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2 puntos OPERACION: Implantacion de un sistema de desfibrilador automatico implantable transvenoso de doble camara con electrodos. INDICACIONES: Un caballero blanco de 67 anos tiene una miocardiopatia isquemica subyacente significativa con una fraccion de eyeccion Guardar respuesta del 25 por ciento, infartos previos, antecedentes remotos de sincope y un alto riesgo de arritmias ventriculares malignas. Se le realize recientemente una prueba de alternancia de la onda T que fue claramente anormal. Tambien se observo que tuvo episodics de bradicardia en reposo. Cumple los criterios Madit II para la insertion de un desfibrilador automatico implantable transvenoso (DAI). PROCEDIMIENTO: Despues de obtener el consentimiento informado, el paciente fue llevado al laboratorio ambulatorio del hospital en ayunas. Se preparo y cubrio el torax anterior izquierdo de manera esteril. Se administro sedacion intravenosa y anestesia local. Despues de la anestesia local, se realize una incision de 5 cm en el surco deltopectoral izquierdo. Con diseccion roma y cauterizacion, se llevo a traves de la fascia prepectoral. Se identifico la vena cefalica y se ligo distalmente. A traves de la venotomia, se realize un venograma subclavio para proporcionar una hoja de ruta. Luego, los cables auriculares y ventriculares avanzaron dentro del vaso hasta el nivel de la auricula derecha bajo guia fluoroscopica. El cable ventricular se maniobro hasta el tracto de salida del ventriculo derecho y luego a traves del apex del ventriculo derecho donde se fijo activamente. Se demostraron buenos umbrales de detection y estimulacion. El cable se anclo a la fascia prepectoral con sutures separadas de Tycron 2-0. La estimulacion de 10 voltios no resulto en capture diafragmatica. El cable auricular se maniobro hasta la pared auricular derecha anterolateral donde se fijo activamente. Se demostraron buenos umbrales de deteccion y estimulacion. El electrodo se anclo a la fascia prepectoral con puntos separados de Tycron 2-0. La estimulacion de 10 voltios no produjo captura diafragmatica. Se creo un bolsillo subcutaneouson buena hemostasia lograda. Posteriormente, el bolsillo se irrigo con una solucion de bacitracina. El generador se conecto al electrodo y luego se coloco en el bolsillo sin tension en el electrodo. La capa fascial profunda se cerro con puntos separados de Vicryl 2-0. El cierre subcutaneouse realize con puntos continuos de Vicryl 3-0. El cierre subcuticular se realize con puntos continuos de Vicryl 4-0. Se aplicaron tiras esteriles. Se indujo la fibrilacion ventricular con una descarga de onda T. Esta se detecto y se termino con exito con una descarga de 15 julios a ritmo sinusal. La impedancin de alto voltaje fue de 39 ohmios. Se coloco un aposito seco sobre la herida. El paciente regreso al piso en condicion estable sin complicaciones aparentes. Cual de los siguientes codigos CPTO describe con precision el procedimiento.basico resumido en este informe? (OPERATION: Dual chamber transvenous implantable pacing cardioverter-defibrillator system implantation with leads. INDICATIONS: A 67 year-old, white gentleman has significant underlying ischemic cardiomyopathy with EF of 25 percent. prior infarcts, remote history of syncope, and at a high risk for malignant ventricular arrhythmias. He has had a recent T wave alternans test which was clearly abnormal. He has had episodes of resting bradycardia, also noted. He meets Madit II criteria for insertion of a transvenous implantable pacing cardioverter-defibrillator (ICD). PROCEDURE: After informed consent had been obtained, the patient was brought to the outpatient hospital lab in the fasting state. The left anterior chest was prepped and draped in a sterile fashion. Intravenous sedation and local anesthetic were given. After local anesthetic, a 5 cm incision was made at the left deltopectoral groove. With blunt dissection and cautery, this was carried down through the prepectoralis fascia. The cephalic vein was identified and ligated distally. Through the venotomy, a subclavian venogram was performed to provide a roadmap. The atrial and ventricular leads were then advanced into the vessel to the level of the right atrium under fluoroscopic guidance. The ventricular lead was maneuvered to the right ventricular outflow tract, and then through the RV apex where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10-volt pacing did not result in diaphragmatic capture. The atrial lead was maneuvered to the anterolateral right atrial wall where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10-volt pacing did not result in diaphragmatic capture. A subcutaneous pocket was created with good hemostasis achieved. The pocket was subsequently irrigated with solution of Bacitracin. The generator was connected to the lead, and then placed in the pocket with no tension on the lead. The deep fascial layer was closed with interrupted 2-0 Vicryl suture. The subcutaneous closure was made with running 3-0 Vicryl suture. Subcuticular closure was made with running 4-0 Vicryl suture. Steri-strips were applied. Ventricular fibrillation was induced with a T wave shock. This was successfully sensed and terminated with a 15 joule shock to sinus rhythm. High voltage impedance was 39 ohms. Dry dressing was placed over the wound. The patient returned to the floor in stable condition C without apparent complications. Which of the following CPTQ code(s) accurately describes the basic procedure summarized in this report?) A. 33208 O B. 33249, 76000-26 O C 33241, 33243. 33249 New Tab – WaveBrowser OD. 33249

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