krisfelty
Guest
I am stuck on this. Not sure what to code for this sine the patient expired. Lisigirl, I hope you see this and can help me. Thanks!!
Kris Felty CPC, CCC, CCVTC
OPERATIVE PROCEDURE:
Replacement of the aortic arch and the ascending aorta in a redo fashion with
hypothermic circulatory arrest.
INDICATIONS:
The patient is an extremely sick gentleman. He underwent what
sounds like emergency thymectomy 2 years ago. At that time,
his wife described his cardiac surgeons saying that if he did not lose weight
and did not control his hypertension, then this would be the cause of his
demise. His surgery was a very rocky course. Over the past month, he has not
been feeling well, and on 12/27, he stated around 2 p.m. that he felt
terrible. He had chest pain and abdominal discomfort. He did have abdominal
bloating and his right leg became numb. He presented to the emergency room
the following day at 4 p.m. He apparently has had uncontrolled hypertension
and has stopped taking his hypertensive medications secondary to finances.
His wife had been away for the last 1 year, and she returned home 3 days ago.
She insisted that he go to the emergency room today. He underwent a CAT scan,OPERATIVE PROCEDURE:
Replacement of the aortic arch and the ascending aorta in a redo fashion with
hypothermic circulatory arrest.
INDICATIONS:
The patient is an extremely sick 41-year-old gentleman. He underwent what
sounds like emergency thymectomy 2 years ago in North Carolina. At that time,
his wife described his cardiac surgeons saying that if he did not lose weight
and did not control his hypertension, then this would be the cause of his
demise. His surgery was a very rocky course. Over the past month, he has not
been feeling well, and on 12/27, he stated around 2 p.m. that he felt
terrible. He had chest pain and abdominal discomfort. He did have abdominal
bloating and his right leg became numb. He presented to the emergency room
the following day at 4 p.m. He apparently has had uncontrolled hypertension
and has stopped taking his hypertensive medications secondary to finances.
His wife had been away for the last 1 year, and she returned home 3 days ago.
She insisted that he go to the emergency room today. He underwent a CAT scan,which demonstrated a dissection essentially from the aortic valve all the way
to the iliac arteries. Additionally, the mesenteric vessels were dissected as
was the aortic arch. I had an extremely long discussion with the patient
about this with the family. I also discussed this with the family after the
patient was taken to the operating room. He had evidence of aortic rupture on
CAT scan. Additionally, he had significant evidence of malperfusion. I
explained to the family I had significant concerns that this was a lethal
condition.
FINDINGS:
This was without question the worst anatomic dissection I have ever operated
on. Firstly, his adhesions were unlike any other adhesions I have ever seen.
He had clips all along his innominate vein, and his innominate vein was
completely stuck to the underside of his sternum. Attempts were made to
remove the vein from the underside of the sternum; however, this was near
impossible. The vein remained under significant tension despite significant
dissection. His aortic tissue was even worse. He had a tremendous amount of
clot adjacent to his aorta. His pericardium was completely adhesed to his
heart. Despite the fact that attempts to try to completely mobilize the
aortic arch, the aortic tissue was extremely poor, and multiple attempts were
made to resect the aortic arch; however, this tissue was extremely poor. I
used a felt-fall technique, and even with this, I was unable to obtain any
closure to the distal arch. I had a very long discussion with the family
about this, and despite the fact that multiple attempts, we were unable to
seal the distal arch. His innominate vein was in terrible condition, his
abdomen was profoundly distended and at 12:46, he was pronounced dead.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed on the operating table in
the supine position. He underwent general endotracheal anesthesia. His
cerebral saturations and blood pressure were extremely tenuous. A left
femoral incision was made secondary to the fact that his right femoral artery
had no pulsatile flow. The femoral artery and femoral vein were cannulated,
and the patient was fully heparinized. He was placed on full cardiopulmonary
bypass. At this point, the previous skin incision was opened, and he had a
tremendous keloid on his skin. I removed the sternal wires and then opened
his sternum. Immediately upon opening the sternum, there was some blue blood
at the top of his chest cavity. A careful dissection was used to attempt to
remove the innominate vein off the underside of the sternum; however, this was
completely adherent as were actual Hemoclips on the innominate vein right to
the sternum. This took a significant amount of time to take down. His entire
pericardium was completely adhesed to his epicardium. The patient was cooled
down; however, his heart was extremely distended. His left ventricle was the
thickest left ventricle I have ever seen. The patient started to fibrillate
and circulatoryarrest was started at about 23 degrees. The distal aortic
arch was identified. I completely resected the ascending aorta and midbody of
the aortic arch. Attempts were made to use a felt-fall technique several times; however, this tissue was extremely poor. The dissection flap continued
down into the descending aorta well beyond the ability to perform an
anastomosis. This whole area was completely adhesed as were both lungs. I
did finally managed to use a felt-fall technique on the transverse arch and
then used a 26-mm Hemashield at this point. I placed a clamp across this
Hemashield graft and attempted to start the heart/lung machine once again.
The aorta completely fell apart at this point. Several attempts were made to
repair this; however, this was unrepairable. I spoke to the family on
multiple occasions about this; however, there was no repairing the situation.
The patient was pronounced dead at 12:46 a.m. on 03/29/2013.
Kris Felty CPC, CCC, CCVTC
OPERATIVE PROCEDURE:
Replacement of the aortic arch and the ascending aorta in a redo fashion with
hypothermic circulatory arrest.
INDICATIONS:
The patient is an extremely sick gentleman. He underwent what
sounds like emergency thymectomy 2 years ago. At that time,
his wife described his cardiac surgeons saying that if he did not lose weight
and did not control his hypertension, then this would be the cause of his
demise. His surgery was a very rocky course. Over the past month, he has not
been feeling well, and on 12/27, he stated around 2 p.m. that he felt
terrible. He had chest pain and abdominal discomfort. He did have abdominal
bloating and his right leg became numb. He presented to the emergency room
the following day at 4 p.m. He apparently has had uncontrolled hypertension
and has stopped taking his hypertensive medications secondary to finances.
His wife had been away for the last 1 year, and she returned home 3 days ago.
She insisted that he go to the emergency room today. He underwent a CAT scan,OPERATIVE PROCEDURE:
Replacement of the aortic arch and the ascending aorta in a redo fashion with
hypothermic circulatory arrest.
INDICATIONS:
The patient is an extremely sick 41-year-old gentleman. He underwent what
sounds like emergency thymectomy 2 years ago in North Carolina. At that time,
his wife described his cardiac surgeons saying that if he did not lose weight
and did not control his hypertension, then this would be the cause of his
demise. His surgery was a very rocky course. Over the past month, he has not
been feeling well, and on 12/27, he stated around 2 p.m. that he felt
terrible. He had chest pain and abdominal discomfort. He did have abdominal
bloating and his right leg became numb. He presented to the emergency room
the following day at 4 p.m. He apparently has had uncontrolled hypertension
and has stopped taking his hypertensive medications secondary to finances.
His wife had been away for the last 1 year, and she returned home 3 days ago.
She insisted that he go to the emergency room today. He underwent a CAT scan,which demonstrated a dissection essentially from the aortic valve all the way
to the iliac arteries. Additionally, the mesenteric vessels were dissected as
was the aortic arch. I had an extremely long discussion with the patient
about this with the family. I also discussed this with the family after the
patient was taken to the operating room. He had evidence of aortic rupture on
CAT scan. Additionally, he had significant evidence of malperfusion. I
explained to the family I had significant concerns that this was a lethal
condition.
FINDINGS:
This was without question the worst anatomic dissection I have ever operated
on. Firstly, his adhesions were unlike any other adhesions I have ever seen.
He had clips all along his innominate vein, and his innominate vein was
completely stuck to the underside of his sternum. Attempts were made to
remove the vein from the underside of the sternum; however, this was near
impossible. The vein remained under significant tension despite significant
dissection. His aortic tissue was even worse. He had a tremendous amount of
clot adjacent to his aorta. His pericardium was completely adhesed to his
heart. Despite the fact that attempts to try to completely mobilize the
aortic arch, the aortic tissue was extremely poor, and multiple attempts were
made to resect the aortic arch; however, this tissue was extremely poor. I
used a felt-fall technique, and even with this, I was unable to obtain any
closure to the distal arch. I had a very long discussion with the family
about this, and despite the fact that multiple attempts, we were unable to
seal the distal arch. His innominate vein was in terrible condition, his
abdomen was profoundly distended and at 12:46, he was pronounced dead.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed on the operating table in
the supine position. He underwent general endotracheal anesthesia. His
cerebral saturations and blood pressure were extremely tenuous. A left
femoral incision was made secondary to the fact that his right femoral artery
had no pulsatile flow. The femoral artery and femoral vein were cannulated,
and the patient was fully heparinized. He was placed on full cardiopulmonary
bypass. At this point, the previous skin incision was opened, and he had a
tremendous keloid on his skin. I removed the sternal wires and then opened
his sternum. Immediately upon opening the sternum, there was some blue blood
at the top of his chest cavity. A careful dissection was used to attempt to
remove the innominate vein off the underside of the sternum; however, this was
completely adherent as were actual Hemoclips on the innominate vein right to
the sternum. This took a significant amount of time to take down. His entire
pericardium was completely adhesed to his epicardium. The patient was cooled
down; however, his heart was extremely distended. His left ventricle was the
thickest left ventricle I have ever seen. The patient started to fibrillate
and circulatoryarrest was started at about 23 degrees. The distal aortic
arch was identified. I completely resected the ascending aorta and midbody of
the aortic arch. Attempts were made to use a felt-fall technique several times; however, this tissue was extremely poor. The dissection flap continued
down into the descending aorta well beyond the ability to perform an
anastomosis. This whole area was completely adhesed as were both lungs. I
did finally managed to use a felt-fall technique on the transverse arch and
then used a 26-mm Hemashield at this point. I placed a clamp across this
Hemashield graft and attempted to start the heart/lung machine once again.
The aorta completely fell apart at this point. Several attempts were made to
repair this; however, this was unrepairable. I spoke to the family on
multiple occasions about this; however, there was no repairing the situation.
The patient was pronounced dead at 12:46 a.m. on 03/29/2013.