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Pre-operative Diagnosis:
Syncope
Post-operative Diagnosis:
Same as above
Procedure Performed :
Placement of temporary transvenous pacemaker
Ventricular lead removal
Implantation of new LV lead
Pulse generator change out
Implants and Procedure Description:
After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken.
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, the pacemaker was dissected from the sub-pectoral pocket. The pacemaker and leads were explanted but remained connected. We then tried manipulating the leads and pacemaker to see if we could reproduce the over sensing that led to ventricular pacing inhibition and syncope. However we were physically unable to reproduce the phenomena (although it did again occur while we were not manipulating the device . We then disconnected the ventricular pacing lead and tested it individually. The impedance was stable at 818 ohms, the pacing threshold was excellent at 0.6 volts and a current of 0.7 mA. R-wave sensing was 19 mV. Since we were unable to determine whether the problem was with the lead, the connection or the pulse generator, the decision was made to attempt retrieval of the ventricular lead.
The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Over the .035 wire, an 7 French peel-away sheath was advanced. The dilator was removed, and a Bard pacing lead was advanced into the right ventricle and used to pace the ventricle.
A stylette was placed in the ventricular lead and the fixation screw was unscrewed. With almost no tension at all the ventricular lead was freed and easily removed. Decision was therefore made to replace the ventricular lead with a new MRI safe pacing lead and a new pulse generator.
Percutaneous access was Again obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Over the .035 wire, an 7 French peel-away sheath was advanced. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an active fixation lead (Medtronic RVDR01 with serial number LFP127822V) Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 19.7 mV, impedance 1311 ohms, threshold was 2 volts, current 3.1 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.
Attention was then turned to the atrial lead. The lead was tested and found to have P waves of 6.2 mV, impedance 423 ohms, threshold was 0.7 volts, current 1.5 milliamps.
The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator (Medtronic RVDR01 with serial number PTN253339H) The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated. The pectoralis muscle and subcutaneous fascia were closed with interrupted 3-0 Vicryl suture. The skin layer was closed with a subcuticular 4-0 Vicryl suture. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.
Pre-operative Diagnosis:
Syncope
Post-operative Diagnosis:
Same as above
Procedure Performed :
Placement of temporary transvenous pacemaker
Ventricular lead removal
Implantation of new LV lead
Pulse generator change out
Implants and Procedure Description:
After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken.
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, the pacemaker was dissected from the sub-pectoral pocket. The pacemaker and leads were explanted but remained connected. We then tried manipulating the leads and pacemaker to see if we could reproduce the over sensing that led to ventricular pacing inhibition and syncope. However we were physically unable to reproduce the phenomena (although it did again occur while we were not manipulating the device . We then disconnected the ventricular pacing lead and tested it individually. The impedance was stable at 818 ohms, the pacing threshold was excellent at 0.6 volts and a current of 0.7 mA. R-wave sensing was 19 mV. Since we were unable to determine whether the problem was with the lead, the connection or the pulse generator, the decision was made to attempt retrieval of the ventricular lead.
The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Over the .035 wire, an 7 French peel-away sheath was advanced. The dilator was removed, and a Bard pacing lead was advanced into the right ventricle and used to pace the ventricle.
A stylette was placed in the ventricular lead and the fixation screw was unscrewed. With almost no tension at all the ventricular lead was freed and easily removed. Decision was therefore made to replace the ventricular lead with a new MRI safe pacing lead and a new pulse generator.
Percutaneous access was Again obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Over the .035 wire, an 7 French peel-away sheath was advanced. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an active fixation lead (Medtronic RVDR01 with serial number LFP127822V) Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 19.7 mV, impedance 1311 ohms, threshold was 2 volts, current 3.1 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.
Attention was then turned to the atrial lead. The lead was tested and found to have P waves of 6.2 mV, impedance 423 ohms, threshold was 0.7 volts, current 1.5 milliamps.
The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator (Medtronic RVDR01 with serial number PTN253339H) The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated. The pectoralis muscle and subcutaneous fascia were closed with interrupted 3-0 Vicryl suture. The skin layer was closed with a subcuticular 4-0 Vicryl suture. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.
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