dtruelson
Guest
Any thoughts on this would be greatly appreciated. What I am stuck on is the tunneling of the electrodes? And there were 2 docs. I have 33229 and 33233.
Procedures
PED POCKET REVISION
Indications
Pain in pacemaker pocket [R52 (ICD-10-CM)]
Pacemaker lead malfunction [T82.110A (ICD-10-CM)]
Conclusion
· Interval increase in transvenous atrial lead threshold requiring change to Boston Scientific generator
○ Threshold intermittently 8.0 V at 1.1 msec
· Complex pocket revision / device reconfiguration as follows:
○ Explant of dual-chamber pectoral pacemaker
○ Explant of dual-chamber abdominal pacemaker by Dr ______
○ Extension and tunneling of 2 transvenous leads from pectoral pocket to abdomen
○ Implant of Boston Scientific U225 CRT-P generator, in absorbable antibiotic envelope, configured:
§ RA port: epicardial atrial lead (Medtronic 4968)
§ RV port: transvenous ventricular lead (Medtronic 4076+Oscor lead extender)
§ LV port: transvenous atrial lead (Medtronic 4076+Oscor lead extender)
○ Capping of epicardial ventricular lead (Medtronic 5071x2 with Y adapter) due to exit block
· Complex pacemaker programming due to intra-atrial block:
○ Technically programmed DDD 50 - 130 [changed to 50 - 140 prior to discharge]
○ VV offset programmed to 100 msec to that "LV" pacing (= LA pacing) will capture and conduct before RV pacing occurs
○ RA output programmed subthreshold, due to patient discomfort [RV output also programmed subthreshold prior to discharge, due to intractable pacemaker-mediated tachycardia with RV pacing]
○ Effective programming at time of discharge then is a modified AAT mode, with sensing of the sinus activity in the lateral right atrial segment via the epicardial atrial lead, and pacing of the remainder of the atrial mass via the transvenous atrial lead, followed by native conduction
Procedure Comments
Procedure Comments 36 y.o. with tricuspid atresia s/p Fontan, s/p epicardial dual-chamber pacemaker originally for sinus node dysfunction (with high thresholds on the atrial lead causing discomfort, and exit block on the ventricular lead), now with recovery of sinus node function but first- and second-degree intra-atrial block recently s/p transvenous dual-chamber pacemaker with leads on the pulmonary artery floor, presenting for pocket revision as the infraclavicular generator was prominent and distressing. The panned procedure was for explant of the old abdominal generator, tunneling of the transvenous leads to the abdomen, testing of different polarities on the atrial lead and then relocation of the newer generator to the abdomen vs reconfiguration with an alternative generator depending on intra-operative findings.
GENERAL ANESTHESIA FOR PPM/ICD. Inhalational anesthetic agents and/or propofol and endotracheal intubation were used. Please see the anesthesia record for details. The patient's warfarin had inadvertently not been held with INR 3.0 so two units of FFP were given during the procedure. The epicardial pacemaker was already programmed ODO. The transvenous pacemaker was interrogated under anesthesia and programmed ODO after confirming stable intrinsic rhythm. Notably the transvenous atrial threshold was intermittently as high as 8.0@1.1, compared to last clinic visit when it had been 8.0@0.7.
PECTORAL INCISION: The entire torso was cleansed with chlorhexidine gluconate and draped. The left pectoral incision was sharply reopened and carried down to the existing pocket using PhotonBlade electrocautery. The pocket was carefully reopened and the generator delivered onto the field. There were no adhesions in the pocket and the lead slack was entirely accessible to the suture sleeve. The atrial lead threshold was tested in different polarities. The threshold with tip-RVring was similar (albeit with higher impedance). The thresholds with ring-tip and ring-RVring were higher. The threshold with tip-abdominal pocket (unipolar) was somewhat lower although unclear if patient would tolerate given sensitivity to unipolar pacing in the past. We concluded that the Medtronic generator (which had maximum output of 8.0@1.2) was not viable and began planning to use a Boston Scientific generator which has maximum output of 7.5@2.0 on the ventricular port(s).
ABDOMINAL INCISION: Concurrently Dr____ had made a midline subxiphoid and dissected down to the old pocket, explanted the epicardial pacemaker, and capped the epicardial ventricular lead as it was nonfunctional due to exit block (the Y connector was completely embedded in capsule and left intact).
LEAD TUNNELING: Each transvenous lead was connected to an Oscor IS1 lead extender and the double set screws tightened confirming pin position. A Medtronic 6996T tunneling tool was used twice to tunnel from the pectoral incision to the abdominal incision, each time leaving an 11 Fr 25 cm peelaway sheath. The lead extenders were fed through and the sheaths split and discarded. The leads were retested through the extenders and confirmed to function the same as when they had been tested directly.
GENERATOR RECONFIGURATION: As the Boston Scientific generators do not have high output pacing on the atrial port, we elected to use a CRT-P generator configured analagously to what is done with conduction system pacing, placing the epicardial atrial lead in the RA port, the transvenous atrial lead in the LV port, and the transvenous ventricular lead in the RV port. This would allow multiple pacing strategies including DDD with LV-only pacing to provide effectively AAT bridging the intra-atrial block, DDD with BiV pacing with VV offset to provide effectively AAT+DDD, and VVIR with BiV pacing with VV offset to provide effectively DVIR ignoring the sinus activity going in the lateral right atrium. The leads were connected to the device confirming set screw position. We programmed the device using the middle of these strategies for the time being.
DEVICE INSERTION: Dr _____ confirmed hemostasis in both pockets. The generator and lead slack were inserted into a large absorbable antibiotic envelope which was then trimmed to size, and inserted into the abdominal pocket. The remnant of the antibiotic envelope, which was a long strip, was wrapped around the lead slack in the pectoral pocket. The leads were tested through the device and confirmed to be functioning as expected. See log for the model numbers and serial number of all hardware.
WOUND CLOSURE: After completion of the implantation procedure, the abdominal incision was closed by Dr Yoshitake. The pectoral incision was closed in layers with careful attention to hemostasis, using 2-0 vicryl for for fascia/capsule, 3-0 monocryl for intra-dermal, and 4-0 monocryl for subcuticular. A xeroform pressure dressing was applied to match the abdominal dressing. The patient was transported to the recovery room in stable condition with orders for a chest x-ray, postoperative antibiotics, electrocardiographic monitoring and frequent vital signs.
ESTIMATED BLOOD LOSS: 20 mL for EP portion
FLUOROSCOPY TIME: 0 min
RADIATION DOSE: 0 mGy
DOSE AREA PRODUCT: 0 mGy x cm2 (= uGy x m2 x 10)
TOTAL CONTRAST: 0 mL
COMPLICATIONS: none
Procedures
PED POCKET REVISION
Indications
Pain in pacemaker pocket [R52 (ICD-10-CM)]
Pacemaker lead malfunction [T82.110A (ICD-10-CM)]
Conclusion
· Interval increase in transvenous atrial lead threshold requiring change to Boston Scientific generator
○ Threshold intermittently 8.0 V at 1.1 msec
· Complex pocket revision / device reconfiguration as follows:
○ Explant of dual-chamber pectoral pacemaker
○ Explant of dual-chamber abdominal pacemaker by Dr ______
○ Extension and tunneling of 2 transvenous leads from pectoral pocket to abdomen
○ Implant of Boston Scientific U225 CRT-P generator, in absorbable antibiotic envelope, configured:
§ RA port: epicardial atrial lead (Medtronic 4968)
§ RV port: transvenous ventricular lead (Medtronic 4076+Oscor lead extender)
§ LV port: transvenous atrial lead (Medtronic 4076+Oscor lead extender)
○ Capping of epicardial ventricular lead (Medtronic 5071x2 with Y adapter) due to exit block
· Complex pacemaker programming due to intra-atrial block:
○ Technically programmed DDD 50 - 130 [changed to 50 - 140 prior to discharge]
○ VV offset programmed to 100 msec to that "LV" pacing (= LA pacing) will capture and conduct before RV pacing occurs
○ RA output programmed subthreshold, due to patient discomfort [RV output also programmed subthreshold prior to discharge, due to intractable pacemaker-mediated tachycardia with RV pacing]
○ Effective programming at time of discharge then is a modified AAT mode, with sensing of the sinus activity in the lateral right atrial segment via the epicardial atrial lead, and pacing of the remainder of the atrial mass via the transvenous atrial lead, followed by native conduction
Procedure Comments
Procedure Comments 36 y.o. with tricuspid atresia s/p Fontan, s/p epicardial dual-chamber pacemaker originally for sinus node dysfunction (with high thresholds on the atrial lead causing discomfort, and exit block on the ventricular lead), now with recovery of sinus node function but first- and second-degree intra-atrial block recently s/p transvenous dual-chamber pacemaker with leads on the pulmonary artery floor, presenting for pocket revision as the infraclavicular generator was prominent and distressing. The panned procedure was for explant of the old abdominal generator, tunneling of the transvenous leads to the abdomen, testing of different polarities on the atrial lead and then relocation of the newer generator to the abdomen vs reconfiguration with an alternative generator depending on intra-operative findings.
GENERAL ANESTHESIA FOR PPM/ICD. Inhalational anesthetic agents and/or propofol and endotracheal intubation were used. Please see the anesthesia record for details. The patient's warfarin had inadvertently not been held with INR 3.0 so two units of FFP were given during the procedure. The epicardial pacemaker was already programmed ODO. The transvenous pacemaker was interrogated under anesthesia and programmed ODO after confirming stable intrinsic rhythm. Notably the transvenous atrial threshold was intermittently as high as 8.0@1.1, compared to last clinic visit when it had been 8.0@0.7.
PECTORAL INCISION: The entire torso was cleansed with chlorhexidine gluconate and draped. The left pectoral incision was sharply reopened and carried down to the existing pocket using PhotonBlade electrocautery. The pocket was carefully reopened and the generator delivered onto the field. There were no adhesions in the pocket and the lead slack was entirely accessible to the suture sleeve. The atrial lead threshold was tested in different polarities. The threshold with tip-RVring was similar (albeit with higher impedance). The thresholds with ring-tip and ring-RVring were higher. The threshold with tip-abdominal pocket (unipolar) was somewhat lower although unclear if patient would tolerate given sensitivity to unipolar pacing in the past. We concluded that the Medtronic generator (which had maximum output of 8.0@1.2) was not viable and began planning to use a Boston Scientific generator which has maximum output of 7.5@2.0 on the ventricular port(s).
ABDOMINAL INCISION: Concurrently Dr____ had made a midline subxiphoid and dissected down to the old pocket, explanted the epicardial pacemaker, and capped the epicardial ventricular lead as it was nonfunctional due to exit block (the Y connector was completely embedded in capsule and left intact).
LEAD TUNNELING: Each transvenous lead was connected to an Oscor IS1 lead extender and the double set screws tightened confirming pin position. A Medtronic 6996T tunneling tool was used twice to tunnel from the pectoral incision to the abdominal incision, each time leaving an 11 Fr 25 cm peelaway sheath. The lead extenders were fed through and the sheaths split and discarded. The leads were retested through the extenders and confirmed to function the same as when they had been tested directly.
GENERATOR RECONFIGURATION: As the Boston Scientific generators do not have high output pacing on the atrial port, we elected to use a CRT-P generator configured analagously to what is done with conduction system pacing, placing the epicardial atrial lead in the RA port, the transvenous atrial lead in the LV port, and the transvenous ventricular lead in the RV port. This would allow multiple pacing strategies including DDD with LV-only pacing to provide effectively AAT bridging the intra-atrial block, DDD with BiV pacing with VV offset to provide effectively AAT+DDD, and VVIR with BiV pacing with VV offset to provide effectively DVIR ignoring the sinus activity going in the lateral right atrium. The leads were connected to the device confirming set screw position. We programmed the device using the middle of these strategies for the time being.
DEVICE INSERTION: Dr _____ confirmed hemostasis in both pockets. The generator and lead slack were inserted into a large absorbable antibiotic envelope which was then trimmed to size, and inserted into the abdominal pocket. The remnant of the antibiotic envelope, which was a long strip, was wrapped around the lead slack in the pectoral pocket. The leads were tested through the device and confirmed to be functioning as expected. See log for the model numbers and serial number of all hardware.
WOUND CLOSURE: After completion of the implantation procedure, the abdominal incision was closed by Dr Yoshitake. The pectoral incision was closed in layers with careful attention to hemostasis, using 2-0 vicryl for for fascia/capsule, 3-0 monocryl for intra-dermal, and 4-0 monocryl for subcuticular. A xeroform pressure dressing was applied to match the abdominal dressing. The patient was transported to the recovery room in stable condition with orders for a chest x-ray, postoperative antibiotics, electrocardiographic monitoring and frequent vital signs.
ESTIMATED BLOOD LOSS: 20 mL for EP portion
FLUOROSCOPY TIME: 0 min
RADIATION DOSE: 0 mGy
DOSE AREA PRODUCT: 0 mGy x cm2 (= uGy x m2 x 10)
TOTAL CONTRAST: 0 mL
COMPLICATIONS: none