I have had a suggestion of using an unlisted code, 33405 and 33866. I'm going to put the dictated note on here and would love to know anyone's thoughts on coding this before I submit my final coding on it. Thanks in advance for any suggestions!
PREOPERATIVE DIAGNOSIS: Transcatheter prosthetic valve endocarditis.
POSTOPERATIVE DIAGNOSIS: Transcatheter prosthetic valve endocarditis.
PROCEDURE PERFORMED:
1. Explant of previously placed Evolut transcatheter valve.
2. Aortic valve replacement using a 25 mm Inspiris valve.
3. Replacement of ascending aorta using a 30 mm Hemashield graft.
FINDINGS:
INDICATIONS: The patient is a 50-year-old gentleman who underwent transcatheter aortic valve replacement a couple of months ago. He has recently been experiencing malaise and fever. He underwent echocardiography, which showed obvious vegetations associated with his transcatheter aortic valve. He had an episode of embolization to his ulnar artery. He was recommended to undergo a valve explant and aortic valve re-replacement. Also noted, is the bicuspid nature of his valve and enlarged ascending aorta, and therefore the aorta was also replaced.
DESCRIPTION OF PROCEDURE: Patient was taken to the operating room and placed on the operating table in the supine position. After the induction of general anesthesia and single-lumen endotracheal tube intubation, patient was prepped and draped sterilely. Standard median sternotomy was performed. The patient was fully heparinized. He was cannulated with a Sarns 8.0 Soft-Flow aortic cannula as well as a dual-stage venous right atrial cannula. Cardiopulmonary bypass was instituted. The cross-clamp was applied, and the heart was arrested with 1 L of del Nido solution. We opened the aorta and transected it. We then carefully mobilized the valve from its points of attachment to the ascending aorta and sinotubular junction. There was no involvement of the aortic root. We then dissected the valve itself off the leaflets and removed the valve entirely. It was covered with vegetations on both sides of the leaflets. Some of this was sent for culture. The valve was sent as a specimen. We then resected the leaflets from this bicuspid valve, which was a Sievers type 1 valve, with fusion of the non and right coronary leaflets. Once the annulus had been meticulously debrided and irrigated, we carefully inspected the remaining tissue. There was no evidence of infection. There was no abscess. Tissue quality was good. We thought this would be reasonable with the recent antibiotic therapy to re-replace his valve and we sized it to a 21 Inspiris. Sutures were placed around the annulus with pledgets on the ventricular side, and this valve was then seated without difficulty and secured in place with Cor-Knot devices. Having resected the ascending aorta to the sinotubular junction, we then selected a 30 mm Hemashield graft and sewed this first proximally, then distally to the native aorta using running 3-0 Prolene. A vent was placed into the graft. The cross-clamp was applied, and then the patient was separated from cardiopulmonary bypass without difficulty. Once off bypass, the post pump transesophageal echo showed a normally functioning prosthetic valve in the aortic position. The protamine was administered and the patient was decannulated. Mediastinal and right pleural chest tubes were placed as well as 2 ventricular pacing wires. Once hemostasis had been achieved, the heart was covered with pericardium and fat, and the chest was closed with #6 stainless steel wire. The subcutaneous tissue and skin were closed with running Vicryl suture. The patient tolerated the procedure wel