bhargavi
Guru
Procedures
Ablation VT repeat w/ poss carto
Link to Procedure Log
Procedure Log
Indications
VT (ventricular tachycardia) [I47.2 (ICD-10-CM)]
Conclusion
Electrophysiologic Study with VT Ablation Procedure
*
Procedure(s): Comprehensive electrophysiologic study with pacing and sensing in the ventricle, pacing and sensing in the atrium and induction mapping and ablation of multiple VT circuits using CARTO 3D mapping
*
Findings:
Multiple discrete VT mechanisms, L sided, 6 different VT morphologies seen
*
Indications:
Drug refractory symptomatic VT
*
Sheaths placed:
6, 7, and 8 F R femoral vein; 8 F right femoral artery--long sheat used to get past aortic endograft
*
Catheters placed:
6 F quad to CS, 6 F quad to RVA, and 6 F quad to HIS. 8F thermocool F-J CARTO 3D catheter to mapping and ablation sites, via aortic retrograde approach.
*
Anticoagulation:
Heparin iv targeting ACT over 150 seconds
*
Anesthesia: MAC
*
*
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Timeout was done.
*
The patient was prepped and draped in the usual sterile fashion and the right femoral region was anesthetized with 10 mL of quarter percent Marcaine. The sheaths were placed into the right femoral vein. Catheters were positioned and baseline measurements were obtained.
*
Pacing and sensing was performed in the atrium, pacing and sensing was performed in the right ventricle, and programmed stimulation was performed to induce arrhythmia in both the atrium and ventricle.
*
Programmed stimulation was performed from the RV apex with 600 ms singles and doubles and predominatly 500 ms doubles which reproducibly induced SMVT. Multiple morphologies of VT were inducible with two dominant morphologies being RBBB with Right inferior axis and the other being RBBB with left superior axis. Both of these were ablated using CARTO 3D mapping system.
*
Catheters and sheaths were removed and hemostasis obtained using manual pressure over the vein.
*
The patient was transferred to the PACU in stable condition for recovery from anesthesia.
*
*
Results:
1. Baseline EKG:
NSR with Biv paced rhythm
*
2. Baseline intervals:
AA 1107
V 1107
PR 145
QRS 169
QT 370
AH 107
HV 85
*
3. SNRT:
Not tested
*
4. AV Node Function:
BiV ICD in place.
*
5. Arrhythmias Induced and RF ablation summary:
Multiple morphologies of VT were inducible, some variants of original VT's. Two dominant morphologies were present, one RBBB with right inferior axis, that localized to the basal anterolateral wall, and was noninducible post ablation. The rate of this VT was 118 BPM. Multiple RF lesions were delivered using CARTO 3D mapping using earliest activation mapping.
*
The second dominant morphology had a RBBB with a left superior axis, earliest activation localized to the mid low L sided septal region near the papillary. Post ablation, this VT was sill present in a nonsustained fashion, self terminating within 3 seconds. This VT was hemodynamically unstable with BP dropping to 60/35 making it challenging to map. The rate of this VT was 130 BPM. The rate of this VT was 118 BPM. Multiple RF lesions were delivered using CARTO 3D mapping using earliest activation mapping.
*
*
Impression:
1. AV BiV paced rhythm on arrival. The Medtronic device was programmed off at the beginning and programmed on at the end of the procedure. It was left on with ATP alone for a slow VT zone 120 BPM.
*
2. Normal BiV ICD function and thresholds post RF ablation.
*
3. VT basal posterior LV wall near the annulus was ablated with the dominant VT rate 118 BPM being ablated without recurrence. This had a RBBB and RI axis. CARTO 3D was used.
*
4. VT mid low LV septal wall was ablated, with the VT rate 130 BPM still being induced, but nonsustained. It was poorly tolerated with drop in BP. This had a RBBB LS axis. CARTO 3D was used. This VT had a delayed onset of intrinsicoid deflection, suggesting an epicardial location.
*
*
COMMENTS:
Given VT is slow in the 118 BPM range, D/C of amiodarone is recommended and resume stotalol 120 mg BID. Epicardial VT ablation may be required if VT continues.
The patient has an abdominal aorta stent graft. An 8F long sheath was used to negotiate through this without complication.
should I code 93654,93655 ?
thank you in advance
Ablation VT repeat w/ poss carto
Link to Procedure Log
Procedure Log
Indications
VT (ventricular tachycardia) [I47.2 (ICD-10-CM)]
Conclusion
Electrophysiologic Study with VT Ablation Procedure
*
Procedure(s): Comprehensive electrophysiologic study with pacing and sensing in the ventricle, pacing and sensing in the atrium and induction mapping and ablation of multiple VT circuits using CARTO 3D mapping
*
Findings:
Multiple discrete VT mechanisms, L sided, 6 different VT morphologies seen
*
Indications:
Drug refractory symptomatic VT
*
Sheaths placed:
6, 7, and 8 F R femoral vein; 8 F right femoral artery--long sheat used to get past aortic endograft
*
Catheters placed:
6 F quad to CS, 6 F quad to RVA, and 6 F quad to HIS. 8F thermocool F-J CARTO 3D catheter to mapping and ablation sites, via aortic retrograde approach.
*
Anticoagulation:
Heparin iv targeting ACT over 150 seconds
*
Anesthesia: MAC
*
*
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Timeout was done.
*
The patient was prepped and draped in the usual sterile fashion and the right femoral region was anesthetized with 10 mL of quarter percent Marcaine. The sheaths were placed into the right femoral vein. Catheters were positioned and baseline measurements were obtained.
*
Pacing and sensing was performed in the atrium, pacing and sensing was performed in the right ventricle, and programmed stimulation was performed to induce arrhythmia in both the atrium and ventricle.
*
Programmed stimulation was performed from the RV apex with 600 ms singles and doubles and predominatly 500 ms doubles which reproducibly induced SMVT. Multiple morphologies of VT were inducible with two dominant morphologies being RBBB with Right inferior axis and the other being RBBB with left superior axis. Both of these were ablated using CARTO 3D mapping system.
*
Catheters and sheaths were removed and hemostasis obtained using manual pressure over the vein.
*
The patient was transferred to the PACU in stable condition for recovery from anesthesia.
*
*
Results:
1. Baseline EKG:
NSR with Biv paced rhythm
*
2. Baseline intervals:
AA 1107
V 1107
PR 145
QRS 169
QT 370
AH 107
HV 85
*
3. SNRT:
Not tested
*
4. AV Node Function:
BiV ICD in place.
*
5. Arrhythmias Induced and RF ablation summary:
Multiple morphologies of VT were inducible, some variants of original VT's. Two dominant morphologies were present, one RBBB with right inferior axis, that localized to the basal anterolateral wall, and was noninducible post ablation. The rate of this VT was 118 BPM. Multiple RF lesions were delivered using CARTO 3D mapping using earliest activation mapping.
*
The second dominant morphology had a RBBB with a left superior axis, earliest activation localized to the mid low L sided septal region near the papillary. Post ablation, this VT was sill present in a nonsustained fashion, self terminating within 3 seconds. This VT was hemodynamically unstable with BP dropping to 60/35 making it challenging to map. The rate of this VT was 130 BPM. The rate of this VT was 118 BPM. Multiple RF lesions were delivered using CARTO 3D mapping using earliest activation mapping.
*
*
Impression:
1. AV BiV paced rhythm on arrival. The Medtronic device was programmed off at the beginning and programmed on at the end of the procedure. It was left on with ATP alone for a slow VT zone 120 BPM.
*
2. Normal BiV ICD function and thresholds post RF ablation.
*
3. VT basal posterior LV wall near the annulus was ablated with the dominant VT rate 118 BPM being ablated without recurrence. This had a RBBB and RI axis. CARTO 3D was used.
*
4. VT mid low LV septal wall was ablated, with the VT rate 130 BPM still being induced, but nonsustained. It was poorly tolerated with drop in BP. This had a RBBB LS axis. CARTO 3D was used. This VT had a delayed onset of intrinsicoid deflection, suggesting an epicardial location.
*
*
COMMENTS:
Given VT is slow in the 118 BPM range, D/C of amiodarone is recommended and resume stotalol 120 mg BID. Epicardial VT ablation may be required if VT continues.
The patient has an abdominal aorta stent graft. An 8F long sheath was used to negotiate through this without complication.
should I code 93654,93655 ?
thank you in advance