PATIENT: ROLANE, JACK ACCOUNT/EHR #: ROLAJA001 Diagnosis: Atrial fibrillation Procedure:

PATIENT: ROLANE, JACK ACCOUNT/EHR #: ROLAJA001 Diagnosis: Atrial fibrillation Procedure: Internal cardiac defibrillator Physician: Frank Vincent, MD Anesthesia: Moderate sedation CLINICAL INFORMATION: A 71-year-old male with a history of paroxysmal atrial fibrillation, on antibiotic therapy, continued paroxysms of atrial fibrillation, now for an atrial defibrillator. We discussed the risks and benefits of this procedure, including 1% less risk of bleeding, infection; injury to the cephalic vein, subclavian vein, and right atrium and right ventricular structures; cardiac perforation; clot formation and lead resistance and distal embolization to arms, legs, kidneys; stroke; death; and lead dislodgement. He understood and agreed to proceed. The patient was then taken to the EP laboratory and given Versed and fentanyl for sedation. After receiving 1 gram of Vancomycin for antibiotic prophylaxis, the whole anterior thorax was prepped and draped in the sterile fashion. Pre-gelled electrodes were placed in the posterior thorax with access to the anesthesia-monitoring machine. Pre-gelled electrode pads were placed in the anterior and posterior and care taken to verify that the heart had been adequately interfaced between the two pads. After this, patient was prepped and draped in a sterile fashion. 1% lidocaine was then used to anesthetize the left prepectoral area. A 7-cm incision was made in the medial to lateral direction with care taken to verify that the deltopectoral groove was within the incision line. Blunt dissection electrocautery was then used to make the ICD pocket, and venotomy technique was then used to cut down to the cephalic vein and introduce the leads. Using venotomy technique, a 0.3 G-tipped guide wire was passed to the level of the left cephalic vein to the subclavian vein. This was then used to pass a 9 French safe sheath to the level of the left subclavian vein. Guide wire remained in place, and then the guide wire was removed and the second guide wire was put in place and the sheath was then removed. An 11 French safe sheath was then passed over one of the guide wires. The guide wire dilator was removed, and the ventricular lead, a Medtronic lead 6942, 65, serial #TCB115488V, was then passed to the level of the inferior vena cava. Under fluoroscopic visualization, leads were then placed in the right ventricular apex. The lead was then sutured in the prepectoral muscle using 2-0 Vicryl suture. Over the second guide wire, a 9 French safe sheath was then passed, guide wire and dilator were removed, and an atrial lead Medtronic 6940, 65, serial #TCB023468V, was then passed to the level of the right atrium. This is an activation lead and was actively fixed. The following pacing thresholds were noted upon implant. A sense P wave of 4.4 mV, sensory R wave of 10.5 mV, with a capture threshold in the atrium and 1.2 volts at 0.5 msec, the ventricle 0.3 volts at 0.5 msec, lead impedance in the atrium is 819 and the ventricle 518. Each lead was sutured in the prepectoral muscle using 2-0 nylon absorbable suture. The lead in the ICD was then placed in the pocket. The ICD was a Medtronic 7258H, dual AF, serial number of PID, 102351R. Under fluoroscopic visualization, the leads were verified to be in stable position and the ICD was sutured to the prepectoral muscle using 2-0 nonabsorbable suture. A total of two inductions of ventricular fibrillation were then induced; each time it was quickly detected, and terminated with an 18-joule biphasic shock, designating the RV electrode and cathode. Defibrillation pressure was established at less than or equal to 18 joules. Atrial fibrillation was then induced two times, each time was quickly detected and terminated with a 4-joule biphasic shock. The atrial defibrillation threshold established was less than or equal to 4 joules. The patient tolerated the procedure well. The wound was then copiously irrigated with a G-U irrigant and closed in layers, using 2-0 Vicryl suture for the first fascial layer, 3-0 Vicryl suture for the second fascial layer, and 4-0 Vicryl suture for subcuticular layer. Steri-strips and sterile occlusive dressing were then placed for final wound approximation. The patient was then taken to the recovery room for further monitoring. Frank Vincent, MD WHAT ARE THE APPROPRIATE CODES?

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