jtb57chevy
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Not sure what to bill for this- any help will be greatly appreciated. I'm thinking 33860 and 33530 but I don't think that includes the valve replacement. 33863 doesn't seem correct since the valve replacement was separate. PREOPERATIVE DIAGNOSIS: Severe aortic stenosis.
POSTOPERATIVE DIAGNOSIS: Severe aortic stenosis.
OPERATION
Redo-redo aortic valve replacement with a #19 mm St. Jude mechanical valve.
Supracoronary ascending aortic replacement with a #26 mm tube graft.
Aortic root enlargement with dacron patch
Transesophageal echocardiography.
INDICATIONS/FINDINGS: The patient is a ... Review of old medical records revealed evidence of a 19 mm Freestyle valve being placed. There was evidence of moderate aortic insufficiency and severe aortic stenosis on echocardiogram, and calcification on CAT scan of the ascending aorta. Cardiac catheterization revealed normal coronary anatomy. Followup CAT scans of the abdomen revealed splenic and renal infarcts markedly improved. The patient has completed her course of antibiotics for endocarditis, and now presents for aortic valve replacement and possible root replacement.
DESCRIPTION OF PROCEDURE: The patient was placed in supine position on the operating room table. Antibiotics were administered according to SCIP protocols, and will be continued postoperatively until cultures are obtained from the aortic valve tissue specimen. Redo sternotomy incision was employed, after a transesophageal echocardiogram probe was passed by Dr. XYZ under general anesthesia. Transesophageal echocardiogram showed evidence of concentric left ventricular hypertrophy, good biventricular function, evidence of severe aortic stenosis with a valve area of less than 0.9, with peak velocities of almost 440. There was mild aortic insufficiency. No significant mitral regurgitation noted.
Redo sternotomy incision was employed. The sternum was divided in the midline with an oscillating saw. Sternal entry was uneventful. In the previous surgery, a gortex patch had been placed anteriorly. This was completely removed. Partial adhenolysis was performed involving the ascending aorta and the right side of the heart. The transverse arch, after systemic heparinization, was cannulated with a #22 aortic cannula. A two-stage venous cannula was placed into the right atrial , and a retrograde cardioplegia cannula was secured in place in the coronary sinus. With ACT greater than 400, the patient was placed on cardiopulmonary bypass. An LV vent was passed through the right superior pulmonary vein. Aortic crossclamp was then applied and cold blood cardioplegia was delivered to the aortic root. Topical ice slush was applied to the heart. The heart promptly arrested after a combination of both antegrade and retrograde cardioplegia doses being delivered.
The aorta was small in size, approximately 2.0 cm or less. A transverse aortotomy incision was made. It was carried down to the sinotubular junction. Examination of the root showed evidence of a small root. There was a extensive fibrosis around both left and right main, although they were widely patent. The aortic Freestyle valve was severely calcified. The valve was completely excised. The annulus was thoroughly débrided. It was a small root, and for this reason the aortic wall was transected down to the level of the mid noncoronary cusp, and across the non coronary annulus onto the anterior leaflet of the mitral valve to perform a root enlargement. A Hemashield tube graft was selected, 26 mm in size. It was cut and fashioned with one tongue that would protrude down into the noncoronary cusp, with the remaining shelf then being sewn at the sinotubular junction. Ethibond sutures were placed about the valve annulus. Initially I sized the valve to a 21 mm mechanical, however on implanting the valve it became quite apparent that the left main was being obstructed. This valve was then removed and a 19 mm St. Jude Regent was then placed. After sutures were tied in place with interrupted Ethibond sutures, there was excellent patency of both left and right main noted. The valve was sutured along the side of the tube graft, above the annular plane. Using 4-0 Prolene suture, the tube graft was then sewn to the sinotubular junction circumferentially. Throughout the procedure, antegrade doses were delivered to both left and right main at 20 minute intervals, as well as retrograde cardioplegia delivered. The distal anastomosis between the tube graft and the aorta was then constructed in a running fashion with 4-0 Prolene suture. A hot shot was given prior to crossclamp removal. With the heart filled with blood the lungs were ventilated. The patient was placed in steep Trendelenburg position. With hot shot running the aortic crossclamp was removed. A vent was placed in the ascending aorta. CO2 was insufflated throughout the case to aid in deairing.
The heart developed a ventricular arrhythmia and was cardioverted, and then developed a spontaneous sinus rhythm. Paired atrial and ventricular pacing wires were placed. Deairing maneuvers were undertaken. The heart was allowed to eject. There was no evidence of intracavitary air. The LV vent was removed and that site closed with the previously placed pursestring. Echocardiography was then used to interrogate the valve, which showed a low gradient less than 5 mm, with normal biventricular function, with no evidence of aortic insufficiency and just trivial mitral regurgitation. The patient was weaned down to a liter and a half of flow. The sump in the ascending aorta was removed. That site was closed with the previously placed pursestring. The patient was placed in supine position. There was absolutely no evidence of intracavitary air. The patient was completely separated from cardiopulmonary bypass. The venous cannula was removed. Retrograde cardioplegia cannula was removed. All sites were closed with the previously placed pursestring.
The patient demonstrated excellent hemostasis and hemodynamic stability. Protamine was administered. When 50% of the protamine dose was given, the aortic cannula was removed. Aortotomy site was closed with the previously placed pursestring. The remaining protamine dose was administered without any adverse effects. With evidence of excellent hemostasis, the wound was thoroughly irrigated with antibiotic irrigation. A chest tube was placed in the right pleural space, one in the anterior mediastinum, one at the base of the heart. The left pleural space was not entered. The chest was then closed in normal fashion with #5 sternal wires. Sterile dressing was applied.
FINDINGS: An old porcine Freestyle with severe calcification, moderate annular calcification, and normal biventricular function. Postop normal biventricular function with no evidence of aortic insufficiency and trivial mitral regurgitation.