CPT® Code 0516T

1. Indications

The insertion of a wireless cardiac stimulator for left ventricular pacing is indicated for patients who require enhanced cardiac resynchronization therapy (CRT) due to various limitations associated with conventional pacing methods. The following conditions may warrant this procedure:

• Inadequate Cardiac Resynchronization Therapy: Patients who do not achieve effective CRT with traditional external left ventricular pacing methods.
• Anatomical Challenges: Individuals who experience difficulties in the placement of LV pacing wires due to anatomical variations or obstructions.
• Lead Dislodgment: Patients who have had issues with lead dislodgment that may lead to unintended nerve stimulation or ineffective pacing.
• Poor Ventricular Response: Those who demonstrate a poor response to conventional pacing techniques that stimulate the left ventricle externally.
• Need for Repositioning: Patients requiring extraction and repositioning of leads due to complications or inadequate pacing results.

2. Procedure

The procedure for the insertion of a wireless cardiac stimulator for left ventricular pacing involves several detailed steps to ensure proper placement and functionality of the device. The following outlines the procedural steps:

• Step 1: The procedure begins with the creation of a subcutaneous pocket in the left anterior chest for the generator. An incision is made in the mid-axillary line, lateral to the parasternal border, typically within the 4th to 6th intercostal spaces.
• Step 2: Transthoracic echocardiography may be performed to identify an appropriate acoustic window, ensuring that there are no obstructions such as bone or lung tissue that could interfere with the communication between the external transmitter and the implanted electrode.
• Step 3: The transmitter is inserted into the created pocket and secured with sutures. A second incision is made adjacent to the transmitter pocket to create another subcutaneous pocket for the battery.
• Step 4: A tunnel is fashioned between the two pockets to accommodate the connecting cable. The battery is then inserted, connected to the transmitter via the cable, and secured with sutures.
• Step 5: Next, percutaneous vascular access is established in a groin vessel to facilitate the retrograde delivery of the pacing electrode. Using standard catheterization techniques, the pacing electrode is advanced through the sheath to a position within 5-10 mm of the tip.
• Step 6: Multiple locations within the ventricle are tested to identify the optimal site for pacing, ensuring the best electrical pattern is achieved.
• Step 7: The tiny receiver electrode is deployed and anchored into place within the ventricular endocardium. This electrode is designed to detect the right ventricular pacing pulse emitted from the co-implanted conventional pacemaker.
• Step 8: The wireless stimulator transmits ultrasound energy to the implanted receiver electrode, which converts this energy into electrical impulses to pace the ventricles in a synchronized manner.
• Step 9: Finally, the devices are interrogated and programmed to ensure optimal function and synchronization of the pacing system.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any immediate complications related to the surgical incisions and the functionality of the implanted device. Patients may be observed for signs of infection, bleeding, or device malfunction. Follow-up appointments are essential for device interrogation and programming adjustments to ensure optimal pacing performance. Patients may also receive instructions regarding activity restrictions and signs of potential complications that should prompt immediate medical attention. Overall, the recovery process will vary based on individual patient factors and the complexity of the procedure.