CPT® Code 0825T

1. Indications

The transcatheter removal and replacement of a permanent single-chamber leadless pacemaker is indicated in the following scenarios:

• Battery Depletion Replacement is typically performed when the battery life of the existing leadless pacemaker has been depleted, necessitating a new device to maintain cardiac function.

2. Procedure

The procedure for the transcatheter removal and replacement of a leadless pacemaker involves several critical steps to ensure successful implantation and functionality of the new device.

• Step 1: Preparation and Access The groin area is prepped and draped to maintain a sterile environment. Access to the femoral vein is achieved, which serves as the entry point for the procedure.
• Step 2: Guidewire Placement A guidewire is inserted into the femoral vein to facilitate the subsequent placement of the necessary catheters. This step may be aided by venous ultrasound to visualize the anatomy and ensure proper placement.
• Step 3: Sheath Placement and Dilation A femoral sheath is placed over the guidewire, and the vein is dilated incrementally to accommodate the retrieval and delivery catheters that will be used in the procedure.
• Step 4: Retrieval of the Existing Pacemaker The leadless pacemaker retrieval introducer is placed into the vein, and the guidewire is removed. Under fluoroscopic guidance, a retrieval catheter is advanced through the inferior vena cava into the right atrium. The catheter employs a snare technique to capture the existing leadless pacemaker securely.
• Step 5: Withdrawal of the Existing Device Once the pacemaker is captured, the retrieval catheter, along with the pacemaker, is withdrawn from the body, completing the removal of the old device.
• Step 6: Introduction of the Replacement Pacemaker A steerable delivery catheter, which contains an integrated guide catheter and the preloaded replacement leadless pacemaker, is threaded through the introducer and advanced into the right atrium via the inferior vena cava.
• Step 7: Testing and Deployment The new pacemaker is tested by sending signals from an external programmer to ensure it is functioning correctly. Mapping is performed to determine the optimal placement within the atrium, and the leadless pacemaker is deployed and positioned securely against the endocardium.
• Step 8: Final Adjustments The pacemaker is undocked but remains tethered. Pacing capture threshold, impedance, and amplitude sensing tests are conducted to confirm the adequacy of the implantation site. Any necessary repositioning and retesting are performed to ensure optimal performance before the tether is released.
• Step 9: Withdrawal of the Delivery Catheter Finally, the delivery catheter is withdrawn from the body, completing the procedure.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any immediate complications and ensuring the proper functioning of the newly implanted leadless pacemaker. Patients may be observed for signs of infection at the access site, as well as for any arrhythmias or other cardiac issues. Follow-up appointments are typically scheduled to assess the pacemaker's performance and to conduct routine checks, including device interrogation and programming adjustments as necessary. Patients are also educated on activity restrictions and signs of potential complications to watch for during their recovery period.