sglamuzina
Guest
Can someone please guide me in the correct directions with billing this, for some reason the Pacemaker and NOW is a AICD is making my brain go blank....
Date of procedure:
5/15/2023
Procedures perfromed:
Upgrade of a dual chamber pacemaker to a dual chamber intracardiac defibrillator (ICD) (using a BiV device) with the old RV PPM lead plugged into the LV port on the BiV device to avoid abandoning the RV pacemaker lead
Peripheral venogram
Preoperative Diagnoses:
#Non-ischemic cardiomyopathy with an ejection fraction less than 35% despite GDMT for at least 3 months, NYHA class II
#Sinus bradycardia s/p BSc DC PPM, dependent on atrial pacing on clinic visit 3/10/23
Postoperative Diagnoses: Same as above
Indication:
xxxxxxxxx is a 86 y.o.-old male with the above PMH. An ICD shared decision making tool was utilized. The ICD is being placed for primary prevention.
Anesthesia:
Local with lidocaine and sedation per anaesthesia.
Procedure:
The indications, risks/benefits, alternatives and details of the procedure were explained to the patient and family. Risks included but were not limited to infection, bleeding, vascular, valvular or pulmonary injury, arrhythmia, pneumothorax, perforation or need for emergent sternotomy, stroke, heart attack, death, and possible need for intubation. After all questions were answered, informed and written consent was provided by the above individual(s).
The patient was brought to the electrophysiology laboratory in a fasting, non-sedated state. The patient was connected to an external defibrillator and an EP recording system and prepped and draped in the usual sterile fashion. Blood pressure, heart rate, oxygen saturation, and cardiac rhythm were continuously monitored.
A left upper extremity venogram was obtained and it showed a patent axillary-subclavian venous system, with some areas of stenosis along the brachiocephalic vein.
After infiltration with lidocaine, a horizontal incision was made near the old incision site. The incision was carried down to the level of the pulse generator pocket, with careful cauterization of all arterial bleeders. The pulse generator was carefully removed from the pocket using blunt dissection. Using Bovie cautery and blunt dissection, a larger ICD device pocket was created.
Subclavian venous access was obtained, using the modified Seldinger technique. This was performed with the placement of one J tipped wire advanced to the IVC. Of note, there was significant stenosis at two points along the brachiocephalic vein, which required a fair amount of wire maneuvering in order to traverse.
A long 8-French sheath was advanced over the wire into the subclavian vein using fluoroscopic guidance. The ICD lead was advanced into the sheath but would not advance past the first area of stenosis within the brachiocephalic vein. Therefore an extra stiff Amplatz .035 wire was advanced through the sheath to the IVC. The sheath was removed and serial dilations of the vein were performed with long 9 and then 10 French sheaths. After dilation with the 10 F sheath, with the Amplatz wire still in place in the IVC down the sheath, the ICD lead was advanced down the 10 F long sheath and this allowed for the lead to be advanced to the RA.
Using the appropriately shaped stylets, the lead was positioned at the mid to apical interventricular septum. The RV lead was actively fixated using the pinch-on tool. Sensing, threshold, and impedance measurements were appropriate. The right ventricular lead was sutured to the underlying fascia with 2-0 non-absorbable suture over its suture sleeve.
The pocket was irrigated with antiobiotic solution, and meticulous hemostasis was ensured with visual inspection and Bovie cautery.
The old leads were removed from the old generator and inspected.
The new device generator was connected to the leads, and the entire system was placed carefully in the pocket.
Of note the retained RV PPM lead was inserted into the LV lead port and this port was programmed off.
The generator was loosely sutured to the underlying pectoralis muscle.
The wound was closed with 2-0, 3-0, and 4-0 absorbable suture in the fascial, subcutaneous and subcuticular layers. Steri-Strips were applied over the wound. A light pressure dressing was placed over the implant site.
The patient was transferred back to the holding area in stable condition.
Complications:
None
Estimated blood loss:
Minimal
IMPLANTED & RETAINED HARDWARE:
Date of implant: 5/15/2023
Retained Right Atrial lead: Medtronic Model 5076, SN: PJN3452754
Retained RV pacemaker lead: Momentum CRT-D Model G124, SN: 507828
Presenting rhythm: A paced and V sensed
Programmed pacing mode: Programmed pacing mode: DDDR 60-130
ICD Therapies:
VF: 240 bpm, Quick convert, 41J x 8
VT: 200 bpm, ATP, 41J x 6
VT-1: 170 bpm, Monitor only
Of note, the old RV pacemaker lead was plugged into the LV port and this was programmed off so as to not pace or sense.
CONCLUSION:
Left venogram revealed patent axillary-subclavian system and some points of stenosis along the brachiocephalic vein
Successful upgrade of a dual chamber pacemaker to a dual chamber intracardiac defibrillator (ICD) (using a BiV device) with the old RV PPM lead plugged into the LV port on the BiV device to avoid abandoning the RV pacemaker lead
RECOMMENDATIONS:
Monitor in PACU and then likely discharge home
Postoperative orders per orders placed in EMR
Date of procedure:
5/15/2023
Procedures perfromed:
Upgrade of a dual chamber pacemaker to a dual chamber intracardiac defibrillator (ICD) (using a BiV device) with the old RV PPM lead plugged into the LV port on the BiV device to avoid abandoning the RV pacemaker lead
Peripheral venogram
Preoperative Diagnoses:
#Non-ischemic cardiomyopathy with an ejection fraction less than 35% despite GDMT for at least 3 months, NYHA class II
#Sinus bradycardia s/p BSc DC PPM, dependent on atrial pacing on clinic visit 3/10/23
| Past Medical History: | ||
| Diagnosis | Date | |
| • | Ataxia | |
| • | Atrial fibrillation (HCC) | |
| • | Benign hypertensive CKD | |
| • | Brain aneurysm | |
| • | Cerebellar infarction (HCC) | |
| • | Cervical post-laminectomy syndrome | |
| • | Chronic systolic heart failure (HCC) | |
| • | CKD (chronic kidney disease) | |
| • | Diverticulitis | |
| • | GERD (gastroesophageal reflux disease) | |
| • | HLD (hyperlipidemia) | |
| • | HTN (hypertension) | |
| • | Iron deficiency anemia | |
| • | Occlusion of left vertebral artery | |
| • | Perforated ear drum, right | |
| • | S/P AVR | |
| • | S/P MVR (mitral valve replacement) | |
| • | Sleep apnea | |
| • | Thoracic ascending aortic aneurysm (HCC) | |
| • | TIA (transient ischemic attack) | |
| • | Vertigo |
Postoperative Diagnoses: Same as above
Indication:
xxxxxxxxx is a 86 y.o.-old male with the above PMH. An ICD shared decision making tool was utilized. The ICD is being placed for primary prevention.
Anesthesia:
Local with lidocaine and sedation per anaesthesia.
Procedure:
The indications, risks/benefits, alternatives and details of the procedure were explained to the patient and family. Risks included but were not limited to infection, bleeding, vascular, valvular or pulmonary injury, arrhythmia, pneumothorax, perforation or need for emergent sternotomy, stroke, heart attack, death, and possible need for intubation. After all questions were answered, informed and written consent was provided by the above individual(s).
The patient was brought to the electrophysiology laboratory in a fasting, non-sedated state. The patient was connected to an external defibrillator and an EP recording system and prepped and draped in the usual sterile fashion. Blood pressure, heart rate, oxygen saturation, and cardiac rhythm were continuously monitored.
A left upper extremity venogram was obtained and it showed a patent axillary-subclavian venous system, with some areas of stenosis along the brachiocephalic vein.
After infiltration with lidocaine, a horizontal incision was made near the old incision site. The incision was carried down to the level of the pulse generator pocket, with careful cauterization of all arterial bleeders. The pulse generator was carefully removed from the pocket using blunt dissection. Using Bovie cautery and blunt dissection, a larger ICD device pocket was created.
Subclavian venous access was obtained, using the modified Seldinger technique. This was performed with the placement of one J tipped wire advanced to the IVC. Of note, there was significant stenosis at two points along the brachiocephalic vein, which required a fair amount of wire maneuvering in order to traverse.
A long 8-French sheath was advanced over the wire into the subclavian vein using fluoroscopic guidance. The ICD lead was advanced into the sheath but would not advance past the first area of stenosis within the brachiocephalic vein. Therefore an extra stiff Amplatz .035 wire was advanced through the sheath to the IVC. The sheath was removed and serial dilations of the vein were performed with long 9 and then 10 French sheaths. After dilation with the 10 F sheath, with the Amplatz wire still in place in the IVC down the sheath, the ICD lead was advanced down the 10 F long sheath and this allowed for the lead to be advanced to the RA.
Using the appropriately shaped stylets, the lead was positioned at the mid to apical interventricular septum. The RV lead was actively fixated using the pinch-on tool. Sensing, threshold, and impedance measurements were appropriate. The right ventricular lead was sutured to the underlying fascia with 2-0 non-absorbable suture over its suture sleeve.
The pocket was irrigated with antiobiotic solution, and meticulous hemostasis was ensured with visual inspection and Bovie cautery.
The old leads were removed from the old generator and inspected.
The new device generator was connected to the leads, and the entire system was placed carefully in the pocket.
Of note the retained RV PPM lead was inserted into the LV lead port and this port was programmed off.
The generator was loosely sutured to the underlying pectoralis muscle.
The wound was closed with 2-0, 3-0, and 4-0 absorbable suture in the fascial, subcutaneous and subcuticular layers. Steri-Strips were applied over the wound. A light pressure dressing was placed over the implant site.
The patient was transferred back to the holding area in stable condition.
Complications:
None
Estimated blood loss:
Minimal
IMPLANTED & RETAINED HARDWARE:
Date of implant: 5/15/2023
| Implant Name | Type | Inv. Item | Serial No. | Manufacturer | Lot No. | LRB | No. Used | Action |
| Reliance 4 Front | 212084 | N/A | 1 | Implanted | ||||
| DFBR CRD .99CM 5.37X8.18CM - S507828 | DFBR CRD .99CM 5.37X8.18CM | 507828 | HMHP BOSTON SCIENTIFIC - BSC | N/A | 1 | Implanted | ||
| BOSTON SCIENTIFIC | Pacemaker | 164821 | 1 | Explanted |
Retained Right Atrial lead: Medtronic Model 5076, SN: PJN3452754
Retained RV pacemaker lead: Momentum CRT-D Model G124, SN: 507828
Presenting rhythm: A paced and V sensed
Programmed pacing mode: Programmed pacing mode: DDDR 60-130
ICD Therapies:
VF: 240 bpm, Quick convert, 41J x 8
VT: 200 bpm, ATP, 41J x 6
VT-1: 170 bpm, Monitor only
| Lead | RA | RV (ICD Lead) |
| Date of Implant | 5/15/2023 | 5/15/2023 |
| Sensed amplitude (mV) | 2.4 mV | 23.2 mV |
| Pacing threshold (V@ms) | 1.5 V @ 0.4 ms | 0.4 V @ 0.4 ms |
| Pacing impedance (Ω) | 321 Ω | 634 Ω |
| High-voltage impedance (ohms) | 49 Ω | |
| % pacing | N/a | N/a implanted today |
Of note, the old RV pacemaker lead was plugged into the LV port and this was programmed off so as to not pace or sense.
CONCLUSION:
Left venogram revealed patent axillary-subclavian system and some points of stenosis along the brachiocephalic vein
Successful upgrade of a dual chamber pacemaker to a dual chamber intracardiac defibrillator (ICD) (using a BiV device) with the old RV PPM lead plugged into the LV port on the BiV device to avoid abandoning the RV pacemaker lead
RECOMMENDATIONS:
Monitor in PACU and then likely discharge home
Postoperative orders per orders placed in EMR