maryir
Networker
I am lost - Please review the operative report below. I've read this note, seems like, millions of times now and it's just over my head.
The surgeon charged: CPT's 33863 & 33463 with
Diagnosis codes A41.9 & R65.20
I was thinking: CPT's 33863 & 33463
Diagnosis codes T82.6XXD, G06.0, Z95.2
Everything seems to be bundled. Nothing was started really or nothing was finished? Add 22 modifiers??
ANY help would be very helpful.
PREOPERATIVE DIAGNOSES:
1. Prosthetic valve endocarditis
2. Prior mechanical aortic valve and ascending aorta replacement with hemiarch
3. Septic emboli to brain
POSTOPERATIVE DIAGNOSES:
1. Prosthetic valve endocarditis
2. Prior mechanical aortic valve and ascending aorta replacement with hemiarch
3. Septic emboli to brain
4. Tricuspid valve endocarditis
5. Membranous VSD secondary to endocarditis
OPERATION PERFORMED:
1. Redo sternotomy
2. Right axillary artery cannulation with perfusion limb (8mm Dacron graft)
3. Redo aortic root replacement with a 24mm aortic homograft, on cardiopulmonary bypass under circulatory arrest with antegrade cerebral perfusion
4. Reimplantation of right and left coronary artery buttons
5. Reconstruction of main pulmonary artery with bovine pericardial patch
6. Repair of perimembranous ventricular septal defect
7. Debridement of tricuspid valve
ANESTHESIA: General endotracheal
COMPLICATIONS: Intractable surgical bleeding leading to death
FINDINGS:
1. Extensive infection involving ascending graft and aortic annulus. Pus also noted to be emanating from transverse sinus.
2. Perimembranous VSD noted from LV outflow tract into RV
3. Little remaining aortic annulus after debridement. Homograft sutured deep into outflow tract but sutures did not hold, bleeding could not be controlled.
4. Vegetation noted underneath the septal leaflet of the tricuspid valve, debrided successfully and not requiring repair.
IMPLANTS:
1. 8 mm Hemashield platinum knitted double velour vascular graft, used as an axillary perfusion limb.
2. 24mm aortic homograft, used for aortic root reconstruction
3. Bovine pericardial patch, used for reconstruction of main PA
DRAINS:
32 Fr straight x2 in right and left pleural spaces, 32 Fr right angle and axiom chest tubes within the mediastinum. Wound vac placed over chest.
WIRES:
1. Unipolar ventricular pacing wires x1
CARDIOPULMONARY BYPASS DATA:
1. Total cardiopulmonary bypass time: 391 minutes.
2. Total cross-clamp time: 331 minutes. Circ arrest time 17 minutes.
3. Lowest temperature achieved: 28 degrees Celsius.
INDICATIONS FOR PROCEDURE:
with a history of a prior mechanical aortic valve replacement and ascending aorta replacement with hemiarch for a bicuspid aortic valve in 2011. She presented with altered mental status and back pain, and was eventually found to have MSSA endocarditis. TEE demonstrated findings concerning for aortic annular abscess surround the mechanical valve, and additional echodensity surrounding the ascending aortic graft concerning for infection. She was noted to have a widening PR interval, and more frequent rigors. Thus, she was consented for emergency redo aortic root replacement with homograft without undergoing preoperative catheterization. The risks and benefits of the operation, including a risk of death, was discussed with the patient and she wished to proceed.
PROCEDURE IN DETAIL: The patient was taken to the operating room and laid supine on the operating table. General endotracheal anesthesia was induced after a bilateral radial arterial lines were placed. A single-lumen endotracheal tube was placed. Both a triple-lumen as well as a Cordis catheter were placed in the patient's right internal jugular vein. A Swan-Ganz catheter was floated through a Cordis catheter. A transesophageal echocardiographic probe was positioned. A Foley catheter was placed. The patient was then prepped and draped from the chin to the thighs in the standard sterile fashion. Perioperative antibiotics were administered. A surgical time-out procedure was performed.
The patient's previous sternal incision was re-incised, and previously placed sternal wires were exposed. The wires were divided, and an oscillating saw was used to divide the anterior and posterior tables of the sternum. The old wires were removed and entry was gained into the patient's chest without injury. Dense adhesions were encountered following division of the sternum. With tedious dissection, we were able to expose all right-sided heart structures as well as the left ventricle. Residual pericardium was dissected free from the heart, and a pericardial well was created. The innominate vein, and innominate artery were dissected free from surrounding tissues. The aorta was mobilized; dense adhesions were encountered at the level of the aorta/pulmonary artery junction, and some of these adhesions were left for dissection until cardiopulmonary bypass was induced.
The patient was systemically heparinized. We then made an incision along the right deltopectoral groove. The subcutaneous tissue was divided with electrocautery, and the cephalic vein was located and reflected laterally. We then exposed the axillary artery and gained proximal and distal control with vessel loupes. The proximal axillary artery was then clamped and the distal vessel loupes were snared. An arteriotomy was performed with an 11 blade and was extended with Wecks. An 8 mm vascular graft was anastomosed to the axillary artery in an end-to-side fashion with a running 5-0 prolene. This was de-aired and hemostasis was achieved. This was connected to the cardiopulmonary bypass circuit.
A 4-0 Prolene pursestring was placed in the superior vena cava, which was then cannulated with a metal-tip right-angle venous cannula. A 4-0 Prolene pursestring was placed in the inferior free wall of the right atrium, and the inferior vena cava was cannulated with a straight venous cannula. These 2 were then connected to the bypasscircuit. Next, a small pursestring was placed at the base of the right atrial appendage near the AV groove. A retrograde cardioplegia catheter was placed through this. Finally, an antegrade root vent was placed in the proximal ascending aorta and secured with 4-0 Prolene. We freed the SVC and IVC circumferentially with blunt dissection and placed caval tapes.
After ensuring an adequate ACT was obtained, the patient was placed on cardiopulmonary bypass via the innominate artery graft and the right atrial cannula. Active cooling was initiated to 28 degrees Celsius. A left ventricular vent was placed via the right superior pulmonary vein. We continued mobilization of the ascending aorta and the aortic root, in particular, mobilizing the aorta from the pulmonary artery, and we were able to obtain circumferential control around the aorta. We further mobilized the aortic root, taking down adhesions to near the level of both the left and right coronary buttons. At this point, the patient was placed in Trendelenburg position. An aortic cross-clamp was applied. Retrograde cardioplegia was administered to achieve a diastolic arrest. A left ventricular temperature was used to ensure adequate myocardial protection. The patient was redosed with cardioplegia every 10 and 20 minutes to ensure appropriate myocardial protection.
A proximal aortotomy was performed in the patient's previous ascending aortic graft. We encountered gross pus on the outerside of the graft. We ensured good effluent from both the left and right coronary os while giving retrograde cardioplegia. The patient's previous graft was transected about 2 cm proximal to the patient's aortic cross-clamp. Metzenbaum scissors were used to excise the graft down to the level of the proximal anastomosis.
The mechanical aortic valve was carefully excised with a 15 blade. There was notable vegetative material on the ventricular side of the valve leaflets. The aortic annulus was almost entirely eaten away by infection, and all infectious debris was removed. We then noted a perimembranous VSD that was from the LVOT to RV, and this was closed with several interrupted 4-0 pledgetted sutures. Dense adhesions were accounted, but with tedious dissection, we were able to free up both the left and right coronary buttons. We also noted a pus pocket that drained from behind the transverse sinus but this was not explored further.
The remaining annulus looked to be appropriately sized for our previously ordered 24mm aortic homograft. We then placed interrupted 4-0 prolene horizontal mattress sutures in a noneverting fashion within the remaining annulus, and the sutures were quite deep within the outflow tract. The tissue was quite friable. The sutures were then placed around the aortic homograft and it was then parachuted down to the annulus.
All annular stitches were then tied down along the aortic annulus, taking great care to apply the appropriate amount of pressure to ensure that the aortic homograft was well seated. We then used metzenbaum scissors to create a neo-ostium for the left coronary button by unroofing the preexisting homograft left coronary ostium. With considerable difficulty, the left main coronary artery was anastomosed to the aortic homograft left coronary ostium using a running 5-0 prolene suture in an end-to-side fashion. It should be noted that during the anastomosis, we noted to have a large amount of dark red blood emanating from the main pulmonary artery. There was noted to be a significant tear, and this was unable to be repaired with numerous pledgetted 4-0 sutures. Thus, all suture material was removed and a piece of bovine pericardium was used to patch the defect using interrupted pledgetted 4-0 prolene sutures. This resulted in successful hemostasis of the main PA. We then turned to the right main coronary artery button, and created a neo-ostium in a similar fashion. The right main coronary artery button was anastomosed to the newly created ostium in a similar end-to-side fashion with running 5-0 prolene.
We then turned to our distal anastomosis. The patient's aortic homograft was appropriately trimmed. We also beveled the proximal aspect of the remaining hemiarch but being sure to resect all remaining aortic graft. We then placed the head down, removed the aortic cross clamp and performed our open distal anastomosis under low flow conditions while giving antegrade perfusion via the axillary perfusion graft. We performed an anastomosis between the distal end of the homograft to the remaining proximal arch/distal ascending using a running 3-0 Prolene suture in an end-to-end fashion. We placed an antegrade root vent inside the homograft and initiated rewarming the patient. We performed multiple de-airing maneuvers. A retrograde hot shot was administered. The patient regained a rhythm after cardioversion. Several repair stitches were placed along the distal suture line. The caval snares were then tightened.
An oblique right atriotomy was performed and the tricuspid valve was inspected. We removed a globular vegetation from underneath the edge of the septal leaflet, which had been localized with intraoperative TEE. No other vegetations were noted, and no repair of the valve was required. We then closed the right atrium with running 5-0 prolene.
At this point, we noted significant bleeding emanating from the aortic homograft proximal suture line. We decided to rearrest the heart to attempt to repair the leakage. The crossclamp was then applied to the distal homograft and antegrade followed by retrograde was given to rearrest the heart. We placed several pledgetted 4-0 prolene sutures along the left side of the proximal suture line, with notable tearing of the tissue noted. We then placed the patient in trendelenburg position, gave another hotshot and the cross clamp was removed. The patient regained normal sinus rhythm after defibrillation. The patient was allowed to resuscitate on cardiopulmonary bypass for about 20 minutes. Unfortunately, there was still significant blood welling up along the proximal suture line despite placing several cardiotomy suckers around the sites in attempt to isolate the location of the bleeding. The root tissue was unfortunately not holding integrity. We placed bioglue around all sites in attempt to curb the bleeding, but even after this the bleeding was felt to be around 200 cc per minute. At this point we did not think the bleeding was repairable, and that this was a nonsurvivable condition. We then attempted to wean CPB and pack the chest to initiate comfort measures.
We removed the patient's left ventricular vent, and this site was oversewn. We removed the patient's retrograde cardioplegia catheter, and this site was also oversewn. There was very trace intracardiac air, and multiple de-airing maneuvers were performed. We then removed the patient's aortic root vent, and the site was oversewn. We initiated high-dose inotropes, and weaned cardiopulmonary bypass completely.
The patient's SVC cannula was removed and this site was oversewn. A test dose of protamine was administered. This was well tolerated. A full dose of protamine was then administered. The IVC cannula was removed and the site was oversewn. The proximal aortic root suture line was packed.
The patient was then volume resuscitated through her axillary artery graft. This graft was then stapled shut proximally using a vascular load Endo-GIA stapler. The axillary cut down wound was then closed in layers.
We gave several rounds of FFP, platelets, cryo, and DDAVP as well as a full dose of FEIBA, but this failed to control the bleeding, which was still occurring at a significant rate. At this time, there was also significant RV dysfunction noted. We then placed a bipolar V pacing wire along with a total of 4 chest tubes via inferior counter incisions and they were secured and connected to suction. Two wound vac white sponges were placed overlying the anterior RV surface and a black wound vac sponge was placed on top and secured to the suction device.
Ongoing resuscitative efforts included large doses of sodium bicarbonate, epinephrine, vasopressin, calcium chloride. Yet we were unable to maintain perfusion with her MAP consistently <40mmHg despite ACLS dosing of resuscitative drugs. The decision was made to take the patient to the ICU for comfort measures. She was transported to the ICU, where she expired minutes after arrival.
The surgeon charged: CPT's 33863 & 33463 with
Diagnosis codes A41.9 & R65.20
I was thinking: CPT's 33863 & 33463
Diagnosis codes T82.6XXD, G06.0, Z95.2
Everything seems to be bundled. Nothing was started really or nothing was finished? Add 22 modifiers??
ANY help would be very helpful.
PREOPERATIVE DIAGNOSES:
1. Prosthetic valve endocarditis
2. Prior mechanical aortic valve and ascending aorta replacement with hemiarch
3. Septic emboli to brain
POSTOPERATIVE DIAGNOSES:
1. Prosthetic valve endocarditis
2. Prior mechanical aortic valve and ascending aorta replacement with hemiarch
3. Septic emboli to brain
4. Tricuspid valve endocarditis
5. Membranous VSD secondary to endocarditis
OPERATION PERFORMED:
1. Redo sternotomy
2. Right axillary artery cannulation with perfusion limb (8mm Dacron graft)
3. Redo aortic root replacement with a 24mm aortic homograft, on cardiopulmonary bypass under circulatory arrest with antegrade cerebral perfusion
4. Reimplantation of right and left coronary artery buttons
5. Reconstruction of main pulmonary artery with bovine pericardial patch
6. Repair of perimembranous ventricular septal defect
7. Debridement of tricuspid valve
ANESTHESIA: General endotracheal
COMPLICATIONS: Intractable surgical bleeding leading to death
FINDINGS:
1. Extensive infection involving ascending graft and aortic annulus. Pus also noted to be emanating from transverse sinus.
2. Perimembranous VSD noted from LV outflow tract into RV
3. Little remaining aortic annulus after debridement. Homograft sutured deep into outflow tract but sutures did not hold, bleeding could not be controlled.
4. Vegetation noted underneath the septal leaflet of the tricuspid valve, debrided successfully and not requiring repair.
IMPLANTS:
1. 8 mm Hemashield platinum knitted double velour vascular graft, used as an axillary perfusion limb.
2. 24mm aortic homograft, used for aortic root reconstruction
3. Bovine pericardial patch, used for reconstruction of main PA
DRAINS:
32 Fr straight x2 in right and left pleural spaces, 32 Fr right angle and axiom chest tubes within the mediastinum. Wound vac placed over chest.
WIRES:
1. Unipolar ventricular pacing wires x1
CARDIOPULMONARY BYPASS DATA:
1. Total cardiopulmonary bypass time: 391 minutes.
2. Total cross-clamp time: 331 minutes. Circ arrest time 17 minutes.
3. Lowest temperature achieved: 28 degrees Celsius.
INDICATIONS FOR PROCEDURE:
with a history of a prior mechanical aortic valve replacement and ascending aorta replacement with hemiarch for a bicuspid aortic valve in 2011. She presented with altered mental status and back pain, and was eventually found to have MSSA endocarditis. TEE demonstrated findings concerning for aortic annular abscess surround the mechanical valve, and additional echodensity surrounding the ascending aortic graft concerning for infection. She was noted to have a widening PR interval, and more frequent rigors. Thus, she was consented for emergency redo aortic root replacement with homograft without undergoing preoperative catheterization. The risks and benefits of the operation, including a risk of death, was discussed with the patient and she wished to proceed.
PROCEDURE IN DETAIL: The patient was taken to the operating room and laid supine on the operating table. General endotracheal anesthesia was induced after a bilateral radial arterial lines were placed. A single-lumen endotracheal tube was placed. Both a triple-lumen as well as a Cordis catheter were placed in the patient's right internal jugular vein. A Swan-Ganz catheter was floated through a Cordis catheter. A transesophageal echocardiographic probe was positioned. A Foley catheter was placed. The patient was then prepped and draped from the chin to the thighs in the standard sterile fashion. Perioperative antibiotics were administered. A surgical time-out procedure was performed.
The patient's previous sternal incision was re-incised, and previously placed sternal wires were exposed. The wires were divided, and an oscillating saw was used to divide the anterior and posterior tables of the sternum. The old wires were removed and entry was gained into the patient's chest without injury. Dense adhesions were encountered following division of the sternum. With tedious dissection, we were able to expose all right-sided heart structures as well as the left ventricle. Residual pericardium was dissected free from the heart, and a pericardial well was created. The innominate vein, and innominate artery were dissected free from surrounding tissues. The aorta was mobilized; dense adhesions were encountered at the level of the aorta/pulmonary artery junction, and some of these adhesions were left for dissection until cardiopulmonary bypass was induced.
The patient was systemically heparinized. We then made an incision along the right deltopectoral groove. The subcutaneous tissue was divided with electrocautery, and the cephalic vein was located and reflected laterally. We then exposed the axillary artery and gained proximal and distal control with vessel loupes. The proximal axillary artery was then clamped and the distal vessel loupes were snared. An arteriotomy was performed with an 11 blade and was extended with Wecks. An 8 mm vascular graft was anastomosed to the axillary artery in an end-to-side fashion with a running 5-0 prolene. This was de-aired and hemostasis was achieved. This was connected to the cardiopulmonary bypass circuit.
A 4-0 Prolene pursestring was placed in the superior vena cava, which was then cannulated with a metal-tip right-angle venous cannula. A 4-0 Prolene pursestring was placed in the inferior free wall of the right atrium, and the inferior vena cava was cannulated with a straight venous cannula. These 2 were then connected to the bypasscircuit. Next, a small pursestring was placed at the base of the right atrial appendage near the AV groove. A retrograde cardioplegia catheter was placed through this. Finally, an antegrade root vent was placed in the proximal ascending aorta and secured with 4-0 Prolene. We freed the SVC and IVC circumferentially with blunt dissection and placed caval tapes.
After ensuring an adequate ACT was obtained, the patient was placed on cardiopulmonary bypass via the innominate artery graft and the right atrial cannula. Active cooling was initiated to 28 degrees Celsius. A left ventricular vent was placed via the right superior pulmonary vein. We continued mobilization of the ascending aorta and the aortic root, in particular, mobilizing the aorta from the pulmonary artery, and we were able to obtain circumferential control around the aorta. We further mobilized the aortic root, taking down adhesions to near the level of both the left and right coronary buttons. At this point, the patient was placed in Trendelenburg position. An aortic cross-clamp was applied. Retrograde cardioplegia was administered to achieve a diastolic arrest. A left ventricular temperature was used to ensure adequate myocardial protection. The patient was redosed with cardioplegia every 10 and 20 minutes to ensure appropriate myocardial protection.
A proximal aortotomy was performed in the patient's previous ascending aortic graft. We encountered gross pus on the outerside of the graft. We ensured good effluent from both the left and right coronary os while giving retrograde cardioplegia. The patient's previous graft was transected about 2 cm proximal to the patient's aortic cross-clamp. Metzenbaum scissors were used to excise the graft down to the level of the proximal anastomosis.
The mechanical aortic valve was carefully excised with a 15 blade. There was notable vegetative material on the ventricular side of the valve leaflets. The aortic annulus was almost entirely eaten away by infection, and all infectious debris was removed. We then noted a perimembranous VSD that was from the LVOT to RV, and this was closed with several interrupted 4-0 pledgetted sutures. Dense adhesions were accounted, but with tedious dissection, we were able to free up both the left and right coronary buttons. We also noted a pus pocket that drained from behind the transverse sinus but this was not explored further.
The remaining annulus looked to be appropriately sized for our previously ordered 24mm aortic homograft. We then placed interrupted 4-0 prolene horizontal mattress sutures in a noneverting fashion within the remaining annulus, and the sutures were quite deep within the outflow tract. The tissue was quite friable. The sutures were then placed around the aortic homograft and it was then parachuted down to the annulus.
All annular stitches were then tied down along the aortic annulus, taking great care to apply the appropriate amount of pressure to ensure that the aortic homograft was well seated. We then used metzenbaum scissors to create a neo-ostium for the left coronary button by unroofing the preexisting homograft left coronary ostium. With considerable difficulty, the left main coronary artery was anastomosed to the aortic homograft left coronary ostium using a running 5-0 prolene suture in an end-to-side fashion. It should be noted that during the anastomosis, we noted to have a large amount of dark red blood emanating from the main pulmonary artery. There was noted to be a significant tear, and this was unable to be repaired with numerous pledgetted 4-0 sutures. Thus, all suture material was removed and a piece of bovine pericardium was used to patch the defect using interrupted pledgetted 4-0 prolene sutures. This resulted in successful hemostasis of the main PA. We then turned to the right main coronary artery button, and created a neo-ostium in a similar fashion. The right main coronary artery button was anastomosed to the newly created ostium in a similar end-to-side fashion with running 5-0 prolene.
We then turned to our distal anastomosis. The patient's aortic homograft was appropriately trimmed. We also beveled the proximal aspect of the remaining hemiarch but being sure to resect all remaining aortic graft. We then placed the head down, removed the aortic cross clamp and performed our open distal anastomosis under low flow conditions while giving antegrade perfusion via the axillary perfusion graft. We performed an anastomosis between the distal end of the homograft to the remaining proximal arch/distal ascending using a running 3-0 Prolene suture in an end-to-end fashion. We placed an antegrade root vent inside the homograft and initiated rewarming the patient. We performed multiple de-airing maneuvers. A retrograde hot shot was administered. The patient regained a rhythm after cardioversion. Several repair stitches were placed along the distal suture line. The caval snares were then tightened.
An oblique right atriotomy was performed and the tricuspid valve was inspected. We removed a globular vegetation from underneath the edge of the septal leaflet, which had been localized with intraoperative TEE. No other vegetations were noted, and no repair of the valve was required. We then closed the right atrium with running 5-0 prolene.
At this point, we noted significant bleeding emanating from the aortic homograft proximal suture line. We decided to rearrest the heart to attempt to repair the leakage. The crossclamp was then applied to the distal homograft and antegrade followed by retrograde was given to rearrest the heart. We placed several pledgetted 4-0 prolene sutures along the left side of the proximal suture line, with notable tearing of the tissue noted. We then placed the patient in trendelenburg position, gave another hotshot and the cross clamp was removed. The patient regained normal sinus rhythm after defibrillation. The patient was allowed to resuscitate on cardiopulmonary bypass for about 20 minutes. Unfortunately, there was still significant blood welling up along the proximal suture line despite placing several cardiotomy suckers around the sites in attempt to isolate the location of the bleeding. The root tissue was unfortunately not holding integrity. We placed bioglue around all sites in attempt to curb the bleeding, but even after this the bleeding was felt to be around 200 cc per minute. At this point we did not think the bleeding was repairable, and that this was a nonsurvivable condition. We then attempted to wean CPB and pack the chest to initiate comfort measures.
We removed the patient's left ventricular vent, and this site was oversewn. We removed the patient's retrograde cardioplegia catheter, and this site was also oversewn. There was very trace intracardiac air, and multiple de-airing maneuvers were performed. We then removed the patient's aortic root vent, and the site was oversewn. We initiated high-dose inotropes, and weaned cardiopulmonary bypass completely.
The patient's SVC cannula was removed and this site was oversewn. A test dose of protamine was administered. This was well tolerated. A full dose of protamine was then administered. The IVC cannula was removed and the site was oversewn. The proximal aortic root suture line was packed.
The patient was then volume resuscitated through her axillary artery graft. This graft was then stapled shut proximally using a vascular load Endo-GIA stapler. The axillary cut down wound was then closed in layers.
We gave several rounds of FFP, platelets, cryo, and DDAVP as well as a full dose of FEIBA, but this failed to control the bleeding, which was still occurring at a significant rate. At this time, there was also significant RV dysfunction noted. We then placed a bipolar V pacing wire along with a total of 4 chest tubes via inferior counter incisions and they were secured and connected to suction. Two wound vac white sponges were placed overlying the anterior RV surface and a black wound vac sponge was placed on top and secured to the suction device.
Ongoing resuscitative efforts included large doses of sodium bicarbonate, epinephrine, vasopressin, calcium chloride. Yet we were unable to maintain perfusion with her MAP consistently <40mmHg despite ACLS dosing of resuscitative drugs. The decision was made to take the patient to the ICU for comfort measures. She was transported to the ICU, where she expired minutes after arrival.