33264, 33272×2, 33273, 33271×2?
Thank you!
The rest of the procedure is monitored anesthesia care for 56 minutes.
PROCEDURES:
1. Fluoroscopy of chronic indwelling pacer leads.
2. Explantation of a depleted Medtronic pulse generator.
3. Chronic lead testing.
4. Insertion of a new Medtronic BiV-ICD pulse generator. The device
is a Medtronic. The model number is a Medtronic Viva, model number
DTBA1D1, the serial number BLF600677S.
CLINICAL DATA:
Mr. T is a 76-year-old male with an ischemic dilated cardiomyopathy,
recurrent heart failure, nonsustained ventricular tachycardia whose
device has been followed in Surveillance Clinic, is now ERI.
DESCRIPTION OF PROCEDURE:
After informed consent, the patient was brought to the EP operating suite.
He received a 1 g of vancomycin. The left anterior hemithorax was
sterilely prepped and draped in the usual manner infiltrated with 2%
lidocaine. The patient had multiple doses of Versed and fentanyl supervised
by myself. A #15 blade was used to create an infraclavicular incision.
Sharp and blunt dissection used to carefully isolate the old generator.
Lead inspection both fluoroscopically and visually revealed no abnormalities.
The patient was device dependent. We removed the coronary sinus lead
first. This was kind of a high threshold and we began temporary pacing
through the external testing device while we removed the other leads.
RV lead was checked, although, we could not measure R-waves. This
was placed in the correct position in the header and secured with the
supplied torque wrench. We subsequently moved the high-voltage leads
in the right atrial lead. The right atrial lead had pulled back and
was dangling in the right atrium. However, this patient has chronic
atrial fibrillation and no attempts were made to remove this chronic
displaced lead. After adequate VVI pacing was assured through the right
ventricular pace sense high-voltage lead, we then placed the coronary
sinus lead in its correct position. The header as noted above, the
current configuration had a high threshold. We checked multiple configurations
and we changed the polarity from tipped coil and we were able to get
slightly higher resistance and lower threshold. We irrigated the pocket
with copious amounts of GU irrigant solution. The patient had been
on the anticoagulants, which had been held. Eliquis had been held since
Friday. We used Bovie cautery for hemostasis. We irrigated the pocket,
copious amounts of GU irrigant solution. At this point time, the device
was delivered into the pocket in the same attitude that had been removed,
coiling the leads underneath the device. The subcutaneous tissue was
closed in 2 layers with 2-0 Vicryl. Skin was closed with 2-0 silk using
vertical mattress suture. The right ventricular lead is a Medtronics
model #6. The right ventricular pace-sense high-voltage lead is a Medtronic
model number #69355, serial number TAU06531. The left ventricular
pace-sense lead is a Medtronic model #41948. The serial number is
LFG102448. The settings were not changed. The only change in programming
was made to the coronary sinus lead. The device was left at a VVI pacing
at the lower rate of 60. Tachytherapies were not changed as the patient
appeared to tolerate the procedure well without any obvious complications.