TWilliam2019
Guru
Would i only code 33266?
1. Subxiphoid pericardial window with posterior left atrial wall ablation for the management of persistent atrial fibrillation (convergent procedure)
2. Left VATS with pericardiotomy and exclusion of left atrial appendage with a 40 mm clip
3. Fluoroscopy with intraoperative visualization and interpretation
4. TEE
Procedure in detail:
The patient had her history and physical updated prior to the procedure. The patient was then transferred to the operating suite and placed on the operating table where she underwent general anesthesia with double-lumen endotracheal intubation. Monitoring lines and devices were placed by anesthesia. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
Fluoroscopy was then brought in and the esophageal temperature probe was placed. Under real-time fluoroscopic visualization, the radiopaque marker of the esophageal temperature probe was positioned approximately 2 vertebral spaces caudal to the carina. Once this was completed, the patient was prepped and draped in usual sterile fashion using DuraPrep solution.
A small vertical incision was made over the xiphoid process. The deep dermis and subcutaneous tissues were divided with electrocautery. The xiphoid was then identified and found to be a bifid xiphoid process. Using a combination of electrocautery as well as sharp curved Mayo scissors, the xiphoid process was excised. The sternum and costochondral margin was retracted by Mr. X using an Army-Navy. The anterior mediastinal soft tissues were divided with electrocautery. The pericardium was identified and the horizontal pericardiotomy was created using electrocautery and further extended with Metzenbaum scissors.
The convergent cannula was then placed within the pericardial space. The VATS camera was also placed within the cannula and advanced into the pericardial space with normal anatomy being identified. Initially, the inferior vena cava, right pulmonary veins, as well as the left pulmonary veins were identified. At the initiation of the procedure, the esophageal temperature probe measured roughly 36 degrees. The epicardial ablation device was placed near the right superior pulmonary vein. Suction was applied to the posterior left atrial wall and the pericardial well was filled with saline. The ablation line was then created. This was repeated in a serial fashion advancing the epicardial ablation instrument laterally towards the left superior pulmonary vein. Once this was completed, the ablation lines were initiated along the right inferior pulmonary vein and carried laterally to the left inferior pulmonary vein. Areas of the posterior left atrial wall were then inspected with any gap lesions treated. Finally, a small triangular isthmus between the IVC extending over to the coronary sinus was treated with epicardial ablation.
The patient tolerated this portion of the procedure well. A total of 16 ablation applications were placed on the posterior left atrial wall. The VATS camera and convergent cannula were removed. A small stab incision was created inferiorly. The Blake drain was then tunneled and placed into the pericardial space along the diaphragm. The soft tissues were injected with half percent Marcaine for local anesthesia. The fascia was reapproximated with interrupted 0 Ethibond. The soft tissues were reapproximated with 2-0 Vicryl. The skin was closed with 4-0 Monocryl in running subcuticular manner. Dermabond was placed over the wound.
Left breast was then retracted. A small incision was made in the lateral chest wall, roughly the fifth intercostal space, mid axillary line. Using an Optiview technique, a 5 mm port and VATS camera was advanced into the left pleural space. Once access was achieved, the left pleural space was insufflated with carbon dioxide to a pressure of 10 mmHg. At approximately the third or fourth interspace, anterior axillary line, a 5 mm port was placed under direct visualization. Finally, a 12 mm port was placed inferiorly near the costophrenic angle.
The electrocautery hook was then used to create a pericardiotomy posterior to the phrenic nerve. Great care was taken to preserve the phrenic nerve. This was further extended cephalad and caudally using the harmonic scalpel. The left atrial appendage was identified and found to be quite a large appendage with the apex extending posterior to the main pulmonary artery in the transverse groove. A 40 mm AtriCure clip was chosen for exclusion. Under real-time TEE visualization, the clip was advanced into the left pleural space and carefully guided into the pericardial space. Using the VATS peanut dissectors, the left atrial appendage was teased into the left atrial appendage clip and the clip was closed at its base. TEE confirmed full closure of the left atrial appendage. At this point, the cord was pulled and the clip was released to finalize closure of the left atrial appendage. The delivery device was then removed.
A second Blake drain was then placed within the left pleural space. The ports were removed under direct visualization and found to be hemostatic. The soft tissues were infiltrated with half percent Marcaine for local anesthesia. The left lung was ventilated with full reexpansion. The VATS camera was then removed. Soft tissues were reapproximated with 2-0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound. The patient tolerated the procedure well, was extubated, then transferred to recovery.
1. Subxiphoid pericardial window with posterior left atrial wall ablation for the management of persistent atrial fibrillation (convergent procedure)
2. Left VATS with pericardiotomy and exclusion of left atrial appendage with a 40 mm clip
3. Fluoroscopy with intraoperative visualization and interpretation
4. TEE
Procedure in detail:
The patient had her history and physical updated prior to the procedure. The patient was then transferred to the operating suite and placed on the operating table where she underwent general anesthesia with double-lumen endotracheal intubation. Monitoring lines and devices were placed by anesthesia. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
Fluoroscopy was then brought in and the esophageal temperature probe was placed. Under real-time fluoroscopic visualization, the radiopaque marker of the esophageal temperature probe was positioned approximately 2 vertebral spaces caudal to the carina. Once this was completed, the patient was prepped and draped in usual sterile fashion using DuraPrep solution.
A small vertical incision was made over the xiphoid process. The deep dermis and subcutaneous tissues were divided with electrocautery. The xiphoid was then identified and found to be a bifid xiphoid process. Using a combination of electrocautery as well as sharp curved Mayo scissors, the xiphoid process was excised. The sternum and costochondral margin was retracted by Mr. X using an Army-Navy. The anterior mediastinal soft tissues were divided with electrocautery. The pericardium was identified and the horizontal pericardiotomy was created using electrocautery and further extended with Metzenbaum scissors.
The convergent cannula was then placed within the pericardial space. The VATS camera was also placed within the cannula and advanced into the pericardial space with normal anatomy being identified. Initially, the inferior vena cava, right pulmonary veins, as well as the left pulmonary veins were identified. At the initiation of the procedure, the esophageal temperature probe measured roughly 36 degrees. The epicardial ablation device was placed near the right superior pulmonary vein. Suction was applied to the posterior left atrial wall and the pericardial well was filled with saline. The ablation line was then created. This was repeated in a serial fashion advancing the epicardial ablation instrument laterally towards the left superior pulmonary vein. Once this was completed, the ablation lines were initiated along the right inferior pulmonary vein and carried laterally to the left inferior pulmonary vein. Areas of the posterior left atrial wall were then inspected with any gap lesions treated. Finally, a small triangular isthmus between the IVC extending over to the coronary sinus was treated with epicardial ablation.
The patient tolerated this portion of the procedure well. A total of 16 ablation applications were placed on the posterior left atrial wall. The VATS camera and convergent cannula were removed. A small stab incision was created inferiorly. The Blake drain was then tunneled and placed into the pericardial space along the diaphragm. The soft tissues were injected with half percent Marcaine for local anesthesia. The fascia was reapproximated with interrupted 0 Ethibond. The soft tissues were reapproximated with 2-0 Vicryl. The skin was closed with 4-0 Monocryl in running subcuticular manner. Dermabond was placed over the wound.
Left breast was then retracted. A small incision was made in the lateral chest wall, roughly the fifth intercostal space, mid axillary line. Using an Optiview technique, a 5 mm port and VATS camera was advanced into the left pleural space. Once access was achieved, the left pleural space was insufflated with carbon dioxide to a pressure of 10 mmHg. At approximately the third or fourth interspace, anterior axillary line, a 5 mm port was placed under direct visualization. Finally, a 12 mm port was placed inferiorly near the costophrenic angle.
The electrocautery hook was then used to create a pericardiotomy posterior to the phrenic nerve. Great care was taken to preserve the phrenic nerve. This was further extended cephalad and caudally using the harmonic scalpel. The left atrial appendage was identified and found to be quite a large appendage with the apex extending posterior to the main pulmonary artery in the transverse groove. A 40 mm AtriCure clip was chosen for exclusion. Under real-time TEE visualization, the clip was advanced into the left pleural space and carefully guided into the pericardial space. Using the VATS peanut dissectors, the left atrial appendage was teased into the left atrial appendage clip and the clip was closed at its base. TEE confirmed full closure of the left atrial appendage. At this point, the cord was pulled and the clip was released to finalize closure of the left atrial appendage. The delivery device was then removed.
A second Blake drain was then placed within the left pleural space. The ports were removed under direct visualization and found to be hemostatic. The soft tissues were infiltrated with half percent Marcaine for local anesthesia. The left lung was ventilated with full reexpansion. The VATS camera was then removed. Soft tissues were reapproximated with 2-0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound. The patient tolerated the procedure well, was extubated, then transferred to recovery.