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Watchman Procedure

Date: Jun 28, 2013

Question:

For the following procedure, is code 0281T appropriate for the scenario?

PROCEDURAL DETAILS: 1. Accesses: Arterial access was established in the right femoral artery with difficulty. He has a history of right total hip replacement, which appears to have been a complete reconstruction, with femoral head way above the corresponding left femoral head. As such, the usual vasculature anatomy appears to be completely mal aligned.  Nevertheless, after some maneuvering, a 5 French short sheath was inserted into the femoral artery. This sheath was sutured at the conclusion of the case, and there was no hematoma. An attempt was made to obtain venous access on the right, again with difficulty, and ultimately, the left femoral approach was used. The left femoral vein was accessed easily, single puncture, allowing the passage of initially an 8 French short sheath. 2. Left heart catheterization was performed through the Mullins sheath. 3. Left atrial appendage angiography was undertaken through a 5 French pigtail catheter, placed in the mid body of the left atrial appendage, hand injection undertaken on multiple occasions. 4. A transseptal puncture: A Toray wire was advanced through the left femoral venous access, sheath removed, and a Mullens sheath advanced up into the SVC then retracted back to the fossa. This was all under fluoroscopic and echocardiographic guidance. The BRK 1 needle advanced into the Mullins sheath, and with hemodynamic monitoring, as well as echocardiographic guidance, a single transseptal puncture was attained yielding a satisfactory position, and left atrial pressure immediately. Throughout the procedure, ACT was maintained at a satisfactory level. 5. Transseptal delivery of Watchman 27 mm device: The initial TEE measurement under general anesthesia condition yielded 21-22 mm diameter for the LAA, suggesting at 24 mm device. The assessment on the previous day was a maximum of 24 mm. Nevertheless, the 24 mm device was delivered, however, not in a satisfactory position, and was retrieved. Given the suggestion that the 24 mm was not yielding a satisfactory compressions ratio, a 27 mm occluder was then used, and on deployment, it appeared that the delivery system was not intubated enough, most likely to do with the left femoral approach, biasing it superiorly. Nevertheless, a third 27 mm occluder was then used (second device fully deployed). This was after advancement of the pigtail catheter deep into the apex of the left atrial appendage, allowing the delivery sheath to be advanced three quarters into the left atrial appendage. On delivery of this 27 mm occluder, it was deployed satisfactorily, occluding the appendage with minimal/trivial Doppler flow, and a tug test demonstrated satisfactory deployment. At this point, the Watchman device was deployed, and the delivery sheath removed en bloc, and a figure-of-eight suture was placed satisfactorily, attaining hemostasis immediately. PROCEDURAL FINDINGS: 1. Opening aortic pressure 96/61. 2. Left heart catheterization: Mean LA 17 mmHg at the commencement of procedure. 3. TEE: See separate report. RESULTS OF INTERVENTION: Successful closure of left atrial appendage ostium with a 27 mm device with excellent position, anchorage, ceiling, and sizing parameters. CONCLUSION: Successful closure of left atrial appendage with a 27 mm Watchman device with no complications.

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