Help!! I have overthought this and confused myself horribly. 
My surgeon removed a 8mm fibroelastoma, came off bypass and on TEE the patient showed mild to moderate aortic insufficiency. One leaflet was a little shorter and an aortic jet was going through that area. The decision was made to proceed with an AVR.
A 23 mm mechanical valve was chosen and sutured in. We had technical difficulties putting the aortic valve through the ST junction and it was not sitting in the aortic annlus nicely. The start of the aortic valve was not going through the annulus. At that point he swapped to a 21mm mechanical valve.
23 mm valve was removed. The sutures were cut. All pledgets were removed as well. Following that, the new 2 Ethibond sutures were placed on the aortic annulus with the pledgets on the aortic side using the inverting technique. The sutures were passed through the prosthetic valve and the prosthetic valve was lowered into the aortic annulus. This time the 21 mm valve was sitting in the annulus nicley. The sutures were tied and cut. The position of the aortic valve was checked. It was sitting in the aortic annulus nicely. It should be noted that in order to place the 21 mm aortic valve into the annulus, I extended the aortotomy through the mid portion of the aortic annulus, the noncoronary cusp area.
In order to close the aortotomy I used a bovine pericardial patch. The triangular segment was shaped out of the pericardial patch and was sutured into the area of the aortic annulus using 4-0 Prolene sutures. The rest of the aortotomy was closed using 3-0 running Prolene suture in 2 layers. All sutures were tied down. Additional pledgeted 3-0 was placed on the aortic annulus at the noncoronary cusp site. Following that the suture line was checked by giving additional cardioplegia on the aortic root and 2 leaking spots on the aortotomy suture line were repaired using 4-0 pledgeted Prolene sutures.
33120 and 33405 vs. 33405 with a modifier 22? And these are just the first 2 scenarios I have tried to talk myself into.
My surgeon removed a 8mm fibroelastoma, came off bypass and on TEE the patient showed mild to moderate aortic insufficiency. One leaflet was a little shorter and an aortic jet was going through that area. The decision was made to proceed with an AVR.
A 23 mm mechanical valve was chosen and sutured in. We had technical difficulties putting the aortic valve through the ST junction and it was not sitting in the aortic annlus nicely. The start of the aortic valve was not going through the annulus. At that point he swapped to a 21mm mechanical valve.
23 mm valve was removed. The sutures were cut. All pledgets were removed as well. Following that, the new 2 Ethibond sutures were placed on the aortic annulus with the pledgets on the aortic side using the inverting technique. The sutures were passed through the prosthetic valve and the prosthetic valve was lowered into the aortic annulus. This time the 21 mm valve was sitting in the annulus nicley. The sutures were tied and cut. The position of the aortic valve was checked. It was sitting in the aortic annulus nicely. It should be noted that in order to place the 21 mm aortic valve into the annulus, I extended the aortotomy through the mid portion of the aortic annulus, the noncoronary cusp area.
In order to close the aortotomy I used a bovine pericardial patch. The triangular segment was shaped out of the pericardial patch and was sutured into the area of the aortic annulus using 4-0 Prolene sutures. The rest of the aortotomy was closed using 3-0 running Prolene suture in 2 layers. All sutures were tied down. Additional pledgeted 3-0 was placed on the aortic annulus at the noncoronary cusp site. Following that the suture line was checked by giving additional cardioplegia on the aortic root and 2 leaking spots on the aortotomy suture line were repaired using 4-0 pledgeted Prolene sutures.
33120 and 33405 vs. 33405 with a modifier 22? And these are just the first 2 scenarios I have tried to talk myself into.