Hello. Can someone help me with this report? I am lining to 93656, 93657, 93655,93613, 93662 but I am not sure how to code Ethanol ablation of the vein of Marshall. Or would it be part of 93655? Here is the part of the report:
"Procedure: EPS/Ablation
Indication:
74 yo woman with a complex arrhythmia history including atrial fibrillation and multiple atrial flutter circuits status post multiple ablation attempts. She is intolerant of antiarrhythmic agents and in clinical heart failure. We are Planning EPS/ablation of atrial fibrillation and atypical atrial flutter, potentially utilizing an ethanol injection into the vein of Marshall.
......
After completion of the transseptal puncture, a left atrial geometry was created using the CARTO electroanatomic mapping system by sampling various points in left atrium and the pulmonary veins with the ablation and the Pentarray mapping catheters. The Pentarray mapping catheter was advanced into each pulmonary vein carina, and recordings of pulmonary vein electrical activity were made.
A detailed activation and multiple map was created of the left atrium using the Pentarray catheter. In the baseline state, pulmonary veins were isolated and the posterior wall was also isolated. There is extensive ablation performed in the roof and anterior portion of the left atrium. There was a region of prior ablation in the lateral mitral isthmus. The activation map didn't suggest counterclockwise mitral annular atrial flutter. Because of the extensive prior endocardial ablation, the decision was made to proceed with ethanol ablation of the vein of Marshall.
The coronary sinus was cannulated with an SL2 long sheath and a coronary sinus catheter. Coronary sinus stability was very challenging due to the anterior positioning of the coronary sinus ostium and posterior course of the proximal portion of this vessel. A balloon occlusive venogram was performed in the LAO and RAO projection. This showed a very small vein of Marshall in a typical location with no extensive collateralization to other vessels.
Unfortunately during catheter manipulation or contrast injection, the atrial flutter terminated to sinus rhythm. Burst pacing was performed and the patient was put back in atrial flutter. The atrial flutter did have a different cycle length, 340 ms.
I attempted to cannulate the vein of Marshall utilizing a 0.014 BMW wire and 6 French IMA guide sheath. Because of the short course of this vessel, cannulation was very difficult with adequate stability. The IMA guide sheath was eventually exchanged for a 6 French JR 3.5. Multiple sheaths were used for the goal of achieving better coronary sinus stability. A medium Curly Jiles sheath was utilized was found to be not effective. A LAMP135 was utilized which did achieve better coronary sinus stability. After multiple attempts, the pain of Marshall was eventually cannulated with the 0.014 wire and guide support was achieved with the JR 3.5 sheath. A compliant 2.0 mm x 8 mm over-the-wire coronary balloon was advanced to the distal portion of the vein of Marshall. The balloon was inflated to 5 atm and contrast was administered showing that the balloon was occlusive the vein.
Dehydrated ethanol was then administered slowly. A total of 1.5 cc was given over the first 3 min. Next, the balloon was pulled back to the ostium of the vein of Marshall. The balloon was then inflated to 8 atm and a small amount of contrast was then given showing that the balloon was occlusive of the vein. Another injection of ethanol, 1 cc, infused over 2 minutes was then performed. Shortly after ethanol infusion, the atrial flutter slowed and terminated.
A detailed voltage map was again created of the left atrium in sinus rhythm. There is a very dense region of scar created in the lateral mitral annulus, which was much more pronounced than the pre-ablation state. Differential pacing was performed which did show intact mitral isthmus block.
Next, arrhythmia induction was again performed by burst pacing the coronary sinus catheter down to 220 ms. Atrial flutter was again eventually induced. Atrial flutter was nonsustained and would terminated after about 2-5 minutes.
Evaluation of the CTI showed there was an area of leak which was ablated with 40 W. Trans-isthmus conduction time was then found to be 170 ms and bidirectional block was proven with differential pacing.
Next, arrhythmia induction was then performed. Atrial flutter was again induced with a cycle length of 370 ms. Coronary sinus activation was proximal to distal. Entrainment from the coronary sinus showed long post-pacing intervals. Entrainment from the medial and lateral CTI showed manifestation of long post-pacing intervals. Activation map of the right atrium was performed which showed a very early area of focal activity near the septal SVC junction. Left atrial mapping was also performed but the arrhythmia terminated when mapping around the region of the anterior septum just in front of the right superior pulmonary vein.
The decision was made to perform ablation in this region of the high right atrium of earliest activation were fractionated activity was found. Ablation was performed at 35 Watts. Ablation was also performed at 40 W in the left atrial septum just anterior to the right superior pulmonary vein.
At the end of the case, arrhythmia induction was then performed. Burst pacing down to 200 ms showed only brief nonsustained atrial flutter/fibrillation which quickly self terminated. The decision was made to stop the case at this point.
Intracardiac echo confirmed the absence of pericardial effusion at the end of the case.
A total of 20 RF applications were given; there was no evidence of coagulum formation or impedance increase throughout the procedure. Radiofrequency ablation was performed using an open-irrigated power-controlled system.
Protamine was given to partially reverse heparin administration for sheath pull. Catheters/sheaths were pulled with manual compression held at the access sites.
FLUORO: 34 min
Contrast: 65cc
This was a very prolonged challenging case due to difficulty of the anatomy of the coronary sinus and a vein of Marshall. Procedure time was more than twice what would typically be expected.
Summary / Conclusions:
1. History of paroxysmal atrial fibrillation
2. Intact isolation of all 4 pulmonary veins and posterior wall of left atrium
3. Successful transseptal puncture
4. CARTO electroanatomic mapping
5. Spontaneous atypical atrial flutter (counterclockwise mitral annular)
6. Successful ablation of atypical atrial flutter utilizing a technique of ethanol ablation in the vein of Marshall
7. Ablation of typical atrial flutter utilizing the cavotricuspid isthmus
8. Ablation of other atrial flutter circuits involving the left interatrial septum
9. No inducible sustained arrhythmias at the end of the case
"Procedure: EPS/Ablation
Indication:
74 yo woman with a complex arrhythmia history including atrial fibrillation and multiple atrial flutter circuits status post multiple ablation attempts. She is intolerant of antiarrhythmic agents and in clinical heart failure. We are Planning EPS/ablation of atrial fibrillation and atypical atrial flutter, potentially utilizing an ethanol injection into the vein of Marshall.
......
After completion of the transseptal puncture, a left atrial geometry was created using the CARTO electroanatomic mapping system by sampling various points in left atrium and the pulmonary veins with the ablation and the Pentarray mapping catheters. The Pentarray mapping catheter was advanced into each pulmonary vein carina, and recordings of pulmonary vein electrical activity were made.
A detailed activation and multiple map was created of the left atrium using the Pentarray catheter. In the baseline state, pulmonary veins were isolated and the posterior wall was also isolated. There is extensive ablation performed in the roof and anterior portion of the left atrium. There was a region of prior ablation in the lateral mitral isthmus. The activation map didn't suggest counterclockwise mitral annular atrial flutter. Because of the extensive prior endocardial ablation, the decision was made to proceed with ethanol ablation of the vein of Marshall.
The coronary sinus was cannulated with an SL2 long sheath and a coronary sinus catheter. Coronary sinus stability was very challenging due to the anterior positioning of the coronary sinus ostium and posterior course of the proximal portion of this vessel. A balloon occlusive venogram was performed in the LAO and RAO projection. This showed a very small vein of Marshall in a typical location with no extensive collateralization to other vessels.
Unfortunately during catheter manipulation or contrast injection, the atrial flutter terminated to sinus rhythm. Burst pacing was performed and the patient was put back in atrial flutter. The atrial flutter did have a different cycle length, 340 ms.
I attempted to cannulate the vein of Marshall utilizing a 0.014 BMW wire and 6 French IMA guide sheath. Because of the short course of this vessel, cannulation was very difficult with adequate stability. The IMA guide sheath was eventually exchanged for a 6 French JR 3.5. Multiple sheaths were used for the goal of achieving better coronary sinus stability. A medium Curly Jiles sheath was utilized was found to be not effective. A LAMP135 was utilized which did achieve better coronary sinus stability. After multiple attempts, the pain of Marshall was eventually cannulated with the 0.014 wire and guide support was achieved with the JR 3.5 sheath. A compliant 2.0 mm x 8 mm over-the-wire coronary balloon was advanced to the distal portion of the vein of Marshall. The balloon was inflated to 5 atm and contrast was administered showing that the balloon was occlusive the vein.
Dehydrated ethanol was then administered slowly. A total of 1.5 cc was given over the first 3 min. Next, the balloon was pulled back to the ostium of the vein of Marshall. The balloon was then inflated to 8 atm and a small amount of contrast was then given showing that the balloon was occlusive of the vein. Another injection of ethanol, 1 cc, infused over 2 minutes was then performed. Shortly after ethanol infusion, the atrial flutter slowed and terminated.
A detailed voltage map was again created of the left atrium in sinus rhythm. There is a very dense region of scar created in the lateral mitral annulus, which was much more pronounced than the pre-ablation state. Differential pacing was performed which did show intact mitral isthmus block.
Next, arrhythmia induction was again performed by burst pacing the coronary sinus catheter down to 220 ms. Atrial flutter was again eventually induced. Atrial flutter was nonsustained and would terminated after about 2-5 minutes.
Evaluation of the CTI showed there was an area of leak which was ablated with 40 W. Trans-isthmus conduction time was then found to be 170 ms and bidirectional block was proven with differential pacing.
Next, arrhythmia induction was then performed. Atrial flutter was again induced with a cycle length of 370 ms. Coronary sinus activation was proximal to distal. Entrainment from the coronary sinus showed long post-pacing intervals. Entrainment from the medial and lateral CTI showed manifestation of long post-pacing intervals. Activation map of the right atrium was performed which showed a very early area of focal activity near the septal SVC junction. Left atrial mapping was also performed but the arrhythmia terminated when mapping around the region of the anterior septum just in front of the right superior pulmonary vein.
The decision was made to perform ablation in this region of the high right atrium of earliest activation were fractionated activity was found. Ablation was performed at 35 Watts. Ablation was also performed at 40 W in the left atrial septum just anterior to the right superior pulmonary vein.
At the end of the case, arrhythmia induction was then performed. Burst pacing down to 200 ms showed only brief nonsustained atrial flutter/fibrillation which quickly self terminated. The decision was made to stop the case at this point.
Intracardiac echo confirmed the absence of pericardial effusion at the end of the case.
A total of 20 RF applications were given; there was no evidence of coagulum formation or impedance increase throughout the procedure. Radiofrequency ablation was performed using an open-irrigated power-controlled system.
Protamine was given to partially reverse heparin administration for sheath pull. Catheters/sheaths were pulled with manual compression held at the access sites.
FLUORO: 34 min
Contrast: 65cc
This was a very prolonged challenging case due to difficulty of the anatomy of the coronary sinus and a vein of Marshall. Procedure time was more than twice what would typically be expected.
Summary / Conclusions:
1. History of paroxysmal atrial fibrillation
2. Intact isolation of all 4 pulmonary veins and posterior wall of left atrium
3. Successful transseptal puncture
4. CARTO electroanatomic mapping
5. Spontaneous atypical atrial flutter (counterclockwise mitral annular)
6. Successful ablation of atypical atrial flutter utilizing a technique of ethanol ablation in the vein of Marshall
7. Ablation of typical atrial flutter utilizing the cavotricuspid isthmus
8. Ablation of other atrial flutter circuits involving the left interatrial septum
9. No inducible sustained arrhythmias at the end of the case