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Is this the appropriate CPT code for this procedure.
0484T – Transapical transcatheter valve in mitral ring via left thoracotomy.
Also require clincial trail number for "29 mm Edwards Sapien 3 transcatheter valve"
Require CPT codes and Clinical Trail for mentioned below procedure.
I though the appropriate CPT code 0484T
PROCEDURE PERFORMED:
1. Transapical transcatheter valve in mitral ring via left thoracotomy.
2. Temporary transvenous pacemaker insertion.
3. Transesophageal echocardiography.
OPERATIVE REASON FOR PROCEDURE: Intermediate risk for surgical mitral valve replacement,
4% to 8% risk of 30-day mortality.
IMPLANTATION: 29 mm Edwards Sapien 3 transcatheter valve in mitral ring via left
thoracotomy transapical approach.
CLINICAL INDICATIONS:
The patient is an 85-year-old male, who recently presented with
progressive symptoms of shortness of breath and fatigue, and was found to have severe
mitral stenosis. He does have a prior history of mitral valve repair with placement of a
mitral annuloplasty ring in 1998. He also has multiple other comorbidities including
nonischemic cardiomyopathy, ejection fraction of 30% to 40%, status post prior AICD
implantation, chronic atrial fibrillation, on long-term oral anticoagulation with
Coumadin, history of atrial fibrillation ablation twice. Due to his severe symptoms of
shortness of breath and fatigue, and underlying mitral valve stenosis, he was evaluated
initially by Cardiovascular Surgery, Dr. Accola, for an open heart surgery. However,
considering his advanced age, multiple comorbidities, diminished left ventricular ejection
fraction, he was felt to be at high risk for postoperative complications. Thus, the
decision was made to proceed with placement of a transcatheter mitral valve in his mitral
ring through a transapical approach. The rationale of the procedure, other options, all
the risks and benefits were extensively discussed with the patient and his family, and
consent was signed to proceed as planned. His case was also discussed extensively in our
structural heart meeting
DETAILS OF PROCEDURE:
Intraoperative transesophageal echocardiography was performed and
showed significant pannus within the prior mitral ring with presence of severe mitral
valve stenosis. There was no significant mitral regurgitation present. The patient was
brought to the hybrid operating room and placed in the supine position. He was prepped
and draped in the usual fashion. The patient was placed under general anesthesia.
Transesophageal echocardiography probe was placed and used throughout the procedure to
evaluate the mitral valve and position of our catheters. A 5-French bipolar pacing
catheter was placed in the apex of the right ventricle through right femoral venous
access. We also obtained access in the right femoral artery and placed a 5-French sheath,
just in case we needed to place an intra-aortic balloon pump for hemodynamic support
during the case. Subsequently, the left chest was opened via anterior thoracotomy, and we
found the anterior apical portion which would be appropriate for placement of the valve.
Two pledgetted sutures were placed around the LV apex. The left apex was cannulated with
a needle, and a soft wire was placed into the left atrium. Using a JR4 catheter, we
placed the wire into the right superior pulmonary vein. Then, we exchanged out the wire
for a stiff Amplatz wire. At that point, the patient had already been anticoagulated with
heparin to keep an ACT greater than 250 seconds. At that point, we placed an Ascendra
transcatheter valve introducer into the left ventricular apex, and subsequently we
prepared a 29 mm Edwards Sapien 3 transcatheter valve. Since this was a 31 mm ring, we
decided to go with a 29 mm regular prep of Sapien valve. We also had measured the ring
area on echocardiography. The transcatheter valve was deployed with rapid ventricular
pacing, and the valve was very carefully deployed under fluoroscopy guidance. The valve
deployed in excellent position. The delivery device was subsequently removed. We did
postdilate the valve by adding 1 mL of contrast due to presence of mild paravalvular leak.
After the postdilatation, there was only trivial paravalvular leak noted. There was no
central mitral regurgitation. The mitral valve seemed to be well seated inside the prior
mitral ring. This concluded the operation. The patient tolerated the surgery well, and
there were no complications. The postprocedure mitral valve area was 2.66 sq cm, the mean
gradient across the valve was 3 mmHg. There was presence of trivial paravalvular mitral
insufficiency after valve deployment. The patient was transferred to the cardiovascular
recovery area in a stable condition.
This is the part of the providers note. Our attention was turned towards the left groin where femoral artery and vein cutdown were performed, 5000 units of heparin were given and using a Seldinger technique and echocardiographic guidance, a left femoral arterial cannula 18-French was placed and a 25-French femoral venous cannula was placed. The femoral venous cannula was advanced so that the tip was in the superior vena cava right atrial junction.
thank you!
Procedure Name: Elective Cystoscopy, Trans-urethral resection of intra-bladder left ureteral inverted stump and fulguration of left ureteral orifice.
History: Intra-bladder inversion of left ureteral stump from prior ureteral avulsion.
Procedure Description: After informed consent was received patient was brought to the operating room and placed in a supine position. Anesthesia was induced. Patient was placed in a dorsal lithotomy position and genitals were prepped and draped in a standard fashion. Appropriate time out was performed. Cystoscopy revealed: Intra-bladder inversion of left ureteral stump from prior ureteral avulsion,
The ureteral stump were resected and the left ureteral orifice was then fulgurated. The ureter was sent to pathology for permanent examination. Hemostasis was achieved. Scope was removed and a Foley catheter was placed and was draining clear urine.
36215-59
75710-26-59-LT
36222-50
36226-RT
99152
Please and thank you!
PROCEDURE: Left subclavian artery angiography, attempted PTA of left subclavian artery, selective right and left common carotid angiography, selective right vertebral artery angiography
*
DATE OF PROCEDURE: 11/20/2018
*
INDICATION: Left subclavian artery stenosis and patient was referred to Kalamazoo when she came with acute situation no revascularization was done at that time
*
PROCEDURES PERFORMED:
1. Selective cannulation of left subclavian artery
2. Attempted PTA of left subclavian artery
3. Selective left and right common carotid artery angiography
4. Selective right vertebral artery angiography
*
EQUIPMENT USED:
1. 0.035 Glidewire, 0.018 estato wire
2. 0.035 Navi cross catheter
*
*
DESCRIPTION OF PROCEDURE:
Patient was brought into the Cath Lab, draped and prepped in conventional fashion and using Xylocaine anesthesia a 6 French sheath was placed in the right common femoral artery. With a Judkins diagnostic right catheter left subclavian artery was cannulated and angiography was performed for the procedure were attempted.
*
Cine report:
Left subclavian artery is totally occluded with a stump
*
After the attempted procedure right innominate artery was cannulated and selective carotid artery angiography was performed right common carotid artery doesn’t show any stenosis done show any filling on the left side
*
Left common carotid artery doesn’t show any filling on the left subclavian artery
*
The right vertebral artery shows ostial stenosis of 80-90% however it does fill up the left vertebral artery retrogradely and fills of the distal subclavian artery as well as axillary artery and brachial artery
*
MODERATE SEDATION:
Moderate sedation was administered using IV Versed and Fentanyl. Patient received continuous EKG, hemodynamic and oximetry monitoring with physician being present for the entire time. Total moderate sedation duration = 51 min.
*
CONTRAST:
Medication Name Total Dose
iodixanol (VISIPAQUE) 320 mg/mL injection 43 mL
*
*
PTA AND STENTING:
I tried to pass the 0.035 wire through the subclavian artery and there was a small dye was noted in the side of the subclavian artery which is a presently subintimal and it would not cross into the subclavian artery. Multiple attempt was done and then the Navy cross catheter was used and will not go through the totally occluded subclavian artery. A estato wire was also tried which will not go through the totally occluded subclavian artery. After trying for more than half an hour procedure was stopped. However this vertebral artery does show retrograde flow from the right to the left side and I could see the brachial artery.
*
CINE INTERPRETATION:
1. Totally occluded left subclavian artery with a stump could not be cannulated failed PTA
*
*
FINAL DIAGNOSIS:
1. Total occlusion of left subclavian artery is a stump noted not at the ostium
2. Right and left common carotid artery doesn’t show any stenosis
3. Right vertebral artery shows ostial stenosis of 80% shows retrograde flow to the left vertebral artery filling of the distal subclavian and axillary and brachial artery
*
RECOMMENDATION:
Plan is to bring the patient and try to go through the brachial artery and retrograde fashion because the distal total occlusion may be easier to cross. If it cannot be opened up I discussed with the vascular surgeon her than the plan for the surgery either left carotid subclavian bypass or productive frequent graft attaching to the subclavian artery to the aorta. Patient will be discharged home and will be brought back again. Now since it is totally occluded I don’t think patient need Coumadin. She’ll be followed up as an outpatient
*
Patient had a partial amputation in same area years ago but has recurrent ulcerations.
Procedure: Two semi-elliptical incisions were created around the base just distal to the base of the hallux first MPJ and full thickness incisions were created down to bone with 15 blade. Toe was disarticulated and the extensor and flexor tendons were identified, protracted and cut… all devitalized tissues were debrided from the wound…bleeders clamped…
CPT 28810? Also diagnosis T87.44 along with the E11.621 ?
TIA
KAM