TWilliam2019
Guru
Procedure:
1. Urgent aortic valve replacement with a 21 mm Inspiris bioprosthetic valve
2. Primary repair of mitral valve anterior leaflet perforation
3. Rigid internal fixation of the sternum
4. Cardiopulmonary bypass
5. TEE
6. Epi-aortic ultrasound with visualization and interpretation
7. Evacuation of left pleural effusion with placement of chest tube for management ? Can this be coded ?
Pre-bypass TEE was performed with findings as described above. Midline sternal incision was made. The soft tissues were cauterized. Sternotomy was performed in the standard fashion.. The patient was heparinized and ACT was found to be therapeutic for the procedure. Sternal retractor was placed. The left pleural space was then entered into using electrocautery. A total of 350 mL of serous fluid was evacuated. The pericardium was opened and teed off along the diaphragm. Stay sutures were placed to create a pericardial well. Epi-aortic ultrasound was used to evaluate the ascending aorta with findings as described. Once this was completed, central cannulation of the heart was performed. Reverse autologous priming the pump was performed. The patient was then placed on full bypass and systemically cooled to 30 °C. Antegrade needle was placed in the mid ascending aorta. Retrograde cardioplegia cannulas placed through the free wall the right atrium and positioned within the coronary sinus. Pursestring was placed in the right superior pulmonary vein. A left ventricular vent was placed and secured. The cross-clamp was placed and cold sanguinous retrograde cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum and ice was placed over the right ventricle. The pericardial well was filled with carbon dioxide.
An oblique aortotomy was then created using Metzenbaum scissors. The aortotomy was extended towards the noncoronary sinus. Upon evaluating aortic root, vegetation extending from the right coronary leaflet was prolapsed into the left main coronary artery. Using DeBakey's, this was carefully retracted out of the left main coronary artery and back into the aortic root. The aortic root was then carefully evaluated with findings as described above. Direct ostial cardioplegia was then delivered to the left main coronary artery as well as the ostial right coronary artery. This achieved cardiac electrical silence. The aortic valve leaflets were excised with Metzenbaum scissors. Portion of the vegetation was submitted for routine, AFB, and fungal cultures. The remainder of the aortic valve leaflets was submitted to pathology.
Upon removing the aortic valve, the posterior aspect of the anterior leaflet was able to be evaluated. The area of concern regarding possible perforation was identified between 2 major chordae tendons. There was no vegetation involving this perforation. The perforation total surface area of less than 5 mm in size. This area was painted with Betadine and then primarily closed using a 5-0 Prolene. The remainder of the posterior aspect of the anterior mitral leaflet was inspected with no other abnormalities identified. Once primary closure of the perforation was achieved, attention was then turned to replacing the aortic valve.
2-0 pledgeted Ethibond sutures were then placed circumferentially in the subannular position. The aortic annulus was sized to a 21 mm valve. The sutures were placed through the sewing cuff of the bioprosthetic valve and the valve was parachuted into the supra annular position. It was then secured using the cor-knot device. The aortotomy was then closed in a 2 layered fashion using 4-0 Prolene.
The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. The heart regained a spontaneous sinus rhythm. The aortotomy was found to be hemostatic. Pacing wires were placed on the right ventricle and brought to the level of the skin. Lungs were ventilated. The heart was then weaned from bypass without difficulty. Final TEE was performed with findings as described. Protamine was then delivered to reverse the effects of heparin and the heart was decannulated in the usual fashion. All cannulation sites were oversewn with 4-0 Prolene.
The chest tubes were then placed, with an angled chest tube placed in the left pleural space for management of the left pleural effusion. The sternum was reapproximated with #7 wires. The most superior wire fractured at the completion of the procedure. Therefore, rigid sternal fixation was performed by placing a 4-hole manubrial plate at the superior aspect of the manubrium and securing it with 14 mm anchoring screws x4. The superior abdominal fascia was then reapproximated with 0 Ethibond. The soft tissues were reapproximated with 0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound. The patient tolerated the procedure well and was transferred to CVRU.
33405
33427
76998 26
thanks in advance
1. Urgent aortic valve replacement with a 21 mm Inspiris bioprosthetic valve
2. Primary repair of mitral valve anterior leaflet perforation
3. Rigid internal fixation of the sternum
4. Cardiopulmonary bypass
5. TEE
6. Epi-aortic ultrasound with visualization and interpretation
7. Evacuation of left pleural effusion with placement of chest tube for management ? Can this be coded ?
Pre-bypass TEE was performed with findings as described above. Midline sternal incision was made. The soft tissues were cauterized. Sternotomy was performed in the standard fashion.. The patient was heparinized and ACT was found to be therapeutic for the procedure. Sternal retractor was placed. The left pleural space was then entered into using electrocautery. A total of 350 mL of serous fluid was evacuated. The pericardium was opened and teed off along the diaphragm. Stay sutures were placed to create a pericardial well. Epi-aortic ultrasound was used to evaluate the ascending aorta with findings as described. Once this was completed, central cannulation of the heart was performed. Reverse autologous priming the pump was performed. The patient was then placed on full bypass and systemically cooled to 30 °C. Antegrade needle was placed in the mid ascending aorta. Retrograde cardioplegia cannulas placed through the free wall the right atrium and positioned within the coronary sinus. Pursestring was placed in the right superior pulmonary vein. A left ventricular vent was placed and secured. The cross-clamp was placed and cold sanguinous retrograde cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum and ice was placed over the right ventricle. The pericardial well was filled with carbon dioxide.
An oblique aortotomy was then created using Metzenbaum scissors. The aortotomy was extended towards the noncoronary sinus. Upon evaluating aortic root, vegetation extending from the right coronary leaflet was prolapsed into the left main coronary artery. Using DeBakey's, this was carefully retracted out of the left main coronary artery and back into the aortic root. The aortic root was then carefully evaluated with findings as described above. Direct ostial cardioplegia was then delivered to the left main coronary artery as well as the ostial right coronary artery. This achieved cardiac electrical silence. The aortic valve leaflets were excised with Metzenbaum scissors. Portion of the vegetation was submitted for routine, AFB, and fungal cultures. The remainder of the aortic valve leaflets was submitted to pathology.
Upon removing the aortic valve, the posterior aspect of the anterior leaflet was able to be evaluated. The area of concern regarding possible perforation was identified between 2 major chordae tendons. There was no vegetation involving this perforation. The perforation total surface area of less than 5 mm in size. This area was painted with Betadine and then primarily closed using a 5-0 Prolene. The remainder of the posterior aspect of the anterior mitral leaflet was inspected with no other abnormalities identified. Once primary closure of the perforation was achieved, attention was then turned to replacing the aortic valve.
2-0 pledgeted Ethibond sutures were then placed circumferentially in the subannular position. The aortic annulus was sized to a 21 mm valve. The sutures were placed through the sewing cuff of the bioprosthetic valve and the valve was parachuted into the supra annular position. It was then secured using the cor-knot device. The aortotomy was then closed in a 2 layered fashion using 4-0 Prolene.
The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. The heart regained a spontaneous sinus rhythm. The aortotomy was found to be hemostatic. Pacing wires were placed on the right ventricle and brought to the level of the skin. Lungs were ventilated. The heart was then weaned from bypass without difficulty. Final TEE was performed with findings as described. Protamine was then delivered to reverse the effects of heparin and the heart was decannulated in the usual fashion. All cannulation sites were oversewn with 4-0 Prolene.
The chest tubes were then placed, with an angled chest tube placed in the left pleural space for management of the left pleural effusion. The sternum was reapproximated with #7 wires. The most superior wire fractured at the completion of the procedure. Therefore, rigid sternal fixation was performed by placing a 4-hole manubrial plate at the superior aspect of the manubrium and securing it with 14 mm anchoring screws x4. The superior abdominal fascia was then reapproximated with 0 Ethibond. The soft tissues were reapproximated with 0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound. The patient tolerated the procedure well and was transferred to CVRU.
33405
33427
76998 26
thanks in advance