Hi - I am fairly new to some Cardio-Thoracic procedures- 2 part question- Is the Aortic exploration included in the primary procedure (Pericardial Window); and do I use a modifier 52 or 53 in this case as the provider stopped the procedure due to the patient's High Risk of continue surgery.. 33025 CPT
Operation
1) Mini-sternotomy
2) Pericardial window and drainage of pericardial effusion/pleural effusion
3) Aortic Exploration
Findings
Severe calcification of ascending aorta, prohibitive for cross clamping
Specimen(s)
None
Complications
Case aborted due to prohibitive risk Technique
After explained the risks benefits associated patient sure he understood the risks and benefits, informed stems obtained. After obtaining informed consent patient brought the operating theater. He is was the operative table supine position. General endotracheal anesthesia was induced. A right radial arterial line was placed. A right central venous line was placed through the Swan-Ganz catheter was placed. A transesophageal echocardiography probe was placed and a transesophageal echocardiogram was performed showing severe aortic stenosis, 2+ aortic insufficiency, no evidence of calcification of the ascending aorta, EF of 60%. After performing appropriate timeout the procedure was commenced.
A 6 cm incision was made from the angle of Louis down to the third intercostal space. Bovie electrocautery was used to dissect down to the level of the sternum. The fascial test of the sternum was divided. The sternoclavicular ligament was divided using Bovie electrocautery. Using a reciprocating saw, a sternotomy was performed from manubrium down to the fourth intercostal space and teed off at the fourth intercostal space. Hemostasis was obtained using Bovie regarding the periosteum and bone wax and the marrow. A Finochietto chest retractor was inserted and the chest wall was spread. Bovie electrocautery was used to divide the pericardial fat pad. Heparinization was given. The pericardium was marsupialized to the skin using 0 Vicryl pop-off sutures. The right pleura was opened. A moderate pleural effusion was drained from the right pleural space. This was serous in nature. A window of pericardium was opened to the right pleural space. A small to moderate pericardial effusion was drained from the pericardial space. The aorta was palpated and explored and noted to be diffusely calcified with no safe space for cannulation or crossclamping. At this point the decision was made that the risk of proceeding with the surgery outweigh the benefits obtained from the surgery. I spoke to the patient's son and decided to abort the case. A 28 French straight chest tube was placed through separate incision into the right pleural space and secured with a 0 silk suture. A 24 French Blake chest tube was inserted into the right pleural space and snaked into the pericardial space and secured with a 0 silk suture. Hemostasis was obtained. Protamine was given. The sternum was closed using 3 interrupted double wires. Hemostasis was checked prior to tightening. The wires were tightened. The incision was closed in the standard 3 layers using 0 PDS in the fascia, 2-0 Vicryl in a running continuous fashion in the dermal layer, and staples in the skin. Patient tolerated procedure well be transferred CVRU for further care.
Thank you for your guidance/help!
Operation
1) Mini-sternotomy
2) Pericardial window and drainage of pericardial effusion/pleural effusion
3) Aortic Exploration
Findings
Severe calcification of ascending aorta, prohibitive for cross clamping
Specimen(s)
None
Complications
Case aborted due to prohibitive risk Technique
After explained the risks benefits associated patient sure he understood the risks and benefits, informed stems obtained. After obtaining informed consent patient brought the operating theater. He is was the operative table supine position. General endotracheal anesthesia was induced. A right radial arterial line was placed. A right central venous line was placed through the Swan-Ganz catheter was placed. A transesophageal echocardiography probe was placed and a transesophageal echocardiogram was performed showing severe aortic stenosis, 2+ aortic insufficiency, no evidence of calcification of the ascending aorta, EF of 60%. After performing appropriate timeout the procedure was commenced.
A 6 cm incision was made from the angle of Louis down to the third intercostal space. Bovie electrocautery was used to dissect down to the level of the sternum. The fascial test of the sternum was divided. The sternoclavicular ligament was divided using Bovie electrocautery. Using a reciprocating saw, a sternotomy was performed from manubrium down to the fourth intercostal space and teed off at the fourth intercostal space. Hemostasis was obtained using Bovie regarding the periosteum and bone wax and the marrow. A Finochietto chest retractor was inserted and the chest wall was spread. Bovie electrocautery was used to divide the pericardial fat pad. Heparinization was given. The pericardium was marsupialized to the skin using 0 Vicryl pop-off sutures. The right pleura was opened. A moderate pleural effusion was drained from the right pleural space. This was serous in nature. A window of pericardium was opened to the right pleural space. A small to moderate pericardial effusion was drained from the pericardial space. The aorta was palpated and explored and noted to be diffusely calcified with no safe space for cannulation or crossclamping. At this point the decision was made that the risk of proceeding with the surgery outweigh the benefits obtained from the surgery. I spoke to the patient's son and decided to abort the case. A 28 French straight chest tube was placed through separate incision into the right pleural space and secured with a 0 silk suture. A 24 French Blake chest tube was inserted into the right pleural space and snaked into the pericardial space and secured with a 0 silk suture. Hemostasis was obtained. Protamine was given. The sternum was closed using 3 interrupted double wires. Hemostasis was checked prior to tightening. The wires were tightened. The incision was closed in the standard 3 layers using 0 PDS in the fascia, 2-0 Vicryl in a running continuous fashion in the dermal layer, and staples in the skin. Patient tolerated procedure well be transferred CVRU for further care.
Thank you for your guidance/help!