REASON FOR PROCEDURE: Paroxysmal atrial fibrillation, hematuria on
anticoagulation.

PROCEDURES:
1. Transesophageal echocardiogram with 2D echo, M-mode Doppler, and color
flow mapping.
2. Watchman left atrial appendage occlusion device implantation.
3. Arterial catheter placement.
4. Venous catheter placement.

HARDWARE:
1. Boston Scientific Watchman access system sheath, double curve, 14-French,
lot #21482043.
2. Boston Scientific watchman 24 mm device, lot #21485158.

DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient,
signed, and placed on the chart. He seemed to understand the risks, benefits,
and alternatives and agreed to proceed. The patient was brought to the
cardiac electrophysiology lab in a fasting state and placed supine on the
fluoroscopy table. General endotracheal anesthesia was administered and
supervised by the Anesthesiology staff. The right groin was prepped with
ChloraPrep and draped in the usual sterile fashion. A bite block was placed,
and this was also draped in sterile fashion. The TEE probe was inserted
through a sterile sleeve, and then inserted into the esophagus without
difficulty.

The transesophageal echocardiography was performed. In the 0, 45, 90, and 135
degrees angles, the appendage ostial width was 15.5 mm, 13 mm, 15 mm, and 17.0
mm, and the length was 25 mm, 18 mm, 17 mm, and 16 mm.

The skin of the right groin was anesthetized with 1% lidocaine local, followed
by the deeper structures. Using the modified Seldinger technique, an 8-French
25 cm sheath, an 8.5-French SL1 sheath were placed in the right common femoral
vein, and a 4-French 11 cm sheath was placed in the right common femoral
artery. All sheaths were aspirated and flushed. Pressure tubing was
connected to the arterial sheath and was handed to the anesthesiologist for
invasive hemodynamic monitoring.

Heparin was given with an additional dose of 15000 units, with repeated bolus
was given to maintain an ACT of greater than 300 seconds.

Under fluoroscopic guidance, the wire in the SL1 sheath was advanced to the
superior vena cava, and the sheath and dilator were advanced over the wire.
The wire was removed, the dilator was flushed, and a flushed Baylis needle was
advanced through the dilator. The dilator, needle, and sheath were withdrawn
under fluoroscopic guidance to the fossa ovalis. Tenting was visualized on
transesophageal echocardiography. The fossa ovalis was small. Once a
suitable location was found, radiofrequency energy was applied and a
transseptal puncture was performed. The needle was flushed, and micro bubbles
were seen in the left atrium as expected. A left atrial pressure waveform was
noted, and the mean left atrial pressure was 17 mmHg.

The dilator was advanced over the needle, and the sheath was advanced over the
dilator. The dilator and needle were slowly withdrawn, and bright red blood
was aspirated from the sheath. The sheath was carefully flushed. An Amplatz
Super Stiff wire was then advanced through the sheath into the left superior
pulmonary vein, and the sheath was exchanged over the wire for a double curve
14-French Watchman access system sheath and dilator.

Once the dilator was in the left atrium, the sheath was advanced over the
dilator and wire, and then the dilator and wire were withdrawn. The sheath
was carefully aspirated and flushed. A flushed 5-French straight pigtail
catheter was advanced through the sheath into the left atrium. The pigtail
catheter was aspirated and flushed. It was inserted into the anterior lobe of
the left atrial appendage, and angiogram of the appendage was recorded using
hand injection of contrast.

The sheath was advanced over the pigtail catheter up to the 24 mm depth
marker. The Watchman 24 mm device was carefully prepared and flushed. The
pigtail catheter was withdrawn, and the Watchman delivery catheter was
inserted through the sheath until the distal markers aligned. The sheath was
then withdrawn to expose the end of the catheter. During apnea, the sheath
was withdrawn to deploy the device in the left atrial appendage ostium.

A tug test was performed, and the device was in stable position. Followup
measurements using TEE were recorded, with measurements at 0, 45, 90, and 135
degrees of 18.6 mm, 17.5 mm, 16.6 mm, and 18.6 mm. This yielded compressions
of 22% to 31%. Color-flow Doppler and injection of contrast through the
sheath showed no residual leak surround the device.

The threaded rod was unscrewed to release the device. IV protamine was given.
The sheath and dilator were removed under fluoroscopy to avoid dislodging
leads. A suture was tied around the insertion site in the groin using #2
Vicryl. Transesophageal echocardiography was performed to rule out
postprocedure pericardial effusion.

After protamine was given, the sheaths were removed, and hemostasis was
obtained with manual compression with tightening the suture. The patient was
successfully extubated and transferred to the PACU.

CPT CODES: 33340 Q0
ICD 10: I48.0, Z00.6
Clincial trial number etc.
As far as the interoperative Tee is concerned, according to the Boston Scientific Guide Point Reimbursement Resources, this can only be charged by a separate individual who is not performing the interventional procedure with CPT 93355.
Our Provider would also like to charge for Arterial Catheter Placement and Venous Catheter Placement; CPT 93503? and 36010? I’m not sure about these codes but I thought they were included in.

Any help will do for information I can provide my provider as to why certain codes cannot be charged while doing a Watchman.

Many thanks,

Jane:)