Rosanat1991
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I am needing to know what we can bill in addition to the code for the TAVR.
PREPROCEDURE DIAGNOSES:
1. Congestive heart failure, acute on chronic, diastolic heart failure with ejection fraction of 65%.
2. Symptomatic critical aortic valve stenosis.
3. History of mild coronary artery disease.
4. History of advanced age and deemed high risk for traditional surgical intervention
5. S/P recent BAV
6. Renal insufficiency
7. Right pleural effusion
POSTPROCEDURE DIAGNOSES:
1. Successful 29-mm Edwards Sapien transcatheter aortic valve replacement through left common femoral artery.
2. Pericardial Tamponade
3. Temporary pacemaker perforation
4. s/p emergent pericardiocentesis
5. Transient Atrial fibrillation
6. Mild-to-moderate systolic and diastolic dysfunction.
7. S/p emergent stenrotomy with closure of RV perforation
PROCEDURES:
1. Access right femoral artery with 6 Frenchs sheath
2. Right femoiral vein with 6 French sheath
3. Access left femoral artery using cut down technique (Dr. 3 and Dr. 4)
4. Temporary pacemaker implantation via right femoral vein
5. Aortic root angiogram x3 (1 x pre and 2x post BAV)
6. Left heart catheterization
7. Ballon aortic valve valvuloplasty pre TAVR
8. Placement of 29-mm Edwards Sapien transcatheter aortic valve replacement via the left common femoral artery.
9. Emergent pericardiocentesis (Dr. 2)
10. Placement of pericardial drain (Dr. 2)
11. Emergent sternotomy by Dr. 3 adn 4
12. Manual hemosatsis
INDICATION FOR PROCEDURE:
The patient is a pleasant 90-year-old frail male with history of mild CAD and significant dyspnea and DOE who had BAV at SGH last month. He was seen by Dr. 3 and Dr. 4 and was deemed appropraiate for TAVR over open procedure. He has had moderate AI since his BAV.
DESCRIPTION OF PROCEDURE:
ACCESS: The patient was brought to cardiac catheterization laboratory in a fasting state. The whole patient including the bilatral groins were prepped and draped in usual sterile fashion. A 20 mL of 2% lidocaine was used to anesthetize the right femoral area.
A 6-French sheath was placed in the right femoral artery using modified Seldinger technique. A 6-French sheath was placed in the right common femoral vein using modified Seldinger technique.
PACEMAKER: A 5-French balloon tip temporary pacemaker failed to cross into the RV. We then used a stiffer 6 Fr regular pacemaker via the right femoral vein. GIven difficulty getting PM in position. Dr. --- was able to position pacer in right ventricle, placed on backup pacing with adequate sensitivities and threshold.
Before the Aortogram, we did note the pressure was transiently low. But this resolved.
AORTOGRAM: Then, a 5-French pigtail catheter was positioned in the right coronary cusp and aortic root angiogram was then performed using 10 cc contrast in the LAO 5 and caudal 4 degrees to evaluate position and to evaluate for aortic insufficiency or dissection.
BAV: The patient had been on heparin with a therapeutic ACT. We achieved a greater than 250 ACT throughtout. Cutdown had already been performed in the left femoral area by Dr. 3 and Dr. 4 to be dictated separately.
Then positioned 20-French Edwards sheath in the left femoral artery using modified Seldinger technique after predilating with a 16-French and then a 20 French dilator, positioned initially Meier wire to deliver the sheath, then used an AL1 catheter to cross the aortic valve with a straight stiff Glide wire, then a J-wire, positioned a pigtail catheter in the left ventricle. Left heart catheterization was then performed in the left ventricle and placed. Pressure was recorded. Pigtail catheter was then removed over an extra stiff Amplatz wire. Balloon valvuloplasty was then performed with a 23-mm Edwards balloon for 3 seconds.
We then tested PPM and would not capture. Then Dr. 2 was able to remaninpulate and position this with capturing.
TAVR: Balloon was deflated, reevaluated with TEE showing more moderate aortic insufficiency, advanced a 29-mm Edwards Sapien transcatheter aortic valve in the aortic position. Performed root angiography under rapid pacing at 150 bpm and off ventilation, then deployed the valve without any difficulties.
We then noted that the patient had low BP. The hear rate recovered with rapid SVT then atrial fibrillation but the BP did not recover despite temporary pacemaker at 80. The TEE showed depressed LV function with small pericardial effusion.
An Aortogram showed patent RCA and LMCA with minimal AI. We then noted expanding pericardial effusion. We quickly concluded that a temporary pacemaker perforation was likely. We quickly proceed with pericariocentesis (see Dr. 2's note).
After protamine for reversal, we removed the left femoral 20 French Edwards's sheath and the cutdown was repaired. Simulatenously we were evacuating blood from the pericardium. We then noted reaccumulation of the pericardial effusion and thus, with further drop in BP, Dr. 3 and Dr.4 proceeded with stenotomy and closure of an identified inferior wall of RV perforation. The temporary pacemaker was removed.
Thanks in Advance,
Paula and Rosana
PREPROCEDURE DIAGNOSES:
1. Congestive heart failure, acute on chronic, diastolic heart failure with ejection fraction of 65%.
2. Symptomatic critical aortic valve stenosis.
3. History of mild coronary artery disease.
4. History of advanced age and deemed high risk for traditional surgical intervention
5. S/P recent BAV
6. Renal insufficiency
7. Right pleural effusion
POSTPROCEDURE DIAGNOSES:
1. Successful 29-mm Edwards Sapien transcatheter aortic valve replacement through left common femoral artery.
2. Pericardial Tamponade
3. Temporary pacemaker perforation
4. s/p emergent pericardiocentesis
5. Transient Atrial fibrillation
6. Mild-to-moderate systolic and diastolic dysfunction.
7. S/p emergent stenrotomy with closure of RV perforation
PROCEDURES:
1. Access right femoral artery with 6 Frenchs sheath
2. Right femoiral vein with 6 French sheath
3. Access left femoral artery using cut down technique (Dr. 3 and Dr. 4)
4. Temporary pacemaker implantation via right femoral vein
5. Aortic root angiogram x3 (1 x pre and 2x post BAV)
6. Left heart catheterization
7. Ballon aortic valve valvuloplasty pre TAVR
8. Placement of 29-mm Edwards Sapien transcatheter aortic valve replacement via the left common femoral artery.
9. Emergent pericardiocentesis (Dr. 2)
10. Placement of pericardial drain (Dr. 2)
11. Emergent sternotomy by Dr. 3 adn 4
12. Manual hemosatsis
INDICATION FOR PROCEDURE:
The patient is a pleasant 90-year-old frail male with history of mild CAD and significant dyspnea and DOE who had BAV at SGH last month. He was seen by Dr. 3 and Dr. 4 and was deemed appropraiate for TAVR over open procedure. He has had moderate AI since his BAV.
DESCRIPTION OF PROCEDURE:
ACCESS: The patient was brought to cardiac catheterization laboratory in a fasting state. The whole patient including the bilatral groins were prepped and draped in usual sterile fashion. A 20 mL of 2% lidocaine was used to anesthetize the right femoral area.
A 6-French sheath was placed in the right femoral artery using modified Seldinger technique. A 6-French sheath was placed in the right common femoral vein using modified Seldinger technique.
PACEMAKER: A 5-French balloon tip temporary pacemaker failed to cross into the RV. We then used a stiffer 6 Fr regular pacemaker via the right femoral vein. GIven difficulty getting PM in position. Dr. --- was able to position pacer in right ventricle, placed on backup pacing with adequate sensitivities and threshold.
Before the Aortogram, we did note the pressure was transiently low. But this resolved.
AORTOGRAM: Then, a 5-French pigtail catheter was positioned in the right coronary cusp and aortic root angiogram was then performed using 10 cc contrast in the LAO 5 and caudal 4 degrees to evaluate position and to evaluate for aortic insufficiency or dissection.
BAV: The patient had been on heparin with a therapeutic ACT. We achieved a greater than 250 ACT throughtout. Cutdown had already been performed in the left femoral area by Dr. 3 and Dr. 4 to be dictated separately.
Then positioned 20-French Edwards sheath in the left femoral artery using modified Seldinger technique after predilating with a 16-French and then a 20 French dilator, positioned initially Meier wire to deliver the sheath, then used an AL1 catheter to cross the aortic valve with a straight stiff Glide wire, then a J-wire, positioned a pigtail catheter in the left ventricle. Left heart catheterization was then performed in the left ventricle and placed. Pressure was recorded. Pigtail catheter was then removed over an extra stiff Amplatz wire. Balloon valvuloplasty was then performed with a 23-mm Edwards balloon for 3 seconds.
We then tested PPM and would not capture. Then Dr. 2 was able to remaninpulate and position this with capturing.
TAVR: Balloon was deflated, reevaluated with TEE showing more moderate aortic insufficiency, advanced a 29-mm Edwards Sapien transcatheter aortic valve in the aortic position. Performed root angiography under rapid pacing at 150 bpm and off ventilation, then deployed the valve without any difficulties.
We then noted that the patient had low BP. The hear rate recovered with rapid SVT then atrial fibrillation but the BP did not recover despite temporary pacemaker at 80. The TEE showed depressed LV function with small pericardial effusion.
An Aortogram showed patent RCA and LMCA with minimal AI. We then noted expanding pericardial effusion. We quickly concluded that a temporary pacemaker perforation was likely. We quickly proceed with pericariocentesis (see Dr. 2's note).
After protamine for reversal, we removed the left femoral 20 French Edwards's sheath and the cutdown was repaired. Simulatenously we were evacuating blood from the pericardium. We then noted reaccumulation of the pericardial effusion and thus, with further drop in BP, Dr. 3 and Dr.4 proceeded with stenotomy and closure of an identified inferior wall of RV perforation. The temporary pacemaker was removed.
Thanks in Advance,
Paula and Rosana
