5 French short sheath was exchanged for a long 8.5 French Vizigo sheath, which 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.

Next the Octaray catheter was used to construct a 3-dimensional left atrial map with the Carto mapping system.

Of note, during LA mapping, the patient entered atrial flutter (AFL1). This AFL had a CL of 300 msec with the earliest CS activation at 5/6. Mapping of the left atrium demonstrated the AFL to likely be either roof dependent or dependent on the anterior wall. ALF1 bump terminated when mapping the anterior wall.

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, posterior wall isolation was performed with delivery of RF lesions creating a roof line (LSPV to RSPV) and foor line (LIPV to RIPV). Additionally, consolidation ablation was performed throughout the posterior wall to help ensure long term posterior wall isolation.

Next an anterior mitral line was ablated from the anterior mitral valve to the RSPV. This alignment of the line was chosen to encompass areas of low voltage/fractionated atrial signals.

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 LA, 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 the LA was remapped and the posterior wall and pulmonary veins were found to be isolated. Additionally the anterior mitral line was found to have a line of scar at the area of ablation. The decision was made to not perform a double transseptal approach given the rotation of the LA/RA as well as the available ICE views.

Next burst pacing from the CS catheter induced the patient into a second atrial flutter (AFL2). AFL2 had a cycle length of 360 msec with a proximal to distal CS activation. Mapping of the LA did not contain the entire cycle length. Mapping of the RA demonstrated clockwise CTI dependent atrial flutter.

At this point the ablation catheter was 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. Ablation was performed at 40 W with a goal Surepoint value of 500.

Rate independent bidirectional CTI block was then confirmed with pacing maneuvers and this block persisted with a 12 mg push of Adenosine. The trans-isthmus time was measured to be 235 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 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:
Successful radiofrequency catheter ablation for atrial fibrillation with posterior wall isolation and repeat pulmonary vein isolation
Left atrial flutter ablation (first independent flutter ablation): mapping demonstrating likely roof or anterior wall dependent flutter ablated with a roof line and anterior mitral line
Right atrial flutter (second independent flutter ablation) CTI dependent flutter: ablation along the CTI. The trans-isthmus time was measured to be 235 msec and this persisted during adenosine push

RECCOMENDATIONS:
Continue oral anticoagulation at 6 hours post procedure
Patient to lay flat for 3 hours
 
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