bhargavi
Guru
Indications
SVT (supraventricular tachycardia) (CMS-HCC) [I47.1 (ICD-10-CM)]
Conclusion
Electrophysiologic Study and RFA Procedure Report
Transseptal Access Performed Under Direct Supervision of Dr.
Procedure(s):
1. Comprehensive electrophysiologic study with pacing and sensing in the ventricle, pacing and sensing in the atrium and induction mapping and ablation of left lateral accessory pathway using Ensite Precision 3D mapping system.
2. ICE cathther imaging to guide transseptal access
3. Infusion of Isuprel
Arrhythmia Ablated:
1. AVRT
Findings:
1. Easily inducible AVRT with variable cycle length due to AV nodal decremental conduction
· TCL-PPI was less then 115msec
· With ventricular entrainment V-A-H-V response was seen
· Para-Hisian Pacing demonstrated no decrement in V-A conduction
· Differential pacing maneuvers confirmed presence of accessory pathway
· Retrograde CS conduction was eccentric (pathway was bracketed along the left lateral wall)
Indications: Drug refractory recurring SVT
Sheaths placed: 7, and 8 F(Exchanged for 10F Bayliss Flex Cath) sheaths right femoral vein. 6F (Upgraded to 10F), 6F, 6F left femoral vein.
Catheters placed: 6 f quad to RV apex and RVOT, 6 f quad to RVA, 6F quad to HIS, 7F decapolar in CS. 8 F quad ablation Ensite 3D mapping navigation catheter to via Flex Cath to map and ablate in the left atrium. 10F sheath through which ICE catheter was introduced.
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 and left femoral veins were anesthetized with 10 mL of quarter percent Marcaine. The sheaths were placed into both femoral veins. Catheters were positioned and baseline measurements were obtained. 5000 units of heparin were given.
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. The AV node was tested both antegrade and retrograde measuring AV nodal ERP and AV block. Rapid atrial pacing from 300 down to 200 ms drive was performed. AVRT was easily inducible
Programmed stimulation was performed from the RV apex with 600 ms drive to VA ERP and VERP.
Transeptal access was obtained. Catheters were already positioned as follows for the EP study. The CRTD was placed at the position of the HIS to mark the location of the non-coronary cusp/Aortic root. The CS catheter was advanced into the main body of the CS to delineate the border of the LA. The ICE catheter and TEE both confirmed no pericardial effusion at baseline. Using the ICE catheter and anatomic fluoroscopic guidance, trans septal puncture was successfully performed using the Baylis Versacross using RF energy without complication, supervised by Dr Manjeet Singh. 8000 units of heparin had been given prior to crossing and an additional 5000 units were given upon crossing the septum. LA position was documented with ICE, fluoroscopy, and advancement of the guide wire into the LSPV. The cathter was leftward and at the level of the HIS on flouroscopy, and advanced parallel to the CS catheter after ICE confirmed tenting on the Fossa and good position of the sheath. ACT measured every 20 minutes targeting ACT over 300 sec. Additional Heparin boluses were given as needed adjusting the ACT. The SJM irrigated ablation catheter was advanced to the left atrium. Radiofrequency ablation was performed using Ensite 3D mapping system in the left atrium and the left lateral accessory pathway was targeted for ablation. At the earliest activation site with a pathway potential we had AV dissociation within 3 seconds after RF energy was delivered. Two insurance burns were performed targeting the ventricular and atrial aspect of the site of successful ablation. Post ablation even after a 30 minute wait the patient was no longer inducible for AVRT. There was no reliable retrograde VA conduction present. With intermittent VA conduction the CS activation pattern was concentric. Isuprel was infused, and the patient remained no-inducible. The sheath and ablation catheter were withdrawn to the right side. ICE was used to verify that no pericardial effusion was present.
Post ablation testing and post ablation intervals was performed. AV nodal properties of AV block and ERP were tested both antegrade and retrograde.
The patient was given a test dose of 5mg followed by 20mg. Once ACT was below 180 catheters and sheaths 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: Normal Sinus Rhythm
2. Baseline intervals:
AA 986ms
VV 995ms
PR 215ms
QRS 81ms
QT 405ms
AH 131ms
HV 46ms
3. SNRT:
Not tested
4. AV Node Function:
Pre-Ablation AVRT was easily inducible. There was no evidence of dual nodal AV physiology (No AH jump present). VA WB could not be achieved as she was easily inducible for AVRT with pacing.
5. Arrhythmias Induced:
AVRT with cycle length of 490-470msec.
6. Radiofrequency ablation summary:
Using CARTO 3D mapping system. Left lateral accessory pathway successfully ablated.
7. Post ablation testing:
No reliable VA-Conduction post ablation. Non-inducible post ablation.
Post ablation:
AVN WB 430ms
AVNERP 600/300
AERP 600/240
VERP: 600/200
No VA conduction at 800ms
8. Post ablation intervals:
AA 952ms
VV 951ms
PR 205ms
QRS 94ms
QT 393ms
AH 131ms
HV 48ms
Impression:
1. Normal baseline intervals.
2. Successful ablation of left sided accessory pathway. No VA conduction post ablation at 800ms.
COMMENTS:
The patient is believed to be cured from AVRT. Continue Aspirin 325mg for 1 month. Stop digoxin. Can continue diltiazem to treat HTN.
thank you in advance
should i code as 93653, 93613, 93623, 93662?
SVT (supraventricular tachycardia) (CMS-HCC) [I47.1 (ICD-10-CM)]
Conclusion
Electrophysiologic Study and RFA Procedure Report
Transseptal Access Performed Under Direct Supervision of Dr.
Procedure(s):
1. Comprehensive electrophysiologic study with pacing and sensing in the ventricle, pacing and sensing in the atrium and induction mapping and ablation of left lateral accessory pathway using Ensite Precision 3D mapping system.
2. ICE cathther imaging to guide transseptal access
3. Infusion of Isuprel
Arrhythmia Ablated:
1. AVRT
Findings:
1. Easily inducible AVRT with variable cycle length due to AV nodal decremental conduction
· TCL-PPI was less then 115msec
· With ventricular entrainment V-A-H-V response was seen
· Para-Hisian Pacing demonstrated no decrement in V-A conduction
· Differential pacing maneuvers confirmed presence of accessory pathway
· Retrograde CS conduction was eccentric (pathway was bracketed along the left lateral wall)
Indications: Drug refractory recurring SVT
Sheaths placed: 7, and 8 F(Exchanged for 10F Bayliss Flex Cath) sheaths right femoral vein. 6F (Upgraded to 10F), 6F, 6F left femoral vein.
Catheters placed: 6 f quad to RV apex and RVOT, 6 f quad to RVA, 6F quad to HIS, 7F decapolar in CS. 8 F quad ablation Ensite 3D mapping navigation catheter to via Flex Cath to map and ablate in the left atrium. 10F sheath through which ICE catheter was introduced.
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 and left femoral veins were anesthetized with 10 mL of quarter percent Marcaine. The sheaths were placed into both femoral veins. Catheters were positioned and baseline measurements were obtained. 5000 units of heparin were given.
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. The AV node was tested both antegrade and retrograde measuring AV nodal ERP and AV block. Rapid atrial pacing from 300 down to 200 ms drive was performed. AVRT was easily inducible
Programmed stimulation was performed from the RV apex with 600 ms drive to VA ERP and VERP.
Transeptal access was obtained. Catheters were already positioned as follows for the EP study. The CRTD was placed at the position of the HIS to mark the location of the non-coronary cusp/Aortic root. The CS catheter was advanced into the main body of the CS to delineate the border of the LA. The ICE catheter and TEE both confirmed no pericardial effusion at baseline. Using the ICE catheter and anatomic fluoroscopic guidance, trans septal puncture was successfully performed using the Baylis Versacross using RF energy without complication, supervised by Dr Manjeet Singh. 8000 units of heparin had been given prior to crossing and an additional 5000 units were given upon crossing the septum. LA position was documented with ICE, fluoroscopy, and advancement of the guide wire into the LSPV. The cathter was leftward and at the level of the HIS on flouroscopy, and advanced parallel to the CS catheter after ICE confirmed tenting on the Fossa and good position of the sheath. ACT measured every 20 minutes targeting ACT over 300 sec. Additional Heparin boluses were given as needed adjusting the ACT. The SJM irrigated ablation catheter was advanced to the left atrium. Radiofrequency ablation was performed using Ensite 3D mapping system in the left atrium and the left lateral accessory pathway was targeted for ablation. At the earliest activation site with a pathway potential we had AV dissociation within 3 seconds after RF energy was delivered. Two insurance burns were performed targeting the ventricular and atrial aspect of the site of successful ablation. Post ablation even after a 30 minute wait the patient was no longer inducible for AVRT. There was no reliable retrograde VA conduction present. With intermittent VA conduction the CS activation pattern was concentric. Isuprel was infused, and the patient remained no-inducible. The sheath and ablation catheter were withdrawn to the right side. ICE was used to verify that no pericardial effusion was present.
Post ablation testing and post ablation intervals was performed. AV nodal properties of AV block and ERP were tested both antegrade and retrograde.
The patient was given a test dose of 5mg followed by 20mg. Once ACT was below 180 catheters and sheaths 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: Normal Sinus Rhythm
2. Baseline intervals:
AA 986ms
VV 995ms
PR 215ms
QRS 81ms
QT 405ms
AH 131ms
HV 46ms
3. SNRT:
Not tested
4. AV Node Function:
Pre-Ablation AVRT was easily inducible. There was no evidence of dual nodal AV physiology (No AH jump present). VA WB could not be achieved as she was easily inducible for AVRT with pacing.
5. Arrhythmias Induced:
AVRT with cycle length of 490-470msec.
6. Radiofrequency ablation summary:
Using CARTO 3D mapping system. Left lateral accessory pathway successfully ablated.
7. Post ablation testing:
No reliable VA-Conduction post ablation. Non-inducible post ablation.
Post ablation:
AVN WB 430ms
AVNERP 600/300
AERP 600/240
VERP: 600/200
No VA conduction at 800ms
8. Post ablation intervals:
AA 952ms
VV 951ms
PR 205ms
QRS 94ms
QT 393ms
AH 131ms
HV 48ms
Impression:
1. Normal baseline intervals.
2. Successful ablation of left sided accessory pathway. No VA conduction post ablation at 800ms.
COMMENTS:
The patient is believed to be cured from AVRT. Continue Aspirin 325mg for 1 month. Stop digoxin. Can continue diltiazem to treat HTN.
thank you in advance
should i code as 93653, 93613, 93623, 93662?