Pericardial Window

CPT 33025
Approach Minimally Invasive
Add-on / Variant CPTs
  • 32661 — Thoracoscopy with pericardial excision (VATS pericardial window)
  • 32659 — Thoracoscopy with drainage of pericardial sac
Preoperative Diagnosis:

[Malignant / recurrent / large] pericardial effusion — [with / without] tamponade physiology — requiring surgical drainage

Postoperative Diagnosis:

Same

Procedure Performed:

Pericardial window via [subxiphoid / VATS left anterior] approach

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal [/ MAC with local for subxiphoid under unstable conditions]

Indications:

The patient is a [age]-year-old [male/female] with [malignant / idiopathic / post-pericardiotomy / uremic] pericardial effusion [with tamponade physiology / recurrent after pericardiocentesis]. Echocardiogram demonstrates [X]-cm posterior effusion with [right heart collapse / pulsus paradoxus > 10 mmHg / equalization of pressures]. Surgical pericardial window was planned for definitive drainage and tissue diagnosis. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

[X] mL of [serosanguineous / bloody / straw-colored] fluid was drained. The pericardium was [thickened / normal / with nodular implants suggesting malignancy]. The cardiac surface was [normal / with [epicardial tumor implants]]. No tamponade physiology was present following drainage.

Description of Procedure:

[SUBXIPHOID APPROACH:]
The patient was positioned supine. Local anesthesia [/ general] was administered. A [5]-cm midline epigastric incision was made over the xiphoid process. The xiphoid was [excised / retracted]. Dissection was carried posteriorly to the pericardium, which was identified and grasped with Allis clamps. The pericardium was opened with a [#15 blade]. [X] mL of [sanguineous / serosanguineous] fluid was drained. A [2 × 2]-cm window was excised from the anterior pericardium with scissors. The pericardial edges were secured to the wound with sutures to maintain patency. Specimens were sent for culture and cytology.

A [19 Fr Blake / 28 Fr] pericardial drain was placed through the pericardial window [and brought out through a separate stab incision below the wound]. The epigastric wound was closed in layers.

[VATS LEFT ANTERIOR APPROACH:]
The patient was positioned in the right lateral decubitus position. A thoracoscopic approach was used with [2–3] ports through the left chest. The pericardium was identified anterior to the phrenic nerve. A [3 × 3]-cm anterior pericardial window was excised anterior to the phrenic nerve. Fluid was drained and specimens sent. A chest tube was placed for drainage.

Complications:

None

Specimens:

Pericardial fluid — Gram stain, culture, cytology
Pericardial tissue — sent to pathology

Estimated Blood Loss:

Minimal

Drains:

[Pericardial drain / chest tube to water seal]

Disposition:

The patient was taken to the PACU in stable condition. Post-operative echocardiogram confirmed resolution of tamponade physiology. Drain output was monitored. The pericardial drain was removed when output was [<25 mL/day].

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** pericardial effusion [with tamponade]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Pericardial window — subxiphoid/VATS
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/MAC + local

INDICATIONS: .PTAGE-year-old .PTSEX with *** pericardial effusion, *** cm, ***. Echo: ***. Consent obtained.

FINDINGS: *** mL *** fluid drained. Pericardium ***. Cardiac surface ***. Post-drainage: tamponade resolved.

PROCEDURE:
[Subxiphoid: Supine. *** cm epigastric incision. Xiphoid ***. Pericardium identified, grasped, opened. *** mL fluid drained. *** × *** cm window excised. Edges secured. Specimens sent.] [VATS: Right lateral decubitus. *** ports left chest. Pericardium anterior to phrenic nerve. *** × *** cm window excised anterior to phrenic nerve. Fluid drained.] Drain placed. Closed.

EBL: Minimal
SPECIMENS: Pericardial fluid (Gram/cx/cyto); pericardium to path
COMPLICATIONS: None
DISPOSITION: PACU. Echo: tamponade resolved. Drain to output <25 mL/day.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Pericardiectomy (Constrictive Pericarditis)

For constrictive pericarditis, a [median sternotomy / anterolateral thoracotomy] was performed. The pericardium was excised from [phrenic nerve to phrenic nerve] anteriorly and inferiorly to the diaphragm. Calcified pericardium was carefully dissected from the epicardial surface with meticulous hemostasis. [Cardiopulmonary bypass was on standby.] Decortication of the right and left ventricles was performed. Full pericardiectomy for constriction requires removal of pericardium from both ventricles and the great vessels — partial pericardiectomy risks recurrent constriction.

Charting Tips
  • Document pericardial window size explicitly. A window that is too small will seal closed, especially in malignant effusions. A minimum [2 × 2 cm] window should be documented. Securing the pericardial edges to adjacent tissue (pleura or abdominal wall) prevents closure.
  • Document relationship to the phrenic nerve for VATS approach. The phrenic nerve runs along the lateral pericardium and must be avoided. Document 'window excised anterior to the phrenic nerve' to confirm nerve preservation.
  • Document pericardial cytology. For suspected malignant effusions, pericardial fluid cytology and tissue biopsy guide oncologic management and staging. Document that specimens were sent and the working clinical suspicion for malignancy.
Billing Tips
  • 33025 (open pericardial window/subxiphoid approach, 12.87 wRVU) is the standard surgical code for operative pericardial decompression with creation of a drainage window.
  • VATS pericardial window: 32659 (thoracoscopy with pericardial drainage, 11.64 wRVU). Use for VATS approach; 32658 (foreign body/clot removal, 11.42 wRVU) if clot evacuation is the primary indication.
  • Pericardiocentesis (33016, 4.29 wRVU) is for image-guided needle drainage, not a surgical window. If pericardiocentesis is performed but fails and operative window is required, bill only the operative code.
  • Global period is 90 days (major). Pericardial drain management and removal within the global period are bundled.
  • If concurrent procedures are performed (e.g., pleural drainage, thoracoscopy for effusion), bill each separately with appropriate modifiers (-51 or -59) and document each as a distinct procedure.
  • For malignant effusion, document the indication (tamponade physiology vs prophylactic drainage), as this affects ICD-10 coding which drives DRG and payer authorization.
  • Biopsy of pericardium at the time of window creation is bundled. Do not bill separately unless a distinct specimen from a separate site is taken.