Please lend your two cents. I've been trying to find info but haven't had luck. A cardioversion was performed during a pacemaker insertion procedure. Modifier -59 is allowed but I don't know if this should've been billed out or not separately.
PROCEDURES PERFORMED:
1. Dual-chamber pacemaker placement.
2. Direct current cardioversion.
PREOPERATIVE DIAGNOSES:
1. Sinus node dysfunction.
2. Irreversible symptomatic bradycardia.
3. Paroxysmal atrial fibrillation.
4. Status post bioprosthetic mitral valve replacement.
POSTOPERATIVE DIAGNOSES:
1. Sinus node dysfunction.
2. Irreversible symptomatic bradycardia.
3. Paroxysmal atrial fibrillation.
4. Status post bioprosthetic mitral valve replacement.
ANESTHESIA: Local Lidocaine and moderate sedation with intravenous Versed and Fentanyl.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: Less than 50 mL
COMPLICATIONS: None.
INDICATION FOR THE PROCEDURE: The patient is a 55-year-old woman who underwent bioprosthetic mitral valve replacement last week for severe mitral stenosis. She had also been having atrial fibrillation with rapid rates and underwent surgical biatrial A-fib ablation. She has been noted to have an ectopic atrial versus a junctional rhythm with paroxysms of rapid atrial fibrillation. The patient was admitted with a fall concerning for symptomatic bradycardia. She is referred for permanent pacing. The patient was noted to go into atrial fibrillation earlier today. Her INR is therapeutic.
DESCRIPTION OF PROCEDURE: The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient and her family, and she provided informed written consent. The patient was brought to the electrophysiology laboratory where she was prepped and draped in the usual sterile fashion. Left upper extremity venography confirmed a patent left subclavian system. She was noted on fluoroscopy to have evidence for pleural effusion.
Lidocaine 2% was used to anesthetize the left pectoral region. Using a scalpel, an incision was made over the left deltopectoral groove. Using blunt dissection and brief bursts of electrocautery, a device pocket was developed superficial to the pectoralis fascia.
Using the venogram as a guide, left subclavian venous access was obtained twice with an introducer needle and 2 wires were placed under fluoroscopic guidance. A 7-French sheath was placed. The RV lead was delivered to the RV apical septum under fluoroscopic guidance. The active fixation mechanism was deployed. Appropriate sensing, threshold, and impedance values were obtained. The pacing morphology was fairly narrow consistent with septal capture. The sheath was split and removed.
A second 7-French sheath was placed over the remaining wire. The RA lead was delivered to the high rate atrium under fluoroscopic guidance. The active fixation mechanism was deployed. Appropriate A-fib sensing and impedance values were obtained. The sheath was split and removed. Both leads were secured to the underlying tissue with 0 silk x2 each.
Given that the patient just went into atrial fibrillation today and her INR was therapeutic, we proceeded with direct current cardioversion. The patient was fully sedated. A single 200 joule synchronized shock converted the patient to sinus arrest with limited escape. Atrial pacing was initiated with intact AV conduction noted.
The pulse generator was then connected to the leads with the appropriate torque wrench. Hemostasis was then ensured in the pocket with further electrocautery. The pocket was irrigated with copious Bacitracin and saline solution. The device and leads assembly were then placed in the cleaned pocket. The pulse generator was secured to the underlying tissue with 0 silk x1.
The pocket was closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material. Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.
The patient tolerated procedure well, and was transferred back to the IMCU in stable condition.
IMPLANTED HARDWARE: The pulse generator is a Medtronic RVDR01, serial number is PTN260123H. RA lead is a Medtronic 5076, serial number PJN3448876. RV lead is a Medtronic 5076, serial number PJN3440502.
Through the device the RA lead senses likely retrograde atrial activity of 5.3 millivolts, threshold 1 volt at 0.4 milliseconds, impedance 792 ohms. RV lead senses 13.9 millivolts, threshold 0.5 volts at 0.4 milliseconds, impedance 632 ohms.
The device was programmed AAIR-DDDR 80-130.
The patient tolerated the procedure well.
**This is an MRI compatible pacemaker system.**
We will plan to decrease the low rate gradually, depending on how her A-fib burden progresses
Thanks,
Jessica CPC, CCC
PROCEDURES PERFORMED:
1. Dual-chamber pacemaker placement.
2. Direct current cardioversion.
PREOPERATIVE DIAGNOSES:
1. Sinus node dysfunction.
2. Irreversible symptomatic bradycardia.
3. Paroxysmal atrial fibrillation.
4. Status post bioprosthetic mitral valve replacement.
POSTOPERATIVE DIAGNOSES:
1. Sinus node dysfunction.
2. Irreversible symptomatic bradycardia.
3. Paroxysmal atrial fibrillation.
4. Status post bioprosthetic mitral valve replacement.
ANESTHESIA: Local Lidocaine and moderate sedation with intravenous Versed and Fentanyl.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: Less than 50 mL
COMPLICATIONS: None.
INDICATION FOR THE PROCEDURE: The patient is a 55-year-old woman who underwent bioprosthetic mitral valve replacement last week for severe mitral stenosis. She had also been having atrial fibrillation with rapid rates and underwent surgical biatrial A-fib ablation. She has been noted to have an ectopic atrial versus a junctional rhythm with paroxysms of rapid atrial fibrillation. The patient was admitted with a fall concerning for symptomatic bradycardia. She is referred for permanent pacing. The patient was noted to go into atrial fibrillation earlier today. Her INR is therapeutic.
DESCRIPTION OF PROCEDURE: The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient and her family, and she provided informed written consent. The patient was brought to the electrophysiology laboratory where she was prepped and draped in the usual sterile fashion. Left upper extremity venography confirmed a patent left subclavian system. She was noted on fluoroscopy to have evidence for pleural effusion.
Lidocaine 2% was used to anesthetize the left pectoral region. Using a scalpel, an incision was made over the left deltopectoral groove. Using blunt dissection and brief bursts of electrocautery, a device pocket was developed superficial to the pectoralis fascia.
Using the venogram as a guide, left subclavian venous access was obtained twice with an introducer needle and 2 wires were placed under fluoroscopic guidance. A 7-French sheath was placed. The RV lead was delivered to the RV apical septum under fluoroscopic guidance. The active fixation mechanism was deployed. Appropriate sensing, threshold, and impedance values were obtained. The pacing morphology was fairly narrow consistent with septal capture. The sheath was split and removed.
A second 7-French sheath was placed over the remaining wire. The RA lead was delivered to the high rate atrium under fluoroscopic guidance. The active fixation mechanism was deployed. Appropriate A-fib sensing and impedance values were obtained. The sheath was split and removed. Both leads were secured to the underlying tissue with 0 silk x2 each.
Given that the patient just went into atrial fibrillation today and her INR was therapeutic, we proceeded with direct current cardioversion. The patient was fully sedated. A single 200 joule synchronized shock converted the patient to sinus arrest with limited escape. Atrial pacing was initiated with intact AV conduction noted.
The pulse generator was then connected to the leads with the appropriate torque wrench. Hemostasis was then ensured in the pocket with further electrocautery. The pocket was irrigated with copious Bacitracin and saline solution. The device and leads assembly were then placed in the cleaned pocket. The pulse generator was secured to the underlying tissue with 0 silk x1.
The pocket was closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material. Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.
The patient tolerated procedure well, and was transferred back to the IMCU in stable condition.
IMPLANTED HARDWARE: The pulse generator is a Medtronic RVDR01, serial number is PTN260123H. RA lead is a Medtronic 5076, serial number PJN3448876. RV lead is a Medtronic 5076, serial number PJN3440502.
Through the device the RA lead senses likely retrograde atrial activity of 5.3 millivolts, threshold 1 volt at 0.4 milliseconds, impedance 792 ohms. RV lead senses 13.9 millivolts, threshold 0.5 volts at 0.4 milliseconds, impedance 632 ohms.
The device was programmed AAIR-DDDR 80-130.
The patient tolerated the procedure well.
**This is an MRI compatible pacemaker system.**
We will plan to decrease the low rate gradually, depending on how her A-fib burden progresses
Thanks,
Jessica CPC, CCC