Minimally invasive endoscopic epicardial maze procedure


Weston, FL
Best answers
Chronic atrial fibrillation.

Chronic atrial fibrillation.

Minimally invasive endoscopic epicardial maze procedure.

Dr, M.D.

Patient identified in the cath lab, placed on cath lab table in
supine position. Generalized endotracheal tube general anesthesia was
given to the patient. A transesophageal echo was performed that
showed mild to moderate mitral regurgitation, no evidence of any
clot, possibly a 4.8 to 5.2 cm left atrium with the patient in atrial

At this point preoperative antibiotic was given to the patient. All
appropriate monitors were placed including a right internal jugular
introducer, as well as a right radial A-line. After all appropriate
monitors were placed, then prepped and draped in sterile fashion. At
this point we commenced the operation.

Using a knife a 2 cm subxiphoid incision was created into the
peritoneal cavity. Once entering into the peritoneal cavity, two 5 mm
ports were placed in a blunt dissection over my finger on both the
midclavicular lines bilaterally at the periumbilical region. At this
point a 12 mm trocar was inserted in the initial incision site of the
subxiphoid area and CO2 was infused to a pneumoperitoneum of 15 mmHg.

At this point with the patient into steep reverse Trendelenburg
position, using a zero-degree 10 mm scope we were able to identify
the central portion of the diaphragm right over the left lobe of the
liver just medial to the falciform ligament. At this point using
endoscopic scissors and Bovie cautery, we were able to create a 2 cm
incision horizontally in the central tendon of the diaphragm and
enter into the pericardial well. While entering the pericardial sac
approximately 150 cc of serous fluid was able to be evacuated. At
this point once the serous fluid was evacuated, the 12 mm trocar was
removed and the in contact trocar was inserted over a 10 mm scope.
Then the trocar was placed into the posterior aspect of the
pericardial well.

At this point under visualization we were able to identify the
complete left atrium, including the right and left pulmonary veins,
as well as the body of the left atrium. At this point using the
VisiTrax 3 cm RF single unipolar radiofrequency device, 3 cm lesions
were created at 30 watts at 90 seconds each - verifying transmural
ablation throughout the entire left atrium, isolating the posterior
aspect of the inferior right and superior right pulmonary veins as
well as the dome of the left atrium and as well as the left pulmonary
veins both superiorly and inferiorly. All the substrates were cleared
of any electrical circuitry by crossing all of our lesions and making
sure that there were no gaps - gross visualization identifying no
visualization of gaps.

Once all the substrates had been completed in the posterior aspect of
the left atrium, we were able to pass the device over the IVC
cautiously into the anterior pericardial region where we were able to
identify the transverse sinus and the anterior pulmonary veins. We
are able to ablate the transverse sinus and the anterior pulmonary
veins all the way down to the IVC and the oblique sinus.

Once this was completed we turned back to our left pulmonary veins
where we went anteriorly. We were able to pass from ligament of
Marshall all the way down to the inferior pulmonary vein at the
coronary sinus area in the left pulmonary vein area.

Once this was completed we were able to identify completeness of all
our lesions by gross visualization of all the areas that we could
possibly reach through this small incision.

At this point a 24-French Blake drain was inserted into the posterior
pericardial well, emanating through a separate stab incision in the
abdominal secured with Ethibond suture connected to a Pleur-evac.

At this point the opposite 5 mm port incision was closed with 2-0
Vicryl suture and Monocryl. The midline incision was closed using
figure-of-8 interrupted 0 Vicryl sutures. Multiple sutures were
utilized to approximate both the anterior and posterior rectus sheath
as well as the peritoneal cavity. Once this was completed 2-0 Vicryl
was utilized at the subcutaneous tissue level and the skin was closed
with 3-0 Monocryl. Dermabond was used at the skin level.

The patient remained hemodynamically stable. The drainage was

The patient was then left in Dr. R's hands to perform the
endocardial portion of the hybrid maze procedure.

The patient was fully heparinized and remained hemodynamically
stable. Please see Dr. R's dictation for the remainder of the

Can some please help me with this Opt Report, I'm confuse on how to code this one.

Thanks in advance..............


True Blue
Richardson, TX
Best answers
MAZE procedure; 33254 since it's limited involving pulmonary veins and left atrium.

On pg. 174 of AMA 2012 CPT, it defines what's considered 'limited' and 'extensive.'

Also, if this was performed at the time of another procedure, take a look at 33257.