bennieyoung
Guru
I am being audited and I'm being questioned about one of the diagnosis I used. Could someone look at this note and tell me what they would use? Thank you advance for any help!
PPM Implant Biventricular
Indications
Complete heart block (CMS/HCC) [I44.2 (ICD-10-CM)]
Pre Procedure Diagnosis
Complete heart block (CMS/HCC) [I44.2]
Conclusion
BIVENTRICULAR PACER IMPLANTATION
PROCEDURE PERFORMED: Biventricular pacemaker implantation using an existing left ventricular epicardial lead in conjunction with newly implanted atrial and right ventricular leads.
COMPLICATIONS: None
ESTIMATED BLOOD LOSS: 25 cc
SITE: left axillary vein access.
INDICATION: 62-year-old male status post cardiovascular surgery now with complete heart block dependent on epicardial leads. He has a low ejection fraction.
PROCEDURE: The risks, benefits, and alternative of the procedure were all discussed with the patients MD POA. The consent was signed and placed in the chart. In the fasting state, the patient was taken to the cardiac catheterization laboratory. A time-out was performed. Prior to the procedure prophylactic antibiotics were administered and a venogram was performed. This identified a widely patent axillary/subclavian system. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Lidocaine was infiltrated into the region below the left clavicle to provide local anesthesia.
Conscious sedation was utilized throughout the procedure. Using a #10 blade, a 3 cm horizontal incision was made in the left infraclavicular region and blunt and sharp dissection were used to fashion the pacemaker pocket. Electrocautery was used for hemostasis. The pocket was then extended medially to wear the existing epicardial left ventricular leads were located. Using blunt dissection this pocket was opened and both of these leads were then pulled into the newly formed pacemaker pocket. One of these leads was uncapped and tested with excellent capture and sensing. We decided to use this lead for the left ventricular lead. An antibiotic-soaked sponge was then placed in the pocket.
Using an 18 gauge Cook needle and the modified Seldinger technique, the left axillary vein was accessed at the level of the 1st rib. A 0.035 guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. This procedure was then repeated. Using the 1st wire, a safe sheath was then placed in the axillary vein. This allowed passage of the right ventricular lead into the right ventricular apex where the lead was screwed into place, the sheath torn away and the lead tested. This demonstrated adequate capture and sensing thresholds. The lead was then secured to the pacemaker pocket floor using 0 Ethibond . Using the remaining J-wire a 2nd safe sheath was placed. This allowed passage of the right atrial lead into the right atrial appendage. The lead was screwed into place, the sheath torn away and the lead tested with adequate capture and sensing thresholds. This lead was then secured to the pacemaker pocket floor using 0 Ethibond. At this point, the antibiotic soaked sponge was removed from the pocket. The pocket was inspected and all bleeders were cauterized. The pocket was then irrigated with antibiotic-containing solution.
The device was then brought to the field and all 3 leads were then affixed to the header according to manufacturer guidelines.. The device and the redundant portions of both leads were then placed in the pocket. The pocket was then closed in 3 layers initially with 2 layers of interrupted suture using 2 0 and 3 0 Vicryl and finally running strata fix for the skin. Steri-Strips and a dry dressing were applied.
COMPLICATIONS: None.
DEVICE INFORMATION: The newly implanted pacemaker is an Abbott Allure RF 3222. The existing left ventricular lead is a Myopore 511211 35 cm in length. The newly implanted right ventricular lead is a Saint Jude Medical Tendril STS 2088 TC 58 cm in length. The newly implanted atrial lead is a Saint Jude Medical Tendril STS 2088 TC 52 cm in length. In the atrium capture was 0.75 volts at 0.5 milliseconds with sensed P waves of 1.2 mV and a lead impedance of 350 Ohms. In the right ventricle capture was 0.5 volts at 0.6 milliseconds. Sensing was not able to be performed due to the absence of R-waves. Lead impedance was 380 Ohms. The left ventricular epicardial lead capture was 1.75 volts at 0.5 milliseconds.
DISPOSITION: The patient will be transferred to the ICU to continue care. An ECG and chest x-ray have been ordered.
PPM Implant Biventricular
Indications
Complete heart block (CMS/HCC) [I44.2 (ICD-10-CM)]
Pre Procedure Diagnosis
Complete heart block (CMS/HCC) [I44.2]
Conclusion
BIVENTRICULAR PACER IMPLANTATION
PROCEDURE PERFORMED: Biventricular pacemaker implantation using an existing left ventricular epicardial lead in conjunction with newly implanted atrial and right ventricular leads.
COMPLICATIONS: None
ESTIMATED BLOOD LOSS: 25 cc
SITE: left axillary vein access.
INDICATION: 62-year-old male status post cardiovascular surgery now with complete heart block dependent on epicardial leads. He has a low ejection fraction.
PROCEDURE: The risks, benefits, and alternative of the procedure were all discussed with the patients MD POA. The consent was signed and placed in the chart. In the fasting state, the patient was taken to the cardiac catheterization laboratory. A time-out was performed. Prior to the procedure prophylactic antibiotics were administered and a venogram was performed. This identified a widely patent axillary/subclavian system. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Lidocaine was infiltrated into the region below the left clavicle to provide local anesthesia.
Conscious sedation was utilized throughout the procedure. Using a #10 blade, a 3 cm horizontal incision was made in the left infraclavicular region and blunt and sharp dissection were used to fashion the pacemaker pocket. Electrocautery was used for hemostasis. The pocket was then extended medially to wear the existing epicardial left ventricular leads were located. Using blunt dissection this pocket was opened and both of these leads were then pulled into the newly formed pacemaker pocket. One of these leads was uncapped and tested with excellent capture and sensing. We decided to use this lead for the left ventricular lead. An antibiotic-soaked sponge was then placed in the pocket.
Using an 18 gauge Cook needle and the modified Seldinger technique, the left axillary vein was accessed at the level of the 1st rib. A 0.035 guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. This procedure was then repeated. Using the 1st wire, a safe sheath was then placed in the axillary vein. This allowed passage of the right ventricular lead into the right ventricular apex where the lead was screwed into place, the sheath torn away and the lead tested. This demonstrated adequate capture and sensing thresholds. The lead was then secured to the pacemaker pocket floor using 0 Ethibond . Using the remaining J-wire a 2nd safe sheath was placed. This allowed passage of the right atrial lead into the right atrial appendage. The lead was screwed into place, the sheath torn away and the lead tested with adequate capture and sensing thresholds. This lead was then secured to the pacemaker pocket floor using 0 Ethibond. At this point, the antibiotic soaked sponge was removed from the pocket. The pocket was inspected and all bleeders were cauterized. The pocket was then irrigated with antibiotic-containing solution.
The device was then brought to the field and all 3 leads were then affixed to the header according to manufacturer guidelines.. The device and the redundant portions of both leads were then placed in the pocket. The pocket was then closed in 3 layers initially with 2 layers of interrupted suture using 2 0 and 3 0 Vicryl and finally running strata fix for the skin. Steri-Strips and a dry dressing were applied.
COMPLICATIONS: None.
DEVICE INFORMATION: The newly implanted pacemaker is an Abbott Allure RF 3222. The existing left ventricular lead is a Myopore 511211 35 cm in length. The newly implanted right ventricular lead is a Saint Jude Medical Tendril STS 2088 TC 58 cm in length. The newly implanted atrial lead is a Saint Jude Medical Tendril STS 2088 TC 52 cm in length. In the atrium capture was 0.75 volts at 0.5 milliseconds with sensed P waves of 1.2 mV and a lead impedance of 350 Ohms. In the right ventricle capture was 0.5 volts at 0.6 milliseconds. Sensing was not able to be performed due to the absence of R-waves. Lead impedance was 380 Ohms. The left ventricular epicardial lead capture was 1.75 volts at 0.5 milliseconds.
DISPOSITION: The patient will be transferred to the ICU to continue care. An ECG and chest x-ray have been ordered.
Thanks again!