Download Cath Coding Sheets - UCLA Department of Surgery

1
Part 2
OR
*3 pgs
for
this
form
Patient ID sticker here
STS Registry- Atrial Fibrillation
For Peds & Adult Cardiac Surgery
Fill out
questions 9-16
9. Left atrial size (diameter in cm) ____________cm
volume _______________________ml/m2
Documentation from: Pre op echo / Intra op TEE circle one
10. Presence of a LA thrombus per TTE or TEE
a. No
b. Yes
11. Pulmonary Vein electrical isolation was confirmed
a. No
b. Yes
12. Surgical Arrhythmia Procedure (Check all that apply.)
a. Pulmonary Vein Isolation
b. Pulmonary Vein Isolation with Connecting Lesions
c. Right Atrial Lesion Set (“non-Maze”/”modified Maze”)
d. Right Atrial Full Maze Lesion Set
e. Left Atrial Lesion Set (“non-Maze”/”modified Maze”)
f. Left Atrial Full Maze Lesion Set
13. Left Atrial Appendage Obliteration
a. No
b. Yes
If Yes, choose one:
i. Excision
ii. Exclusion
14. Autonomic ganglia ablation performed
a. No
b. Yes
15. Predominant technique used to create the lesion set
(choose one)
a. Epicardial Application of Energy Source
b. Endocardial Application of Energy Source
c. Incisions (surgical) “cut & sew”
16. Energy sources used
a. Radiofrequency
1. No
2. Yes
If Yes, answer i. and ii.)
i. □Unipolar (Medtronic)
□ Bipolar (Atricure, Medtronic, Estech)
ii. □ Irrigated
□ Non-Irrigated
b. High Intensity Focused Ultrasound
i. No
ii. Yes
If Yes, choose one
a) St. Jude/Epicor
c. Cryoablation
i. No
ii. Yes
If Yes, choose one
a) Nitrous Oxide Cryosurgery (Frigitronic)
b) Argon Cryosurgery (Cryocath)
d. Microwave
i. No
ii. Yes
If Yes, choose one
a) Guidant
b) Boston Scientific
e. Laser
i. No
ii. Yes
f. “Cut and Sew”
i. No
ii. Yes
Satou rev 9/08
OR Form date:___________________________________________
Name of person completing Form:___________________________
MD Signature:___________________________________________
Definition’s see below :Q12/ Q14/Q15

Identify specific lesions on diagram
(see next page)
Q 12. Surgical Arrhythmia Procedure
a. Pulmonary Vein Isolation Box lesion isolating all four
pulmonary veins.
b. Pulmonary Vein Isolation with Connecting Lesions Lesion
around the right pulmonary veins as a pair and left pulmonary
veins as a pair with a connecting lesion between the two pairs.
c. Right Atrial Lesion Set (“non-Maze”/”modified Maze”)
Surgeon includes at a minimum the lesion below and does not
perform the three lesions of a full Maze procedure.
 Right atrial isthmus lesion -Extending from tricuspid
annulus to coronary sinus or IVC
d. Right Atrial Full Maze Lesion Set
Surgeon must perform all the following:

Lesion from SVC to IVC

Lesion from body of right atrium to tricuspid annulus

Lesion from right atrial appendage to tricuspid annulus
e. Left Atrial Lesion Set (“non-Maze”/”modified Maze”)
Surgeon includes at a minimum the lesion below and does not
perform the three lesions of a full Maze procedure.
Isolation of left atrial pulmonary veins
f. Left Atrial Full Maze Lesion Set
Surgeon must perform all the following:
Isolation of all 4 pulmonary veins with
connections between right and left superior
pulmonary veins and right and left inferior
pulmonary veins
Connecting lesion to mitral annulus
Connecting lesion to left atrial appendage
Q 14. Autonomic ganglia ablation
Testing and ablation of autonomic ganglia
Q 15. Predominant technique used to create the lesion set
Epicardial application of energy source: All lesions are
placed from the epicardial surface of the heart regardless of
energy source (radiofrequency, laser, microwave, Cryoablation,
ultrasound). No atriotomy is performed.
Endocardial application of energy source: Some lesions are
placed via atriotomy on the endocardial surface of the heart
regardless of the type of energy used. This technique
predominates, but may be used in combination with epicardial
lesions. This technique may be left atrial or bi-atrial.
Incisions (surgical) “cut & sew”: This technique may be left
atrial or bi-atrial. Full thickness incisions are made and sutured in
the atrium to create the ablation lines. This technique may
include placement of cryolesions at the mitral valve annulus and
the tricuspid valve annulus and the the coronary sinus.
2
See Lesion Diagram to complete this portion of the Data Collection Tool:
Cryo type circle one: Argon or Nitric
Lesion
Confirmed
Ablated
Arrest Heart/Beat Heart
Cryo
MW
Laser
Block
#1
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#2
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#3
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#4
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#5
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#6
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#8
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#9
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#10
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#11
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#12
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#13
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#15
□
□ AH □ BH
□ Epi □ Endo
□ C/S
□
□
□
□
□
□
□
□
#7
#14
LAA Removed
RAA Removed
□ Yes □ No
□ Yes □ No
Choose one APPROACH
Excluded
Excluded
Bipolar Unipolar
Irrigated
□ Yes □ No
□ Yes □ No
RIGHT APPENDAGE
LEFT APPENDAGE
SVC
14
7
15
1
8
12
11
HIFU
Lesion Line Key
1. Pulmonary Vein Isolation
2. Box Lesion
3. Pulmonary Vein Connecting Lesion
4. Posterior Mitral Annular Line
5. Pulmonary Vein Connecting Lesion to Anterior
Mitral Annulus
6. Mitral Valve Cryo Lesion
7. LAA Ligation/Removal
8. Pulmonary Vein to LAA
9. Intercaval Line to Tricuspid Annulus
10. Tricuspid Cryo Lesion
11. Intercaval Line
12. Tricuspid Annular Line to RAA
13. Tricuspid Cryo Lesion
14. RAA Ligation/Removal
15. Intercaval Line towards RAA
3
MITRAL ANNULUS
9
13
cryo
lesion
6
cryo
lesion
CORONARY
SINUS
4 to
posterior
annulus
2
10
TRICUSPID
ANNULUS
CORONARY
ARTERY
7
5
IVC
3
8
Circle surgery type: off pump
Circle Surgery type: Hybrid
Satou rev 9/08
on pump
Robotic
combination
Full Sternotomy
Endoscopic
1
1
3
Ganglia Mapping: See Lesion Diagram to complete this portion of the data collection tool:
Right Side:
Left Side:
PRE
Pos Neg
Pos
POST
Neg
PRE
Pos Neg
POST
Pos Neg
R1
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L1
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R2
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L2
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R3
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L3
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R4
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L4
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R5
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L5
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R6
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L6
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R7
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L7
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R8
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L8
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R9
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L9
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□
R10
□
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L10
□
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R11
□
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R12
□
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R13
□
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□
Satou rev 9/08