Wiki Help with Coding a Report

[sglamuzina]

Can someone please help me....

1. Late presentation of inferior STEMI which probably occurred 4 days prior to patient's presentation. Coronary angiography demonstrated severe multivessel coronary artery disease. Upon presenting to Hoag from Kaiser the patient was hypotensive, had a heart rate in the low 40s, and an EKG demonstrated a profound first-degree AV block with PR interval of 500 ms. I immediately started dopamine and took the patient to the Cath Lab emergently.
2. Our first action was to place a temporary transvenous pacemaker from the right femoral vein using ultrasound guidance for access and fluoroscopy for guidance/placement of the transvenous pacemaker tip. Patient was paced at a rate of 65 bpm and dopamine drip was weaned off during the case.
3. Following this I attempted to perform the left heart catheterization/coronary angiography from the radial approach however met resistance in the arm and therefore selective right radial angiography was performed identifying a very significant radial artery loop that could not be traversed. Therefore we transitioned back to the right femoral for arterial access.
4. Ultrasound guidance was used to obtain access within the right femoral artery and a short 6 French sheath was placed however I could not advance a standard J-wire passed the right common iliac artery and therefore selective right common iliac artery angiography was performed demonstrating a 70 % stenosis of the right common iliac artery. There is also severe diffuse disease of the right internal iliac artery. I used a angled Glidewire along with an angled glide sheath to cross the common iliac artery stenosis and placed the glide sheath catheter into the descending thoracic aorta. We then exchanged the Glidewire for a long Amplatz wire over which along 65 cm peripheral sheath was placed.
5. Coronary angiography was then performed but it was clear that the patient also has an a sending aortic aneurysm. Ultimately a JL 5 catheter was successful at engaging the coronary artery.
   1. Left main with diffuse 30 % stenosis.
   2. Proximal LAD with an eccentric 80 % stenosis at the takeoff of a fairly large first diagonal system which itself exhibits an ostial 90 % stenosis. The mid LAD exhibits a fairly good target for grafting.
   3. The left circumflex exhibits an ostial eccentric 70 % stenosis followed quickly by a napkin ringlike 80 % stenosis within the proximal segment. There is a intermediate to large sized obtuse marginal branch with minimal disease and is a good target for bypass. The distal left circumflex is a CTO and fills via left to left collaterals from the OM.
   4. There are Rentrop grade 2 left to right collaterals from the LAD septals to the right PDA and from the distal left OM to the right PL.
   5. RCA exhibits a distal 100 % acute on chronic occlusion. I attempted to cross the lesion as I did not know exactly how fresh the occlusion was in hopes of trying to find a microchannel. However after significant effort it was clear that this occlusion had occurred several days prior and despite great effort could not cross the lesion.
6. Left heart catheterization demonstrated elevated LVEDP of 22 mmHg.
7. Left ventriculogram was performed using power injection demonstrating LVEF of 40 % with good anterior and anteroapical wall movement and inferior akinesis. There is also supported at least moderate to severe aortic regurgitation.
8. No evidence of a significant gradient upon pullback across the aortic valve.
9. At this point they knew the patient's only option would be bypass grafting therefore left subclavian selective angiography was then performed using an IMA catheter to evaluate candidacy of LIMA grafting. The left subclavian is tortuous but without any significant stenosis.
10. Given that this patient is going to be pacemaker dependent I then obtained right jugular vein venous access using ultrasound guidance and placed a second transvenous pacemaker into the right ventricle. I positioned it very close to the first 1 before then removing the first transvenous pacemaker. Patient then entered asystole for at least 20 sec with recovery rate in the 30s before we had good RV septal position with the second pacemaker. The right IJ transvenous pacemaker was carefully secured in place.
11. The right femoral arteriotomy and venotomy were both closed with Perclose device

 

[Jim Pawloski]

I would code this a LHC with bypass grafts - 93459, and a temp. pacemaker - 33210.