Wiki Complete EP study and Venogram


Maumee, OH
Best answers
Could someone please help me....... This was coded 93620, 93621, 93613, 93662, 75820-26, 36005-59, & 93651.....I know it is long and I know some codes are not right I am just looking for a second opinion.

PROCEDURE PERFORMED: Electrophysiology study.

HISTORY: The patient is a 60-year-old female with past medical
history of obstructive sleep apnea, hypertension,
persistent/permanent atrial fibrillation and diabetes mellitus.
We have tried a variety of rhythm control treatment options
including p.o. amiodarone as the patient has had difficulties
with increasing shortness of breath since the prevalence of her
atrial fibrillation has increased. She underwent cardioversion
with early recurrence of atrial fibrillation, was not able to
maintain sinus rhythm more than one minute. Despite multiple
rhythm control attempts and continued symptomatic atrial
fibrillation, the patient has made the decision to move forward
with a catheter based ablative procedure. Prior to the
procedure, the patient was bridged off her Pradaxa with Lovenox.
She underwent a transesophageal echocardiogram yesterday,
demonstrating left atrial enlargement but no evidence of a left
atrial appendage thrombus.

PROCEDURE DETAILS: Following informed consent, the patient was
brought to the EP lab in the fasting post-absorptive state.
Anesthesia was provided via the anesthesia service. Using the
standard sterile technique, both groins were prepped and draped
in the usual fashion. Using 1% lidocaine for local anesthesia,
access into the right and left femoral veins were performed
utilizing the modified Seldinger technique and the micropuncture
kit. Wires were confirmed in the inferior vena cava. Over these
wires, two 8-French short sheaths and one 7-French short sheath
were placed in the right femoral vein and one 9-French sheath was
placed in the left femoral vein. All sheaths were flushed with
heparinized saline. Through the French sheath in the left
femoral vein, an Acuson 8-1/2 French catheter was maneuvered into
the area of the right atrial appendage for visualization of the
fossa ovalis. A CS EZ Steer FJ curve CS catheter was maneuvered
through the 7-French sheath into the coronary sinus. The two
8-French short sheaths were then exchanged out for SL0 long
sheaths and we were able to cross into the left atrium with the
wire. Right atrial pressure was then recorded at 12/3. We then
visualized fossa ovalis with the ultrasound catheter. We
advanced the dilator and sheath over the wire into the subclavian
system and in a standard LAO pull down, we were able to easily
cross into the left atrium The wire was advanced the sheath over
the dilator and wire into the left atrium. Three stable blood
pressures were seen and half the initial heparin bolus was given.
We then used a FF curve ThermoCool catheters through the second
SL0 sheath and again were easily able to cross in an LAO
traditional transseptal pull down into the left atrium. The
remaining heparin bolus was given. An OmniFlush catheter was
then utilized to do pulmonary venogram on the left superior and
right superior pulmonary veins. An esophogram was then done with
barium swallow, showing the esophagus located primarily over the
right posterior veins. Using the _____ mapping and the CARTO 3
mapping system, we were able to create the geometry of the left
atrium. We did perform CARTO merge with the CT scan, which was
performed. The patient's anatomy was somewhat different in that
she had several small right-sided veins and a large right-sided
antrum. There were two inferior veins which were smaller than 10
mm, the right superior vein came off at an acute angle. The left
side had a common antra of a large left superior vein and the
inferior vein was also quite small. The left atrium was clearly
enlarged. Antral circles were then performed using power and
temperature limits of 30 watts in the anterior wall, 25 in the
posterior wall. Great care was taken not to ablate within the
coronary ostia. With antral circles, pulmonary vein isolation of
the left superior and inferior veins were performed. The
patient's ablation was done during atrial fibrillation. Then
went to the right side. The right superior vein after following
an antral circle which could not be completed fully in the
posterior wall due to the esophagus. We did have clear isolation
of the right superior vein. In the ablation around the right
superior vein in the anterior and superior portion, we did paste
for phrenic nerve capture prior to ablation. Any ablation done
in the posterior wall was done for less than 10 seconds and we
did not ablate in any area that we thought fluoroscopically was
within 0.5-1 centimeters of the esophagus. We then created a
roof line adjoining the antral circles and then ablated, creating
a mitral isthmus line with power limits of 35 watts. We then
cardioverted the patient to normal sinus rhythm. Previously, she
had not been able to maintain sinus rhythm, we were able at this
time to maintain sinus rhythm, confirmed bidirectional block with
pacing from both the coronary sinus as well as left atrial
appendage. Roof block could not be confirmed. Additional
ablation was done across the roof line, but we could not get a
block across the roof line. The right superior, left inferior
and left superior veins all were confirmed to have isolation at
the end of the case. The electrophysiology catheters were then
removed into the right atrium. Baseline numbers showed the
patient in sinus rhythm, pacing from the RV apex demonstrated no
VA conduction at baseline. The PR interval was 190, HV interval
of 110, HV of 46, QRS of 120, QT of 390. Sinus cycle length of
720. AV Wenckebach cycle length was 470 and AV nodal ERP was
600/360. The SL0 sheaths were then exchanged out for two
9-French short sheaths. All sheaths were flushed with
heparinized saline and all were secured in place with 0 silk. At
conclusion of the study, the Acuson catheter was maneuvered into
the RV. There was a small pericardial fat pad which remained
unchanged. There is a trace pericardial effusion which remained
unchanged from the beginning of the case. This was documented.
Closing blood pressure was 137/76 with a heart rate of 82.