# Mitral Valve Repair



## slc112071 (Mar 21, 2013)

Could you please help?  I am in a discussion with the performing physician on this case on what should be billed.  Could you please tell me what you would code?

PREOPERATIVE DIAGNOSIS:  Severe mitral valve regurgitation.
POSTOPERATIVE DIAGNOSIS:  Severe mitral valve regurgitation.
PROCEDURE:
1.  Mitral valve repair with P2 scallop resection and reconstruction as well
as 26 mm Cosgrove annuloplasty, posterior annuloplasty ring.
2.  Right mini-anterolateral thoracotomy approach for minimally invasive
approach.
3.  Exposure of right femoral artery and vein for access.
4.  Cannulation of right femoral vein with a 25 QuickDraw cannula, and
cannulation of the femoral artery with a 19 French Bio-Medicus cannula.
4.  Repair of right femoral artery and vein.
OPERATIVE REPORT:  The patient is a very pleasant patient with unfortunate
severe mitral regurgitation.  She underwent a left heart catheterization by
Dr.  that showed normal coronary arteries.  After appropriate discussion
with her, she agreed to a minimally invasive mitral valve repair.  She was
brought to the operating room.  She was placed in supine position.  After
appropriate timeout, she underwent endotracheal intubation and general
anesthesia.  Appropriate invasive monitoring lines were placed by Dr. 
 and the anesthesia team.  She was prepped and draped.  A Foley
catheter was placed by the nursing team.  She was positioned with a 30 degree
bump elevating her right side, tucking her arms and keeping her arm slightly
away from her right chest and padding her appropriately.
She was prepped and draped.  I made an incision in her 4th intercostal space
by elevating her breasts.  Subcutaneous tissue and muscle was dissected with
electrocautery.  The fourth intercostal space was entered after the right lung
was placed down.  She had a double lumen tube by the anesthesia team.
I opened her right femoral groin in a small transverse incision, dissecting
down to the right femoral artery and vein and exposing them; 10,000 units of
heparin was given.  A pursestring was placed in the right femoral artery and
vein.  They were cannulated with a 25 QuickDraw cannula that was confirmed in
the right atrium on transesophageal echo and a 19 French Bio-Medicus arterial
cannula.  Once the chest was opened, a subcutaneous Alexis retractor was
placed as well as a minimally invasive Edwards retractor.  Cardiopulmonary
bypass was instituted.  A space was made beneath the aorta and a transthoracic
clamp was placed.  An antegrade cardioplegia long needle was placed for
antegrade cardioplegia.  Crossclamp was placed and antegrade cardioplegia was
given.  The heart did not arrest despite the aorta being distended; it was
unclear why.  The crossclamp was removed.  I started to cool her down to 28
degrees, planning to have her fibrillate and do this under cold fib.  In the
meantime, once she fibrillated, I opened the left atrium and the intraatrial
groove.  Once I opened the interatrial groove, there was a lot of blood flow
back despite a drop sucker.  Despite the drop sucker, the drainage might not
have been adequate.  I placed an extra cannula in the right atrium towards the
and that helped her drainage dramatically and the field was
dry.  I was then able to see and we felt that might be the reason the heart
was not arresting.  I placed the crossclamp again and gave antegrade
cardioplegia and the heart arrested well this time very quickly.
I opened the remainder of the left atrium and I had a very
clear view of the mitral valve.
There was a myxomatous Barlow's valve with a large P2 segment.  I placed
stitches from trigone to trigone with 2-0 Tycron sutures, and I then elevated
the valve to the field.  I resected a good portion of P2 in a triangular
fashion.  I reconstructed it with 5-0 Gore-Tex suture.  I then sized my
anterior leaflet to a 26 mm size Cosgrove annuloplasty posterior ring.  I
placed the ring through the sutures and tied them all down.  I then reinforced
the ring to the atrium with several 3-0 Prolene pledgeted sutures for
buttressing it to avoid migration.  I then closed the P1/P2 commissure, which
was open.  I then tested the valve with multiple tests and it tested well with
no leak at all.  I was happy with the repair and I closed my atrium with
pledgeted 3-0 Prolene.  Once I did that, the head was placed down.  I deaired
the ventricle and I removed my crossclamp.  We had been starting to rewarm to
normothermia.  Once we were warm to normothermia, I placed an atrial pacing
wire.  We paced at 80 and we weaned off cardiopulmonary bypass successfully
with a very small dose of Levophed.
Dr. came to the room and I inspected the echocardiogram.  We had
trace MR after the repair, and the ventricular function was normal.  Once off
cardiopulmonary bypass, protamine was given and the venous cannula was removed
from the groin.  I checked all my sites in the chest for hemostasis, including
my atrial suture line as well as my antegrade cardioplegia site, which I
removed and oversewn with pledgeted prolenes.  Once I was happy with
hemostasis in the chest, I placed two 19-French Blake's.  I removed the venous
and arterial from the groin and I repaired the femoral arterial site with 5-0
Prolene as well as the femoral venous side.  The chest was closed with #2
heavy Vicryl sutures and subcutaneous tissue with 0 Maxon and 2-0 Maxon, the
skin with subcuticular stitch.  The wound was covered with a sterile silver
dressing.  The Blake's were hooked to suction at -20 cm of water, and the
groin was closed with 2-0 Maxon, the skin with 3-0 Monocryl, and staples and a
vac placed on the groin, after it was closed, for extra protection.  The
patient was then woken up and then taken to the Intensive Care Unit in
hemodynamically stable condition.  Sponge count and instrument count were
correct at the end of the case.


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## conleyclan (Mar 21, 2013)

I had asked STS regarding the different approach/and bypass placement for the MVR.  This was their response: Currently there is no code differential for the type of exposure associated with the the mitral valve repair, so you would just identify the code for the repair, and report that one. The bypass is included in the repair, so even though he accomplished it using a different technique, it is still valued into the repair procedure.  

I would bill yours as 33427 and add the 22 modifier.   Your dr had difficultcy getting the patient onto bypass.


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