bennieyoung
Guru
I could use some help and advice on how to code this. At first I thought it was fairly simple but now I'm second guessing myself. Help!
PREOPERATIVE DIAGNOSIS:
1. Marfan syndrome with acute type A dissection and cardiogenic shock.
2. Suspected early tamponade.
POSTOPERATIVE DIAGNOSIS:
1. Acute type A dissection without tamponade with acute aortic valve insufficiency I suspect.
2. Dissection extending into the left main with ischemia.
3. Aortic valve insufficiency.
PROCEDURE PERFORMED:
1. Aortic root replacement, valve sparing (David procedure).
2. Aortic valve replacement with a 21 Inspiris bioprosthetic.
3. Ligation of the left main coronary artery with saphenous vein graft to the left anterior descending and the circumflex.
4. Placement of right common femoral artery intra-aortic balloon pump.
5. Left apical to ascending aorta left ventricular assist device.
6. Harvesting saphenous veins from both lower legs.
FINDINGS:
DESCRIPTION OF PROCEDURE: This patient presented with syncope and neck discomfort with known Marfan syndrome. She was hemodynamically unstable. CAT scan confirmed type A dissection. We were notified and took her directly to the operating room within minutes of visiting her. She was intubated. She remained hemodynamically stable. Right radial artery cannulation was performed as well as left subclavian catheter and Foley were placed. She was prepped and draped in sterile classical manner. Intraoperative TEE revealed mild to moderate eccentric aortic valve insufficiency with presumed normal architecture and a non- dilated aortic root and ascending aorta. Because of her Marfan's, I had intended to replace her transverse arch and ascending aorta as a root to avoid further arch complications in the future. For that reason, I exposed the right axillary artery which was small. I then heparinized her and sewed an 8 mm Hemashield graft end-to-side with cannula. We then opened the sternum which had extensive venous bleeding. I suspected she had tamponade physiology to cause that. It was quite extensive and quite heavy bleeding from the venous tributaries. When we opened the pericardium, there was no evidence of tamponade. However, she appeared to be volume overloaded, probably iatrogenic. Her aorta was obviously dissected. It was rather small, measuring 3.5 cm at most extending by CAT scan all the way into her neck and inonnimate and carotids and distal descending aorta. We then cannulated the right atrium and put in a retrograde catheter and LV sump. Cardiopulmonary bypass was begun. We began cooling to 16 degrees centigrade. After she fibrillated, I placed a cross-clamp proximally on the aorta and gave retrograde cardioplegia as well as topical hypothermia and systemic cooling as stated. After cardiac arrest, we continued cooling while the aorta was excised proximally. The dissection included both ostia of the left and right coronary artery extending approximately 4 or 5 mm at least into the left main and similar on the right. The leaflets appeared normal with very little fenestration. I suspected that they were competent prior to her dissection. There was obviously prolapse of part of the valve infrastructure. Because of her young age, I planned to do a valve-sparing root replacement and excised the sinuses, although they were all dissected down close to fibrous tissue along the commissures in the anulus. We then dissected the pulmonary artery away from the outflow tract and placed circumferential 4-0 Ti-Cron sutures circumferentially in the outflow tract below the anulus avoiding the membranous sinus. We then sized the patient who had a rather small valve in the anulus for 26 Hemashield graft, was sewn down over the valve struts. These were then suspended. I felt that we would get good apposition and good competence of the valve. Rather than completing at that point, the patient had been at 16 degrees for some time. We were unable to place an EEG because of the emergent nature of the procedure, but she had been cooling for quite some time. With the head packed in ice in Trendelenburg, we removed the cross-clamp and began to excise the transverse arch. It became evident to me that the arch was small and not dilated and that I would be able to avoid replacing the arch and adding unnecessary risk. For that reason, I did a hemi arch taking the undersurface of the arch all the way to the left subclavian and to the base of the innominate and basically sewed that on as a patch to a beveled 28 mm Hemashield graft with felt reinforcement inside and outside. We placed BioGlue and tested this under pressure and there was no evidence of leak. We then began rewarming. I then went down and completed the 3 suture lines from commissure to commissure tying them posteriorly to make sure that it was watertight. Testing with volume revealed no loss of volume to the ventricle under suction. I felt that we had a competent valve. I then reimplanted a very friable and partially dissected left main coronary artery staying as close to the ostium of the coronary as I could leaving no button. At the completion, I realized there was an opening consistent with a dissection plane inside the ostia, but I felt that we had secured enough of the adventitia and media and intima that this should be stable. We were able to retrograde flow with good high flow retrograde cardioplegia. I could see it come directly out the main lumen. I felt that we were likely safe. We found the same thing on the right coronary artery which was re-anastomosed to the graft without difficulty. We then completed the graft-to-graft anastomosis, removed the cross-clamp at which point she had rather diffuse coagulopathy and some minor suture hole bleeding which was controlled with simple sutures. We then were able to wean from bypass and she was able to stay off bypass for quite some time, although I was concerned that there was still mild-to-moderate aortic insufficiency as found preoperatively. I felt that as long as she remained hemodynamically stable and did not require much in pressor support that that would be well tolerated long-term and that within time she would be able to get a TAVR replacement valve when those became standard of care. For aortic insufficiency in the meantime, with relatively normal LV function, I felt that she would tolerate it. We had given protamine when we started to experience some bleeding from behind the aorta and realized that the left main artery had started to leak in the midshaft of it away from the anastomosis. I suspected that the dissection was more severe. I re-arrested the heart and looked at it and felt that the dissection had probably extended up under the pulmonary artery and was not salvageable. I therefore over-sewed and placed a large clip across the left main and closed the opening to the graft where it was anastomosed with a pledgeted 3-0 Prolene. At that point, we knew we had to bypass the heart while she was resting. We took veins from both ankles and grafted the LAD which was a small vessel measuring 1.6 mm in the mid segment and the circumflex which was a 2.2 mm vessel. The vein grafts were brought off the graft to the LAD and then the vein graft to the circ was brought off the side of the vein graft to the LAD. We then again weaned from bypass. We had some hemodynamic instability, ongoing bleeding. We went off and on bypass several times. She required increasing pressor support and over time her LV started to dilate and fail. I felt that the only remaining untreated problem was her aortic insufficiency, re-arrested the heart, excised her valve and sewed a valve inside the graft to the ascending aorta graft with a 21 mm Inspiris valve which maybe later could be dilated. We then again de-aired the patient and weaned from bypass. She did well for a while, then began to fail again. At that point, I was concerned about having been on pump quite a long time, although Del Nido protocol was utilized with more frequent cardioplegia dosing. Please see perfusion record as well as persisting topical hypothermia, taking great care to protect the heart. At this point, I reassessed the vein grafts. Appeared to be have good flow with Doppler, although the apex was not moving well. Again, we have been on and off pump several times and been on pump for quite some time. I placed a 24 mm cannula in the left atrium through the left atrial appendage and connected it to a ventricular assist device. Initially, she did well with that. However, we were unable to achieve adequate flows, likely due to the cannula locking up against the wall. I therefore switched that to a 25 mm cannula through the apex of the left ventricle with 2 pledgeted mattress sutures with complete emptying of the left heart and much better hemodynamics and flow. We then spent a great deal of time looking for any surgical bleeding. She was coagulopathic and received blood products, but no obvious surgical bleeding. We decided to leave her chest open with drains and return her to the ICU in critical condition.
PREOPERATIVE DIAGNOSIS:
1. Marfan syndrome with acute type A dissection and cardiogenic shock.
2. Suspected early tamponade.
POSTOPERATIVE DIAGNOSIS:
1. Acute type A dissection without tamponade with acute aortic valve insufficiency I suspect.
2. Dissection extending into the left main with ischemia.
3. Aortic valve insufficiency.
PROCEDURE PERFORMED:
1. Aortic root replacement, valve sparing (David procedure).
2. Aortic valve replacement with a 21 Inspiris bioprosthetic.
3. Ligation of the left main coronary artery with saphenous vein graft to the left anterior descending and the circumflex.
4. Placement of right common femoral artery intra-aortic balloon pump.
5. Left apical to ascending aorta left ventricular assist device.
6. Harvesting saphenous veins from both lower legs.
FINDINGS:
DESCRIPTION OF PROCEDURE: This patient presented with syncope and neck discomfort with known Marfan syndrome. She was hemodynamically unstable. CAT scan confirmed type A dissection. We were notified and took her directly to the operating room within minutes of visiting her. She was intubated. She remained hemodynamically stable. Right radial artery cannulation was performed as well as left subclavian catheter and Foley were placed. She was prepped and draped in sterile classical manner. Intraoperative TEE revealed mild to moderate eccentric aortic valve insufficiency with presumed normal architecture and a non- dilated aortic root and ascending aorta. Because of her Marfan's, I had intended to replace her transverse arch and ascending aorta as a root to avoid further arch complications in the future. For that reason, I exposed the right axillary artery which was small. I then heparinized her and sewed an 8 mm Hemashield graft end-to-side with cannula. We then opened the sternum which had extensive venous bleeding. I suspected she had tamponade physiology to cause that. It was quite extensive and quite heavy bleeding from the venous tributaries. When we opened the pericardium, there was no evidence of tamponade. However, she appeared to be volume overloaded, probably iatrogenic. Her aorta was obviously dissected. It was rather small, measuring 3.5 cm at most extending by CAT scan all the way into her neck and inonnimate and carotids and distal descending aorta. We then cannulated the right atrium and put in a retrograde catheter and LV sump. Cardiopulmonary bypass was begun. We began cooling to 16 degrees centigrade. After she fibrillated, I placed a cross-clamp proximally on the aorta and gave retrograde cardioplegia as well as topical hypothermia and systemic cooling as stated. After cardiac arrest, we continued cooling while the aorta was excised proximally. The dissection included both ostia of the left and right coronary artery extending approximately 4 or 5 mm at least into the left main and similar on the right. The leaflets appeared normal with very little fenestration. I suspected that they were competent prior to her dissection. There was obviously prolapse of part of the valve infrastructure. Because of her young age, I planned to do a valve-sparing root replacement and excised the sinuses, although they were all dissected down close to fibrous tissue along the commissures in the anulus. We then dissected the pulmonary artery away from the outflow tract and placed circumferential 4-0 Ti-Cron sutures circumferentially in the outflow tract below the anulus avoiding the membranous sinus. We then sized the patient who had a rather small valve in the anulus for 26 Hemashield graft, was sewn down over the valve struts. These were then suspended. I felt that we would get good apposition and good competence of the valve. Rather than completing at that point, the patient had been at 16 degrees for some time. We were unable to place an EEG because of the emergent nature of the procedure, but she had been cooling for quite some time. With the head packed in ice in Trendelenburg, we removed the cross-clamp and began to excise the transverse arch. It became evident to me that the arch was small and not dilated and that I would be able to avoid replacing the arch and adding unnecessary risk. For that reason, I did a hemi arch taking the undersurface of the arch all the way to the left subclavian and to the base of the innominate and basically sewed that on as a patch to a beveled 28 mm Hemashield graft with felt reinforcement inside and outside. We placed BioGlue and tested this under pressure and there was no evidence of leak. We then began rewarming. I then went down and completed the 3 suture lines from commissure to commissure tying them posteriorly to make sure that it was watertight. Testing with volume revealed no loss of volume to the ventricle under suction. I felt that we had a competent valve. I then reimplanted a very friable and partially dissected left main coronary artery staying as close to the ostium of the coronary as I could leaving no button. At the completion, I realized there was an opening consistent with a dissection plane inside the ostia, but I felt that we had secured enough of the adventitia and media and intima that this should be stable. We were able to retrograde flow with good high flow retrograde cardioplegia. I could see it come directly out the main lumen. I felt that we were likely safe. We found the same thing on the right coronary artery which was re-anastomosed to the graft without difficulty. We then completed the graft-to-graft anastomosis, removed the cross-clamp at which point she had rather diffuse coagulopathy and some minor suture hole bleeding which was controlled with simple sutures. We then were able to wean from bypass and she was able to stay off bypass for quite some time, although I was concerned that there was still mild-to-moderate aortic insufficiency as found preoperatively. I felt that as long as she remained hemodynamically stable and did not require much in pressor support that that would be well tolerated long-term and that within time she would be able to get a TAVR replacement valve when those became standard of care. For aortic insufficiency in the meantime, with relatively normal LV function, I felt that she would tolerate it. We had given protamine when we started to experience some bleeding from behind the aorta and realized that the left main artery had started to leak in the midshaft of it away from the anastomosis. I suspected that the dissection was more severe. I re-arrested the heart and looked at it and felt that the dissection had probably extended up under the pulmonary artery and was not salvageable. I therefore over-sewed and placed a large clip across the left main and closed the opening to the graft where it was anastomosed with a pledgeted 3-0 Prolene. At that point, we knew we had to bypass the heart while she was resting. We took veins from both ankles and grafted the LAD which was a small vessel measuring 1.6 mm in the mid segment and the circumflex which was a 2.2 mm vessel. The vein grafts were brought off the graft to the LAD and then the vein graft to the circ was brought off the side of the vein graft to the LAD. We then again weaned from bypass. We had some hemodynamic instability, ongoing bleeding. We went off and on bypass several times. She required increasing pressor support and over time her LV started to dilate and fail. I felt that the only remaining untreated problem was her aortic insufficiency, re-arrested the heart, excised her valve and sewed a valve inside the graft to the ascending aorta graft with a 21 mm Inspiris valve which maybe later could be dilated. We then again de-aired the patient and weaned from bypass. She did well for a while, then began to fail again. At that point, I was concerned about having been on pump quite a long time, although Del Nido protocol was utilized with more frequent cardioplegia dosing. Please see perfusion record as well as persisting topical hypothermia, taking great care to protect the heart. At this point, I reassessed the vein grafts. Appeared to be have good flow with Doppler, although the apex was not moving well. Again, we have been on and off pump several times and been on pump for quite some time. I placed a 24 mm cannula in the left atrium through the left atrial appendage and connected it to a ventricular assist device. Initially, she did well with that. However, we were unable to achieve adequate flows, likely due to the cannula locking up against the wall. I therefore switched that to a 25 mm cannula through the apex of the left ventricle with 2 pledgeted mattress sutures with complete emptying of the left heart and much better hemodynamics and flow. We then spent a great deal of time looking for any surgical bleeding. She was coagulopathic and received blood products, but no obvious surgical bleeding. We decided to leave her chest open with drains and return her to the ICU in critical condition.