zuzu7400
New
PROCEDURE PERFORMED
1. MITRAL VALVE REPLACEMENT.
a. 29 MM MOSAIC BIOPROSTHETIC VALVE.
2. THORACIC ASCENDING AORTIC ANEURYSM RESECTION AND REPAIR.
a. HEMIARCH INTERPOSITION HEMASHIELD GRAFT (34 MM).
3. DEEP HYPOTHERMIC CIRCULATORY ARREST.
PROCEDURE
The patient was brought to the operating room and placed supine on the operating room table. After induction of general anesthesia by endotracheal intubation and placement of invasive monitoring lines, he was prepped and draped in the usual sterile fashion. A standard midline sternotomy incision was performed. Wide exposure was obtained. A pericardial cradle was made. CO2 was insufflated into the field. Inspection of the ascending aortic aneurysm quickly revealed that this appeared to extend into the transverse aortic arch and that a more extensive resection/repair would be necessary. At this juncture, the chest was covered with sterile towels, and working simultaneously, Dr. Rosenberg explored and subsequently cannulated the right subclavian artery, whereas I explored and subsequently cannulated the right femoral artery. Following arterial cannulation which of course occurred after systemic heparinization, wide exposure of the anterior mediastinum was then obtained. A pericardial cradle was made. Two-stage atrial caval cannulation was effected. A retrograde coronary sinus catheter was placed. High-flow hypothermic cardiopulmonary bypass was instituted with the patient cooled to 22 degrees centigrade.
The aorta was cross-clamped. 500 mL of antegrade, followed by 500 mL retrograde cold blood cardioplegia was given with rapid diastolic standstill. Cold topical slush was used for right ventricular protection throughout the course of the procedure. Retrograde cold blood cardioplegia was given every 10 to 20 minutes, also throughout the course of the procedure. Waterston groove was developed. Left atrium was entered. Wide exposure was obtained. The posterior leaflet was regurgitant in a couple of different areas. Because of the lengthy anticipated cardiopulmonary bypass time, the need to affect a perfect mitral solution without risk of future intervention and because of the patient's desire to only have 1 operation over the remainder of his life, it was decided that a mitral replacement would be performed, even though a mitral repair in all likelihood would have been successful. This being the case, the anterior leaflet of the mitral valve was excised in its entirety. The valve sized to a 29 mm Mosaic bioprosthetic valve, was brought onto the back table and prepared.
Circumferential annular sutures of 2-0 Ethibond in a horizontal mattress configuration were then placed with the pledget on the left ventricular side. The valve was brought into the operative field. The sutures were placed, sewing in the valve. The valve was seated. All sutures were tied and subsequently transected. The valve seated without difficulty. The left atriotomy was then closed with a pledgeted 3-0 Prolene suture.
Attention was then turned to the aorta. The patient was placed in steep Trendelenburg. The aorta was opened with low-flow cardiopulmonary bypass. It was immediately evident that the aorta began above the sino-tubular junction. Therefore, a formal reimplantation of the coronary arteries would not be necessary. It was also readily apparent that the aneurysm extended into the aortic arch, although the __________ vessels appeared to be relatively unaffected. It was decided at that juncture, that a hemiarch approach to reconstruction would be utilized to avoid the need for reimplantation of the great vessels onto the new tube graft. Therefore, the aorta was excised from the sino-tubular junction onto the arch in a slanted fashion. A 34 mm Hemashield graft was then brought onto the table. It was also skived into the configuration necessary for the distal anastomosis.
At this juncture, the right innominate artery was occluded. Retrograde cerebral profusion was performed, and the pump was discontinued, thereby proceeding into the time frame of total circulatory arrest. The distal anastomosis along the arch constituting the hemiarch reconstruction, was then performed with continuous 3-0 Prolene suture. Following completion of the anastomosis which took approximately 20 minutes, the cross-clamp was then applied to the graft itself. The right innominate snare was loosened, and flow was once again re-initiated through the right innominate and the right femoral arteries. The graft was allowed to fill. The anastomotic site was inspected for bleeding, and it all appeared to be hemostatic. The patient was then rewarmed as the proximal anastomosis was performed for the graft to the superior aspect of the sino-tubular junction, again with continuous 3-0 Prolene suture.
Following completion of this anastomosis, a root vent was placed in the graft itself, and the cross-clamp was removed. Hemostasis appeared to be reasonable at that juncture, still in steep Trendelenburg. The patient was subsequently rewarmed and then ventilation was begun. The patient was allowed to eject. Extensive de-airing maneuvers were performed. At that juncture, intraoperative TEE demonstrated good ventricular function, no intracavitary air, good function of the mitral bioprosthesis with no perivalvular leaks. The root vent was subsequently removed.
The patient was then weaned from cardiopulmonary bypass with minimal inotropic support. Protamine was given. The patient was decannulated. Two mediastinal chest tubes and temporary atrial and ventricular pacing wires were placed. Both pleural spaces were opened and evacuated. After this, the patient was subsequently decannulated and remained hemodynamically stable throughout. After an instrument and sponge count were correct x2, hemodynamics were stable and hemostasis was assured, the sternum was subsequently reapproximated with the use of sternal wire followed by a multilayer closure and the application of a sterile dressing. The patient tolerated the procedure well. He was transported to the ICU in critical but stable condition.
I came up with the following codes:
33860
33430
33202
35650
1. MITRAL VALVE REPLACEMENT.
a. 29 MM MOSAIC BIOPROSTHETIC VALVE.
2. THORACIC ASCENDING AORTIC ANEURYSM RESECTION AND REPAIR.
a. HEMIARCH INTERPOSITION HEMASHIELD GRAFT (34 MM).
3. DEEP HYPOTHERMIC CIRCULATORY ARREST.
PROCEDURE
The patient was brought to the operating room and placed supine on the operating room table. After induction of general anesthesia by endotracheal intubation and placement of invasive monitoring lines, he was prepped and draped in the usual sterile fashion. A standard midline sternotomy incision was performed. Wide exposure was obtained. A pericardial cradle was made. CO2 was insufflated into the field. Inspection of the ascending aortic aneurysm quickly revealed that this appeared to extend into the transverse aortic arch and that a more extensive resection/repair would be necessary. At this juncture, the chest was covered with sterile towels, and working simultaneously, Dr. Rosenberg explored and subsequently cannulated the right subclavian artery, whereas I explored and subsequently cannulated the right femoral artery. Following arterial cannulation which of course occurred after systemic heparinization, wide exposure of the anterior mediastinum was then obtained. A pericardial cradle was made. Two-stage atrial caval cannulation was effected. A retrograde coronary sinus catheter was placed. High-flow hypothermic cardiopulmonary bypass was instituted with the patient cooled to 22 degrees centigrade.
The aorta was cross-clamped. 500 mL of antegrade, followed by 500 mL retrograde cold blood cardioplegia was given with rapid diastolic standstill. Cold topical slush was used for right ventricular protection throughout the course of the procedure. Retrograde cold blood cardioplegia was given every 10 to 20 minutes, also throughout the course of the procedure. Waterston groove was developed. Left atrium was entered. Wide exposure was obtained. The posterior leaflet was regurgitant in a couple of different areas. Because of the lengthy anticipated cardiopulmonary bypass time, the need to affect a perfect mitral solution without risk of future intervention and because of the patient's desire to only have 1 operation over the remainder of his life, it was decided that a mitral replacement would be performed, even though a mitral repair in all likelihood would have been successful. This being the case, the anterior leaflet of the mitral valve was excised in its entirety. The valve sized to a 29 mm Mosaic bioprosthetic valve, was brought onto the back table and prepared.
Circumferential annular sutures of 2-0 Ethibond in a horizontal mattress configuration were then placed with the pledget on the left ventricular side. The valve was brought into the operative field. The sutures were placed, sewing in the valve. The valve was seated. All sutures were tied and subsequently transected. The valve seated without difficulty. The left atriotomy was then closed with a pledgeted 3-0 Prolene suture.
Attention was then turned to the aorta. The patient was placed in steep Trendelenburg. The aorta was opened with low-flow cardiopulmonary bypass. It was immediately evident that the aorta began above the sino-tubular junction. Therefore, a formal reimplantation of the coronary arteries would not be necessary. It was also readily apparent that the aneurysm extended into the aortic arch, although the __________ vessels appeared to be relatively unaffected. It was decided at that juncture, that a hemiarch approach to reconstruction would be utilized to avoid the need for reimplantation of the great vessels onto the new tube graft. Therefore, the aorta was excised from the sino-tubular junction onto the arch in a slanted fashion. A 34 mm Hemashield graft was then brought onto the table. It was also skived into the configuration necessary for the distal anastomosis.
At this juncture, the right innominate artery was occluded. Retrograde cerebral profusion was performed, and the pump was discontinued, thereby proceeding into the time frame of total circulatory arrest. The distal anastomosis along the arch constituting the hemiarch reconstruction, was then performed with continuous 3-0 Prolene suture. Following completion of the anastomosis which took approximately 20 minutes, the cross-clamp was then applied to the graft itself. The right innominate snare was loosened, and flow was once again re-initiated through the right innominate and the right femoral arteries. The graft was allowed to fill. The anastomotic site was inspected for bleeding, and it all appeared to be hemostatic. The patient was then rewarmed as the proximal anastomosis was performed for the graft to the superior aspect of the sino-tubular junction, again with continuous 3-0 Prolene suture.
Following completion of this anastomosis, a root vent was placed in the graft itself, and the cross-clamp was removed. Hemostasis appeared to be reasonable at that juncture, still in steep Trendelenburg. The patient was subsequently rewarmed and then ventilation was begun. The patient was allowed to eject. Extensive de-airing maneuvers were performed. At that juncture, intraoperative TEE demonstrated good ventricular function, no intracavitary air, good function of the mitral bioprosthesis with no perivalvular leaks. The root vent was subsequently removed.
The patient was then weaned from cardiopulmonary bypass with minimal inotropic support. Protamine was given. The patient was decannulated. Two mediastinal chest tubes and temporary atrial and ventricular pacing wires were placed. Both pleural spaces were opened and evacuated. After this, the patient was subsequently decannulated and remained hemodynamically stable throughout. After an instrument and sponge count were correct x2, hemodynamics were stable and hemostasis was assured, the sternum was subsequently reapproximated with the use of sternal wire followed by a multilayer closure and the application of a sterile dressing. The patient tolerated the procedure well. He was transported to the ICU in critical but stable condition.
I came up with the following codes:
33860
33430
33202
35650
Last edited:
