CardioCoder79
Networker
I'm thinking 33264-SC, 33223 and 75822-26 here but other opinions are welcome. TIA!!!
INDICATIONS: Fractured RV ICD lead, pacemaker dependent, complete heart block.
PROCEDURE COURSE: Mrs. Martindale presented to the EP lab in the fasting state. The procedure was performed under conscious sedation with the assistance of our Anesthesia colleagues. After the huddle, she was prepped and draped in usual sterile fashion. She was administered 2 grams of Ancef prior to the start of the case. Venograms were performed of the bilateral upper extremity showing that there was significant stenosis of the left upper extremity; however, there was certainly a channel and the right upper extremity venous system was widely patent. Given the way to the left upper extremity looked knowing that we were going to have to open up the pocket anyway, I elected to go ahead and attempt access in the left upper extremity. The spot over the existing pocket in the left prepectoral area was anesthetized with 20 mL of local lidocaine. An incision was created over the existing pulse generator and then using electrocautery, the existing pulse generator was removed from the pocket and hemostasis was obtained. Then, using the 1st rib approach, venous access was obtained x 1 and I was able to get the wire to advance certainly through the innominate with a lot of difficulty at the SVC. I was able to get a sheath to go over the wire in the innominate. However, with multiple attempts with multiple different wires including straight J-wire, a Versacore wire, a micropuncture wire and a Glidewire, it was noted that nothing would have her track down the SVC. Two different venograms were performed showing that there was dissection of the SVC just at the distal end of the proximal coil. Given this, I pulled the sheath back into the true lumen, tried multiple other attempts to advance the wire and it just would not. It kept going into the dissection flap. Given this, I elected to go ahead and get access on the right side, place a new lead and then tunnel it. A pocket was created in the right subclavian area using standard technique and then venous access was obtained x 1 using the 1st rib approach and wire was passed easily down the SVC into the IVC and a 9-French sheath was placed over this. Through this, a long 62 cm single coil Medtronic ICD lead was advanced into the RV apical septum and the helix was extended. Device check showed appropriate sensing of the device with paced RV waves of 15 with an impedance of 513 and a capture threshold of 0.75. The lead was then given a little bit more slack. The 9-French tear-away sheath was removed and the lead was tied down to the pectoralis fascia with nonabsorbable suture. Initially, I tried using the Boston Scientific tunneling tool. However, the lead would never track through the small tunneled that the tunneling tool created. So, we used a chest tube set up and used the chest tube trocar insertion device to make a new tunnel and then pulled the chest tube through. Cut the chest tube on either end and then easily advanced the lead through the chest tube through the subcutaneous tissue into the left prepectoral pocket site. The 2 pockets were then cleansed with vancomycin solution. The new RV ICD lead was attached to a new Medtronic Bi-V ICD can. The existing LV lead was attached to the new can with a threshold of 2, close to her chronic values, and the atrial lead was attached to the new can showing that she was in atrial flutter for greater than 9 months with P waves of 1.3 millivolts. Capture threshold obviously was not checked. The old ICD lead was capped and placed in the pocket. Then, the new device and leads were placed into a Medtronic pouch and then placed into the pocket. The pocket was then closed in 3 layers with absorbable suture. The right prepectoral pocket was also closed in 3 layers with absorbable suture. Fluoroscopy showed good positioning of the lead and a nice smooth contour as it tunneled through the subcutaneous tissue. Device settings were VVIR 80-130. VT monitor 167, VT of 200, VF of 240. Mrs. Martindale tolerated the procedure well without any apparent complications. She was transferred back to the CCU in stable condition. She will get a chest x-ray.
INDICATIONS: Fractured RV ICD lead, pacemaker dependent, complete heart block.
PROCEDURE COURSE: Mrs. Martindale presented to the EP lab in the fasting state. The procedure was performed under conscious sedation with the assistance of our Anesthesia colleagues. After the huddle, she was prepped and draped in usual sterile fashion. She was administered 2 grams of Ancef prior to the start of the case. Venograms were performed of the bilateral upper extremity showing that there was significant stenosis of the left upper extremity; however, there was certainly a channel and the right upper extremity venous system was widely patent. Given the way to the left upper extremity looked knowing that we were going to have to open up the pocket anyway, I elected to go ahead and attempt access in the left upper extremity. The spot over the existing pocket in the left prepectoral area was anesthetized with 20 mL of local lidocaine. An incision was created over the existing pulse generator and then using electrocautery, the existing pulse generator was removed from the pocket and hemostasis was obtained. Then, using the 1st rib approach, venous access was obtained x 1 and I was able to get the wire to advance certainly through the innominate with a lot of difficulty at the SVC. I was able to get a sheath to go over the wire in the innominate. However, with multiple attempts with multiple different wires including straight J-wire, a Versacore wire, a micropuncture wire and a Glidewire, it was noted that nothing would have her track down the SVC. Two different venograms were performed showing that there was dissection of the SVC just at the distal end of the proximal coil. Given this, I pulled the sheath back into the true lumen, tried multiple other attempts to advance the wire and it just would not. It kept going into the dissection flap. Given this, I elected to go ahead and get access on the right side, place a new lead and then tunnel it. A pocket was created in the right subclavian area using standard technique and then venous access was obtained x 1 using the 1st rib approach and wire was passed easily down the SVC into the IVC and a 9-French sheath was placed over this. Through this, a long 62 cm single coil Medtronic ICD lead was advanced into the RV apical septum and the helix was extended. Device check showed appropriate sensing of the device with paced RV waves of 15 with an impedance of 513 and a capture threshold of 0.75. The lead was then given a little bit more slack. The 9-French tear-away sheath was removed and the lead was tied down to the pectoralis fascia with nonabsorbable suture. Initially, I tried using the Boston Scientific tunneling tool. However, the lead would never track through the small tunneled that the tunneling tool created. So, we used a chest tube set up and used the chest tube trocar insertion device to make a new tunnel and then pulled the chest tube through. Cut the chest tube on either end and then easily advanced the lead through the chest tube through the subcutaneous tissue into the left prepectoral pocket site. The 2 pockets were then cleansed with vancomycin solution. The new RV ICD lead was attached to a new Medtronic Bi-V ICD can. The existing LV lead was attached to the new can with a threshold of 2, close to her chronic values, and the atrial lead was attached to the new can showing that she was in atrial flutter for greater than 9 months with P waves of 1.3 millivolts. Capture threshold obviously was not checked. The old ICD lead was capped and placed in the pocket. Then, the new device and leads were placed into a Medtronic pouch and then placed into the pocket. The pocket was then closed in 3 layers with absorbable suture. The right prepectoral pocket was also closed in 3 layers with absorbable suture. Fluoroscopy showed good positioning of the lead and a nice smooth contour as it tunneled through the subcutaneous tissue. Device settings were VVIR 80-130. VT monitor 167, VT of 200, VF of 240. Mrs. Martindale tolerated the procedure well without any apparent complications. She was transferred back to the CCU in stable condition. She will get a chest x-ray.