jtb57chevy
Networker
- Messages
- 75
- Best answers
- 0
Need help with coding this procedure. The only code I have right now is 33265. Am I missing anything? ANY Help will be greatly appreciated.
PREOPERATIVE DIAGNOSIS: Persistent atrial fibrillation.
POSTOPERATIVE DIAGNOSIS: Persistent atrial fibrillation.
OPERATION: Mini-MAZE procedure with bilateral pulmonary vein isolation with RF ablation, bilateral ganglionic plexi interrogation ablation and left atrial appendage closure via bilateral mini-thoracotomies and video assisted thoracoscopy.
INDICATIONS/FINDINGS: This is a very pleasant patient whose history goes back three years ago when patient had an atrial flutter ablation by Dr. XXX. Now patient has had atrial fibrillation in spite of being on medicine including Coumadin and Tikosyn, having multiple episodes a week, lasting fifteen to twenty-four hours. Patient has had intermittent atrial fibrillation for six to seven years. CT of heart showed no abnormalities in the pulmonary veins.
OPERATIVE FINDINGS: No atrial thrombus, no mitral regurgitation, ganglionic plexus right 2 was positive, this was ablated. On the left side 3 and 10 were positive and these were ablated. Bidirectional block was obtained. Atrial appendage was closed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position on the operating room table where general anesthesia was induced via double lumen endotracheal tube after physiologic monitoring lines were placed. The patient was then placed in the left lateral decubitus position, right chest up, back at approximately 60 degrees, tilted back, axillary roll, arms on an arm board, bean bag, pillow between the hips, compression device on both legs, both lower legs folded, taped at the hips. The right chest was prepped and draped in the usual sterile fashion. Approximately fifth interspace port was introduced. Then, a mini-thoracotomy was placed at the third interspace, mid axillary line. The phrenic nerve was then identified through its entire course. Anterior to it the pericardium was opened from the diaphragm to the level of the aorta. Traction sutures were placed through the posterior chest wall. Dissection was carried out between the pulmonary artery and the right pulmonary vein as well as below the inferior pulmonary vein and the inferior vena cava. With this accomplished, dissector was introduced and placed around the veins. It passed without difficulty. Red rubber catheter was passed. It was hooked up to the Atricure clamp which was passed without difficulty. The clamp was in position. Sensing was done on the pulmonary veins which were very active. Then, the clamp was applied five times on the right and then it was sensed and paced through the pulmonary veins and there was bidirectional block. The ganglionic plexus was interrogated and R2 was positive. This was ablated and was negative. With this accomplished the clamp was removed. Pacing wire was placed on the pericardium over the atrium. Using a mixture of Marcaine and Lidocaine an intercostal block was accomplished. On-Q system was placed in the pleural space and one in the mini-thoracotomy incision through separate stab wounds and secured with silk. A Blake drain was placed through inferior stab wound side ports, secured with silk. The wounds were closed with Vicryl and subcuticular of 4-0 Vicryl and Dermabond to the skin. The lung was re-expanded on the right. The patient was placed in the left down position at 90 degrees, axillary roll, arms on arm board, head supported, lower legs folded, pillow between the legs, compression device, bean bag and tape at the hips. The left chest was prepped and draped in the usual sterile fashion. Going somewhat posterior the fifth interspace was opened. Camera port was introduced. A mini-thoracotomy was placed at approximately fourth space, somewhat more posterior. This was opened. As well as on the other side, a plastic retractor was used. The phrenic nerve was carefully identified. The hilum was dissected and the pericardium was then opened posterior to the phrenic nerve to the level of the pulmonary artery. This was retracted posteriorly with stay sutures. Dissection was carried out between the pulmonary artery and left inferior pulmonary vein. Then, the ligament of Marshall was ablated using bipolar cautery. Then, the dissector was placed through a separate posterior incision, approximately fifth interspace, placed into the pericardium inferiorly and then around the pulmonary veins, following the red rubber catheter. This was done without difficulty. There was a good atrial transmission signal. The veins were then ablated times six. There was no ablated pace from the pulmonary veins or given by direction block. The ganglionic plexi on the left were interrogated, 3 and 10 were positive. These were ablated and then were not positive. The clamp was then removed. The left atrial appendage was then isolated. Then, EZ-45 staples were placed around the base of it without difficulty. With this done the intercostal block was secured and ½ Marcaine and ½ Lidocaine. Retention sutures were removed. Blake drain was placed through the inferior posterior stab wound and secured with silk. Two On-Q systems were placed, one in the incision of the mini-thoracotomy and one in the subpleural space and secured with silk. With adequate hemostasis the wound was closed using running sutures of Vicryl, subcuticular stitch in the dermis and Dermabond to the skin. Chest tube sites were also closed with 4-0 Vicryl and Dermabond to the skin. Sterile dressings were applied. All needle, sponge and instrument counts were found to be correct. The patient was then placed in the supine position, extubated and taken to the recovery room.
PREOPERATIVE DIAGNOSIS: Persistent atrial fibrillation.
POSTOPERATIVE DIAGNOSIS: Persistent atrial fibrillation.
OPERATION: Mini-MAZE procedure with bilateral pulmonary vein isolation with RF ablation, bilateral ganglionic plexi interrogation ablation and left atrial appendage closure via bilateral mini-thoracotomies and video assisted thoracoscopy.
INDICATIONS/FINDINGS: This is a very pleasant patient whose history goes back three years ago when patient had an atrial flutter ablation by Dr. XXX. Now patient has had atrial fibrillation in spite of being on medicine including Coumadin and Tikosyn, having multiple episodes a week, lasting fifteen to twenty-four hours. Patient has had intermittent atrial fibrillation for six to seven years. CT of heart showed no abnormalities in the pulmonary veins.
OPERATIVE FINDINGS: No atrial thrombus, no mitral regurgitation, ganglionic plexus right 2 was positive, this was ablated. On the left side 3 and 10 were positive and these were ablated. Bidirectional block was obtained. Atrial appendage was closed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position on the operating room table where general anesthesia was induced via double lumen endotracheal tube after physiologic monitoring lines were placed. The patient was then placed in the left lateral decubitus position, right chest up, back at approximately 60 degrees, tilted back, axillary roll, arms on an arm board, bean bag, pillow between the hips, compression device on both legs, both lower legs folded, taped at the hips. The right chest was prepped and draped in the usual sterile fashion. Approximately fifth interspace port was introduced. Then, a mini-thoracotomy was placed at the third interspace, mid axillary line. The phrenic nerve was then identified through its entire course. Anterior to it the pericardium was opened from the diaphragm to the level of the aorta. Traction sutures were placed through the posterior chest wall. Dissection was carried out between the pulmonary artery and the right pulmonary vein as well as below the inferior pulmonary vein and the inferior vena cava. With this accomplished, dissector was introduced and placed around the veins. It passed without difficulty. Red rubber catheter was passed. It was hooked up to the Atricure clamp which was passed without difficulty. The clamp was in position. Sensing was done on the pulmonary veins which were very active. Then, the clamp was applied five times on the right and then it was sensed and paced through the pulmonary veins and there was bidirectional block. The ganglionic plexus was interrogated and R2 was positive. This was ablated and was negative. With this accomplished the clamp was removed. Pacing wire was placed on the pericardium over the atrium. Using a mixture of Marcaine and Lidocaine an intercostal block was accomplished. On-Q system was placed in the pleural space and one in the mini-thoracotomy incision through separate stab wounds and secured with silk. A Blake drain was placed through inferior stab wound side ports, secured with silk. The wounds were closed with Vicryl and subcuticular of 4-0 Vicryl and Dermabond to the skin. The lung was re-expanded on the right. The patient was placed in the left down position at 90 degrees, axillary roll, arms on arm board, head supported, lower legs folded, pillow between the legs, compression device, bean bag and tape at the hips. The left chest was prepped and draped in the usual sterile fashion. Going somewhat posterior the fifth interspace was opened. Camera port was introduced. A mini-thoracotomy was placed at approximately fourth space, somewhat more posterior. This was opened. As well as on the other side, a plastic retractor was used. The phrenic nerve was carefully identified. The hilum was dissected and the pericardium was then opened posterior to the phrenic nerve to the level of the pulmonary artery. This was retracted posteriorly with stay sutures. Dissection was carried out between the pulmonary artery and left inferior pulmonary vein. Then, the ligament of Marshall was ablated using bipolar cautery. Then, the dissector was placed through a separate posterior incision, approximately fifth interspace, placed into the pericardium inferiorly and then around the pulmonary veins, following the red rubber catheter. This was done without difficulty. There was a good atrial transmission signal. The veins were then ablated times six. There was no ablated pace from the pulmonary veins or given by direction block. The ganglionic plexi on the left were interrogated, 3 and 10 were positive. These were ablated and then were not positive. The clamp was then removed. The left atrial appendage was then isolated. Then, EZ-45 staples were placed around the base of it without difficulty. With this done the intercostal block was secured and ½ Marcaine and ½ Lidocaine. Retention sutures were removed. Blake drain was placed through the inferior posterior stab wound and secured with silk. Two On-Q systems were placed, one in the incision of the mini-thoracotomy and one in the subpleural space and secured with silk. With adequate hemostasis the wound was closed using running sutures of Vicryl, subcuticular stitch in the dermis and Dermabond to the skin. Chest tube sites were also closed with 4-0 Vicryl and Dermabond to the skin. Sterile dressings were applied. All needle, sponge and instrument counts were found to be correct. The patient was then placed in the supine position, extubated and taken to the recovery room.