Lhc, ptca, intraortic balloon pump-two drs acls protocol - help!!!!!!!

Jane5711

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Port Charlotte, Florida
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This is a doozy of a procedure! Patient prior to this procedure had a PTCA to the RCA and was unstable. Here's the rest....
OPERATIVE PROCEDURES PERFORMED:
1. Left heart cardiac catheterization for a left coronary artery
angiography, right coronary artery angiography and left coronary
artery angiography.
2. Angioplasty and stenting of the mid left circumflex artery with a
3.0/12 mm Xience Alpine Everolimus drug-eluting stent.
3. Intraaortic balloon pump insertion through the left femoral arterial
approach.
4. Attempted angioplasty of the left anterior descending artery.

INDICATIONS:
1. Acute ST-segment elevation myocardial infarction following previous
angioplasty and stent of the right coronary artery.
2. Totally occluded proximal left circumflex artery with acute stent
thrombosis/in-stent restenosis.
3. Cardiac arrest with subtotal occlusion of the mid left anterior
descending artery.
4. Cardiorespiratory resuscitation with ACLS protocol.

PROCEDURE: After the patient had completed the angioplasty and stent of
the right coronary artery and she has been hemodynamically unstable for a
few minutes requiring resuscitation with IV fluids as well as dopamine and
stabilization of the hemodynamic status with reopening of the distal
coronary artery, which had resulted in coronary vasospasm, the patient was
being transferred to the ICU. While she was in the hallway, getting ready
to go to the ICU. About 40 minutes after the angioplasty, the patient
started having significant drop in systolic blood pressure dropped to 50
systolic. When the nurse alerted us, the patient was brought urgently back
into the cardiac catheterization lab.

The right groin arterial sheath was reprepped. The existing right groin
arterial sheath in the right femoral artery, which is a 6-French arterial
sheath was reprepped.

A 6-French IMA guide was advanced for a guidewire, and was used to engage
the right coronary artery and right coronary artery angiography was
performed, which showed the patent right coronary artery in its entire
portion with a patent stent and distal TIMI-3 flow.

Then, hence, a 6-French XB 3.5 guide was used to engage the left coronary
artery.
.
The left coronary artery angiography was performed. This revealed that the
left anterior descending artery had 80 to 90 percent stenosis in its
midportion just at the origin of the diagonal branch with a long lesion
and there was a total occlusion of the proximal left circumflex artery
within the stent itself. This was suggestive possibly of acute stent
thrombosis since the patient had become hemodynamically unstable suddenly.
Hence, 0.014 PT Graphix wire was used to cross the lesion in the proximal
mid left circumflex artery. The wire could not advance beyond the distal
mid left circumflex artery and hence a 2.0/15 mm balloon was advanced
through the wire and was used to dilate the proximal portion of the stent,
but the stent still could not advance well. At this point, the 0.014 Asahi
Sion blue wire was used. This wire was able to cross the lesion in the
proximal and mid left circumflex artery stent as well as the midportion of
the left circumflex artery between the 2 stents with the lesion present
there. The wire was advanced to the distal left circumflex artery. Over
this wire, a 3.0/13 mm balloon was advanced and was used to make
sequential inflations of the entire proximal mid and distal left
circumflex artery at up to 16 atmospheres in different locations.

TIMI-2 flow to TIMI-3 flow was established in the mid distal left
circumflex artery and obtuse marginal branch.

There is a segment of the mid left circumflex artery, which is between the
2 stents, and which was felt where contrast hang up might be occurring
hence it was decided to stent this segment.

A 3.0/12 mm Xience Alpine Everolimus drug-eluting stent was advanced in
the mid left circumflex artery and was deployed at 16 atmospheres with
good results. The stent balloon was removed and angiographic images were
obtained, which showed good flow in the distal left circumflex artery.
Since the patient had just suffered from cardiogenic shock with
significant hypotension with ST-segment elevation, which was clearly
related to the left circumflex artery with the total occlusion. It was
felt that the mid distal LAD lesion wihich is also significant critical
would be best managed at this time with intra-aortic balloon pump and
optimization of the medical therapy first before reintervention in the
LAD.

While this was being considered a guidewire and guiding catheter removed
from the right femoral artery sheath. At this point, preparations were
being made for balloon pump insertion through the right femoral arterial
approach. Balloon pump could not advance easily and the guidewire was
reintroduced, the guidewire had difficulty crossing back into the aorta.

This over time the patient was noted to become unresponsive. She did have
initially rhythm _____ nonresponsive and hence CODE BLUE was called and
CPR was initiated with manual compressions of the chest. While this was
being done, the rest of the therapies also intubated the patient. After
the patient was given BiPAP in the beginning.

At this point, ACLS protocol was run completely in its entirety with the
help of another cardiologist Dr. as well as the rest of the staff

Various drugs were given for the ACLS protocol as noted in the procedure
log.

Vascular access was then obtained in the left femoral artery, and an
8-French angiographic sheath was placed in the left femoral artery.

Through the left femoral arterial sheath intraaortic balloon pump was
advanced over a guidewire, and was started and one-to-one intraaortic
balloon pump functioning. While _____ was obtained that despite CPR
patient did not regain any rhythm and attempts were made by Dr. De to get
arterial access in the right radial artery, which was not successful.

At this point, it was decided to have another arterial sheath access in
the left femoral artery, which was successfully done by me and a 6-French
angiographic sheath was placed in the left femoral artery above the
previously placed 8-French arterial sheath.

Then, through the 6-French arterial sheath in the left femoral artery, a
6-French XB 3.5 guide was reintroduced and images were obtained of the
left coronary artery with angiography. It was now noted that the left
anterior descending artery is totally occluded.

A 0.014 runaway wire was used to cross the lesion into the diagonal
branch, but was not able to successfully cross into the mid LAD and it was
becoming more difficult to cross it because the patient was having active
CPR with manual chest compressions.

It was noted at this point that we had to perform the ACLS protocol and
CPR with manual compression for about 30 minutes and it was decided by me
that it was becoming futile with extremely poor prognosis. The patient
noted that prior to this we had tried to cross into aortic valve, through
the aortic valve with the help of the JR4 catheter as well as a 6-French
AL1 catheter with multiple attempts with the guidewires by me as well as
by Dr. to cross through the aortic valve, it was felt that the aortic
valve was severely stenotic and hence Impella was not able to be inserted
because we could not cross the aortic valve at all. It was also felt the
Impella device would be considered contraindicated at this point.

As focus was mostly on giving the patient intraaortic balloon pump support
and doing an angioplasty of the LAD, but because significant amount of
time had lapsed with the CPR and the patient have not ably recovered, it
was decided it will be futile to consider angioplasty of the LAD at this
point. The patient had severely decreased left ventricular systolic
function with severe aortic valve stenosis, severe mitral valve
regurgitation and severely decreased left ventricular systolic function
with left ventricular ejection fraction probably now in the range of 20
percent previously.
Hence, it was decided at this point to terminate the ACLS protocol and the
patient was declared expired. A routine procedure with regards to removal
of the device, removal of the wires and guiding catheters were done and
the removal of the arterial sheaths were done from the patient.

RESULTS:
1. The patient was brought to the cardiac catheterization lab with
recurrent cardiogenic shock and hypotension, systolic pressure of 50
with ST elevations noted on the telemetry monitor.
2. Cardiogenic shock related likely due to total thrombotic occlusion of
the proximal left circumflex artery with likely stent thrombosis with
widely patent stent in the proximal mid right coronary artery, which
was implanted earlier during the day; and 80-90 percent stenosis of
the mid left anterior descending artery with subsequently support from
a total occlusion during the procedure
3. The total occlusion of the mid LAD is likely related to cardiogenic
shock itself. Despite the patient being on anticoagulant such as
Angiomaxx as well as in the antiplatelet agents such as Aggrastat
drip.
5. Successful angioplasty and stent of the mid left circumflex artery
with a 3.0/12 mm Xience Alpine Everolimus drug-eluting stent, but
unsuccessful attempt at the angioplasty of the left anterior
descending artery.
6. Unsuccessful CPR and ACLS for cardiorespiratory arrest with patient
expiring after about 30 minutes of attempted resuscitation with ACLS
protocol.

Appropriate calls were made to the attending physician as well as the
patients relatives regards to the patients demise

Here are some codes I come up with - Do not see LHC only angiography of coronary arteries - 93454, 26, 92928, LC, 33967
ANY HELP WILL DO! Thanks!!!! Happy Holidays!
 
Last edited:

Jane5711

Networker
Messages
67
Location
Port Charlotte, Florida
Best answers
0
"coding king" any thoughts - "jim" any thoughts

Need help as soon as possible; need to code. Any thoughts or codes will do. Thanks!!!!!

This is a doozy of a procedure! Patient prior to this procedure had a PTCA to the RCA and was unstable. Here's the rest....
OPERATIVE PROCEDURES PERFORMED:
1. Left heart cardiac catheterization for a left coronary artery
angiography, right coronary artery angiography and left coronary
artery angiography.
2. Angioplasty and stenting of the mid left circumflex artery with a
3.0/12 mm Xience Alpine Everolimus drug-eluting stent.
3. Intraaortic balloon pump insertion through the left femoral arterial
approach.
4. Attempted angioplasty of the left anterior descending artery.

INDICATIONS:
1. Acute ST-segment elevation myocardial infarction following previous
angioplasty and stent of the right coronary artery.
2. Totally occluded proximal left circumflex artery with acute stent
thrombosis/in-stent restenosis.
3. Cardiac arrest with subtotal occlusion of the mid left anterior
descending artery.
4. Cardiorespiratory resuscitation with ACLS protocol.

PROCEDURE: After the patient had completed the angioplasty and stent of
the right coronary artery and she has been hemodynamically unstable for a
few minutes requiring resuscitation with IV fluids as well as dopamine and
stabilization of the hemodynamic status with reopening of the distal
coronary artery, which had resulted in coronary vasospasm, the patient was
being transferred to the ICU. While she was in the hallway, getting ready
to go to the ICU. About 40 minutes after the angioplasty, the patient
started having significant drop in systolic blood pressure dropped to 50
systolic. When the nurse alerted us, the patient was brought urgently back
into the cardiac catheterization lab.

The right groin arterial sheath was reprepped. The existing right groin
arterial sheath in the right femoral artery, which is a 6-French arterial
sheath was reprepped.

A 6-French IMA guide was advanced for a guidewire, and was used to engage
the right coronary artery and right coronary artery angiography was
performed, which showed the patent right coronary artery in its entire
portion with a patent stent and distal TIMI-3 flow.

Then, hence, a 6-French XB 3.5 guide was used to engage the left coronary
artery.
.
The left coronary artery angiography was performed. This revealed that the
left anterior descending artery had 80 to 90 percent stenosis in its
midportion just at the origin of the diagonal branch with a long lesion
and there was a total occlusion of the proximal left circumflex artery
within the stent itself. This was suggestive possibly of acute stent
thrombosis since the patient had become hemodynamically unstable suddenly.
Hence, 0.014 PT Graphix wire was used to cross the lesion in the proximal
mid left circumflex artery. The wire could not advance beyond the distal
mid left circumflex artery and hence a 2.0/15 mm balloon was advanced
through the wire and was used to dilate the proximal portion of the stent,
but the stent still could not advance well. At this point, the 0.014 Asahi
Sion blue wire was used. This wire was able to cross the lesion in the
proximal and mid left circumflex artery stent as well as the midportion of
the left circumflex artery between the 2 stents with the lesion present
there. The wire was advanced to the distal left circumflex artery. Over
this wire, a 3.0/13 mm balloon was advanced and was used to make
sequential inflations of the entire proximal mid and distal left
circumflex artery at up to 16 atmospheres in different locations.

TIMI-2 flow to TIMI-3 flow was established in the mid distal left
circumflex artery and obtuse marginal branch.

There is a segment of the mid left circumflex artery, which is between the
2 stents, and which was felt where contrast hang up might be occurring
hence it was decided to stent this segment.

A 3.0/12 mm Xience Alpine Everolimus drug-eluting stent was advanced in
the mid left circumflex artery and was deployed at 16 atmospheres with
good results. The stent balloon was removed and angiographic images were
obtained, which showed good flow in the distal left circumflex artery.
Since the patient had just suffered from cardiogenic shock with
significant hypotension with ST-segment elevation, which was clearly
related to the left circumflex artery with the total occlusion. It was
felt that the mid distal LAD lesion wihich is also significant critical
would be best managed at this time with intra-aortic balloon pump and
optimization of the medical therapy first before reintervention in the
LAD.

While this was being considered a guidewire and guiding catheter removed
from the right femoral artery sheath. At this point, preparations were
being made for balloon pump insertion through the right femoral arterial
approach. Balloon pump could not advance easily and the guidewire was
reintroduced, the guidewire had difficulty crossing back into the aorta.

This over time the patient was noted to become unresponsive. She did have
initially rhythm _____ nonresponsive and hence CODE BLUE was called and
CPR was initiated with manual compressions of the chest. While this was
being done, the rest of the therapies also intubated the patient. After
the patient was given BiPAP in the beginning.

At this point, ACLS protocol was run completely in its entirety with the
help of another cardiologist Dr. as well as the rest of the staff

Various drugs were given for the ACLS protocol as noted in the procedure
log.

Vascular access was then obtained in the left femoral artery, and an
8-French angiographic sheath was placed in the left femoral artery.

Through the left femoral arterial sheath intraaortic balloon pump was
advanced over a guidewire, and was started and one-to-one intraaortic
balloon pump functioning. While _____ was obtained that despite CPR
patient did not regain any rhythm and attempts were made by Dr. De to get
arterial access in the right radial artery, which was not successful.

At this point, it was decided to have another arterial sheath access in
the left femoral artery, which was successfully done by me and a 6-French
angiographic sheath was placed in the left femoral artery above the
previously placed 8-French arterial sheath.

Then, through the 6-French arterial sheath in the left femoral artery, a
6-French XB 3.5 guide was reintroduced and images were obtained of the
left coronary artery with angiography. It was now noted that the left
anterior descending artery is totally occluded.

A 0.014 runaway wire was used to cross the lesion into the diagonal
branch, but was not able to successfully cross into the mid LAD and it was
becoming more difficult to cross it because the patient was having active
CPR with manual chest compressions.

It was noted at this point that we had to perform the ACLS protocol and
CPR with manual compression for about 30 minutes and it was decided by me
that it was becoming futile with extremely poor prognosis. The patient
noted that prior to this we had tried to cross into aortic valve, through
the aortic valve with the help of the JR4 catheter as well as a 6-French
AL1 catheter with multiple attempts with the guidewires by me as well as
by Dr. to cross through the aortic valve, it was felt that the aortic
valve was severely stenotic and hence Impella was not able to be inserted
because we could not cross the aortic valve at all. It was also felt the
Impella device would be considered contraindicated at this point.

As focus was mostly on giving the patient intraaortic balloon pump support
and doing an angioplasty of the LAD, but because significant amount of
time had lapsed with the CPR and the patient have not ably recovered, it
was decided it will be futile to consider angioplasty of the LAD at this
point. The patient had severely decreased left ventricular systolic
function with severe aortic valve stenosis, severe mitral valve
regurgitation and severely decreased left ventricular systolic function
with left ventricular ejection fraction probably now in the range of 20
percent previously.
Hence, it was decided at this point to terminate the ACLS protocol and the
patient was declared expired. A routine procedure with regards to removal
of the device, removal of the wires and guiding catheters were done and
the removal of the arterial sheaths were done from the patient.

RESULTS:
1. The patient was brought to the cardiac catheterization lab with
recurrent cardiogenic shock and hypotension, systolic pressure of 50
with ST elevations noted on the telemetry monitor.
2. Cardiogenic shock related likely due to total thrombotic occlusion of
the proximal left circumflex artery with likely stent thrombosis with
widely patent stent in the proximal mid right coronary artery, which
was implanted earlier during the day; and 80-90 percent stenosis of
the mid left anterior descending artery with subsequently support from
a total occlusion during the procedure
3. The total occlusion of the mid LAD is likely related to cardiogenic
shock itself. Despite the patient being on anticoagulant such as
Angiomaxx as well as in the antiplatelet agents such as Aggrastat
drip.
5. Successful angioplasty and stent of the mid left circumflex artery
with a 3.0/12 mm Xience Alpine Everolimus drug-eluting stent, but
unsuccessful attempt at the angioplasty of the left anterior
descending artery.
6. Unsuccessful CPR and ACLS for cardiorespiratory arrest with patient
expiring after about 30 minutes of attempted resuscitation with ACLS
protocol.

Appropriate calls were made to the attending physician as well as the
patients relatives regards to the patients demise

Here are some codes I come up with - Do not see LHC only angiography of coronary arteries - 93454, 26, 92928, LC, 33967
ANY HELP WILL DO! Thanks!!!! Happy Holidays![/QUOTE]
 

espressoguy

Expert
Messages
406
Location
Tacoma, WA
Best answers
0
Need help as soon as possible; need to code. Any thoughts or codes will do. Thanks!!!!!

This is a doozy of a procedure! Patient prior to this procedure had a PTCA to the RCA and was unstable. Here's the rest....

This over time the patient was noted to become unresponsive. She did have
initially rhythm _____ nonresponsive and hence CODE BLUE was called and
CPR was initiated with manual compressions of the chest. While this was
being done, the rest of the therapies also intubated the patient. After
the patient was given BiPAP in the beginning.

The patient had severely decreased left ventricular systolic
function with severe aortic valve stenosis, severe mitral valve
regurgitation and severely decreased left ventricular systolic function
with left ventricular ejection fraction probably now in the range of 20
percent previously.


Here are some codes I come up with - Do not see LHC only angiography of coronary arteries - 93454, 26, 92928, LC, 33967
ANY HELP WILL DO! Thanks!!!! Happy Holidays!
[/QUOTE]

I would also code 92950 for the CPR. I think you are ok with the LHC since left ventricular systolic function and ejection fraction are mentioned.
 
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