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PREOPERATIVE DIAGNOSIS: Heаrt BlоckPOSTOPERATIVE DIAGNOSIS: Heаrt BlоckANESTHESIA: Lоcаl anesthesia NAME OF PROCEDURE: Reimplantation of dual chamber pacemakerDESCRIPTION: The chest was prepped with Betadine and draped in the usual sterile fashion. Local anesthesia was obtained by infiltration of 1% Xylocaine. A subfascial incision was made about 2.5 cm below the clavicle, and the old pulse generator was removed. Using the Seldinger technique, the subclavian vein was cannulated and through this, the old atrial lead was removed, and a new atrial lead (serial # 6662458) was placed in the right atrium and to the atrial septum. Thresholds were obtained as follows: The P-wave was 1.4 millivolts, atrial threshold was 1.6 millivolts with a resultant current of 3.5 mA and resistance of 467 ohms.Using a second subclavian stick in the Seldinger technique, the old ventricular lead was removed and a new ventricular lead (serial # 52236984) was inserted and placed into the right ventricular apex. The thresholds were obtained and were as follows: R-wave was 23.5 millivolts. The patient was pacing at 100% at 0.5 volts, with resultant current of 0.8 mA and resistance of 480 ohms. When we were satisfied with the thresholds, the leads were connected to the pacemaker generator (serial # 22561587), which was inserted into the previously created pocket.The wound was thoroughly irrigated with antibiotic solution and hemostasis was obtained. The incision was closed in layered fashion with 2-0 Dexon. A compressive dressing was applied, and the patient tolerated the procedure very well. He was taken to the recovery room in satisfactory condition. What CPT® codes are reported?
INDICATIONS FOR CORONARY INTERVENTION: Acute inferiоr myоcаrdiаl infаrctiоn. Documented mildly occlusive plaque with much clot in the right coronary artery.PROCEDURE: Insertion of temporary pacemaker in the right femoral vein. Primary stenting of the right coronary artery with a 4.5 x 16 mm Express stent. Angio-Seal to the vessels of the right common femoral artery post procedure, and also Angio-Seal of the right common femoral vein.TECHNIQUE: Judkins percutaneous approach from the right groin with Perclose at the arterial puncture site post procedure.CATHETERS: 4 French Angio-Jet catheter device, insertion of a 5 French temporary pacing wire, a 4.5 x 16 mm Express stent.PRESSURES: Aortic Pressure: 107/78RESULTS:Coronary stenting procedure of the right coronary artery: The right coronary artery was primarily stented with a 4.5 x 16 mm Express stent. It was expanded to 12 atmospheres. There was no residual stenosis.IMPRESSION: Successful Angio-Jet and stenting of the distal right coronary artery with no residual stenosis. Angio-Seal to the right femoral vein post procedure.PROCEDURE: Through the femoral artery sheath, the EBU was advanced to the right coronary. Following this a PT graphic intermediate wire was used to cross the lesion. Following this angioplasty of the lesion was performed, utilizing a 2.5 x 20-millimeter CrossSail balloon at multiple sites to ten atmospheres. Following this there was a fair result; however, there was a significant stenosis and significant calcification at the area, and the decision was made to pursue trying to stent the lesion. Multiple stents were attempted, including a 2.5 x 9-millimeter zipper MX and a 2.5 x 13-millimeter Guidant stent. This was abandoned, and in switching out to a balloon for further ballooning, the patient became hypertensive and with difficulty in terms of her respiratory status. Angiography revealed an occlusion of the mid left anterior descending and thrombus throughout the proximal left anterior descending extending into the left main. Recheck of ACT showed the ACT to be at eight seconds. This likely represented subtherapeutic range for her anticoagulation. A check of her medications revealed that instead of Angiomax, the patient had been given ReoPro without antithrombotic agent. She was therefore given IV heparin up to 12,000 units, and her ReoPro was continued. The lesion was then rewired, and an AngioJet was used to try to suction out this area of thrombus.Unfortunately, the AngioJet was unable to cross the mid left anterior descending lesion and therefore was somewhat limited in its use for a more distal thrombus, although it did suction out the proximal left anterior descending thrombus. At this point, the patient was emergently intubated, and multiple pressors were started, including dopamine, Levophed, vasopressin, and epinephrine. Following this, a laser was attempted to cross the lesion an excimer laser X80 Spectranetics 0.9 Vitesse; however, this laser was unable to cross the lesion. Therefore, a long balloon, a 2.0 x 40-millimeter CrossSail balloon, was used to cross the lesion and inflate multiple segments of the mid left anterior descending up to a maximum inflation pressure of ten atmospheres. This improved flow though by no means restored it back to normal. Therefore, following this, longer balloon inflations were performed utilizing a 2.0 x 20-millimeter CrossSail balloon up to fourteen atmospheres for one and a half minutes. This did not improve significantly the flow distally, and therefore the decision was made to try to stent the mid segment with a 2.5 x 9-millimeter zipper MX stent to a maximum inflation pressure of fourteen atmospheres. This resolved the issue in terms of the mid left anterior descending lesion; however, beyond the stent there continued to be residual stenosis, and multiple balloons were used to balloon this up to a 2.5 x 20-millimeter balloon up to fourteen atmospheres. The final result in the left anterior descending revealed a lesion in the mid-left anterior descending that was approximately 40 percent, there was TIMI III flow throughout the proximal and mid left anterior descending. However, at the level of the apex, there was TIMI 0 flow. Throughout the angioplasty, the patient had episodes of bradycardia, and a temporary pacemaker was placed, and this was removed at the end of the procedure.IMPRESSION: Successful stent to the mid left anterior descending, complicated by thrombotic event in the left anterior descending system. Final result was a successful stent to the mid left anterior descending with residual TIMI 0 flow in the distal left anterior descending. We returned to the right coronary artery and successfully employed a 4.5 x 16 mm Express sent. At the end of the case, an intra-aortic balloon pump was placed in the left femoral artery sheath, and the patient was sent to the Coronary Care Unit on multiple pressors including epinephrine, vasopressin, Levophed and dopamine. What CPT® coding is reported?