We’re having a problem with this op report as the provider would like to separate the radiology codes from the attempted biv insert. We believe the radiology codes are included. Can someone please either confirm or advise whether they are or are not included so we can advise our provider again. Many thanks!!!!

CPT Codes to bill:

33249-52
75827, 26
75820, 26
75860, 26
93280, 26

PROCEDURES PERFORMED:
1. Attempted upgrade of dual-chamber pacemaker to an atrial synchronous
biventricular cardioverter-defibrillator.
2. Interrogation and reprogramming of a dual-chamber pacemaker.
3. Peripheral angiography of the upper extremity as well as subclavian and
superior vena cava.

INDICATION: gentleman with a history of a
cardiomyopathy, left ventricular systolic function of approximately 25% with
New York Heart Association classification 3. Heart failure with chronically
right ventricular pacing, who is referred at this time for upgrade of his dual-
chamber pacemaker to an atrial synchronous biventricular cardioverter-
defibrillator.

PROCEDURE IN DETAIL: The patient was brought to electrophysiology laboratory
in a fasting postabsorptive state. Informed written consent was obtained.
Vancomycin 1 g IV was administered prior to the procedure. The patient was
prepped and draped in the usual sterile fashion. 1% bupivacaine was
infiltrated into the left deltopectoral region. An incision was made over the
existing pacemaker generator and the existing pacemaker (make Biotronik) was
removed from the pocket. Subsequently, utilizing a standard Seldinger
technique, an 18-gauge needle was inserted into the left subclavian vein under
fluoroscopic guidance. A guidewire was subsequently advanced to the region of
the inferior vena cava under fluoroscopic guidance. Similarly utilizing
standard Seldinger technique, a 2nd 18-gauge needle was inserted into the left
subclavian vein under fluoroscopic guidance. The guidewire was also advanced
to the region of the inferior vena cava under fluoroscopic guidance. Through
the first guidewire, a 9.5-French sheath was subsequently inserted into the
left subclavian vein under fluoroscopic guidance. The coronary sinus sheath
was subsequently advanced under fluoroscopic guidance; however, resistance was
met at the juncture of the innominate vein and the superior vena cava. A Swan
wire was attempted to be placed over the Swan-Ganz catheter that was within
the coronary sinus guide, which again could not be advanced past this area.
Subsequently, intravenous contrast was injected into the subclavian vein and
superior vena cava region demonstrating occlusion of the superior vena cava at
close to the juncture of the connection between the SVC and the right atrium.
There was some extravasation of contrast suggestive of possible SVC
dissection. At this point, given the fact that the patient was anticoagulated
and there was no evidence of distal flow, it was decided to abort the
procedure. Further fluoroscopic evaluation had demonstrated that the contrast
indeed was able to flow via collaterals to the right atrium. There was no
further evidence of dissection nor SVC rupture. The patient remained
hemodynamically stable. A 2D echocardiogram was performed in the cath lab,
which demonstrated no evidence of pericardial effusion.

The patient was subsequently returned to the intensive care unit for further
monitoring. Serial H and H were drawn every 2 hours to monitor the patient
carefully.

IMPRESSION: Aborted upgrade of a pacemaker to an atrial synchronous
biventricular cardioverter-defibrillator due to SVC occlusion.

PLAN: Plan is to observe the patient on telemetry in the ICU. We will
continue to monitor H and H’s carefully. Do a followup chest x-ray to rule
out any evidence of hemothorax. The chest x-ray performed immediately after
the procedure demonstrated no evidence of hemothorax. Eventually, once this
heals, we may consider performing peripheral angiography from the right side
to see if there is any patency from the right side through the SVC into the
right atrium. If indeed there is, then we will proceed with implantation of
an atrial synchronous biventricular cardioverter-defibrillator from the right
subclavian approach. I discussed this at length with the patient as well as
his family and all questions were answered in detail.

Many thanks
Jane