denali1116
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Please help. Can these both be coded and how?
OPERATION: *
1. Mitral Valve Replacement (29 mm St Jude Epic Porcine Valve)
2. Tricuspid Valve Repair (26 mm Medtronic Triad Ring)
3. Inspection of the Aortic Valve
4. Debridement of Vegetations on Interventricular septum
We started by performing a midline incision. This was taken through the subcutaneous tissue to expose the sternum. We then performed a median sternotomy . The sternum was gently retracted. The pericardium was opened to expose an* enlarged* heart with a dilated and dysfunctional right ventricle. We made a small laceration to the right ventricle acute margin during opening which we later repaired with a plegeted prolene suture. The patient was heparinized.
Cannulae were placed in the ascending aorta and also in the superior vena cavae. We did not manipulate the heart in this process to prevent inadvertent embolization. Cardiopulmonary bypass was instituted. The aorta was cross-clamped and the heart was protected with del Nido cardioplegia administered in the r antegrade route with redosing an hour later via the coronary sinus. With the aorta clamped we placed a second cannula in the inferior vena cava.
The interatrial groove was then dissected generously and a left atriotomy performed. Inspection of the mitral valve showed large vegetation, obscuring the valve orifice. This was mostly attached to the anterior leaflet and also there was large conglomeration of vegetation along the posterior mitral annulus spreading along the atrial wall up to 4 cm from the valve. We carefully excised the vegetation off the anterior leaflet with the tip of A2. We then debrided the anterior leaflet of vegetation material. A perforation in the A3 segment was revealed. We then debrided all the vegetations from the artial wall and posterior annulus and leaflet. This revealed normal P1 and P2 segments. However the P3 segment was retracted into the ventricle with abnormal thickened shortened chords. There was also some vegetation material which we debrided. Through the valve we observed seeding of vegetations on the interventricular septum. The ventricular septum was debrided. Once we had all the infected material debrided, I had Dr Adams evaluate for reparability. While the anterior leaflet pathology was potentially repairable, the heavily retracted P3 (this could not be mobilized even after division of the thick chordae) could not allow a valve repair without potentially losing this area for valve coaptation, which would result in stenosis. Additionally this would be a long complex repair with unpredictable outcome. We felt the most appropriate strategy would be to do a valve replacement. *
The anterior leaflet was partly excised and chordal attachments reattached to the annulus. The posterior leaflet was left intact. We then placed 2-0 Ethibond sutures with pledgets through the mitral valve annulus with the pledgets on the ventricular side. These were passed through a 29 mm Epic* heart valve and the valve was then lowered into the atrium and tied securely. The atriotomy was closed with running Prolene sutures.
An aortotomy was performed. The aortic valve was inspected and found to be free of vegetations. The aortotomy was closed. Of note the aortotomy is close to the right coronary ostium so if need for repeat aortotomy then this should be done distal to the existing suture line to avoid the right coronary artery.
A hot-shot was administered. The patient was placed in the Trendelenburg position and the cross-clamp was removed.
A right atriotomy was performed.* Inspection of the tricuspid valve revealed mild annular dilatation. No vegetations were seen. We then placed 2-0 Ethibond sutures around the tricuspid valve annulus and then through a 26 mm Triad* Ring. This was tied down securely. The right atriotomy was closed.
The heart was de-aired. Following a period of re-perfusion, cardiopulmonary bypass was discontinued with aid of moderate dose inotropes. Echocardiography showed no significant mitral regurgitation or stenosis. The Heparin was reversed and the patient was de-cannulated. Hemostasis was secured on all the surgical sites. We placed atrial and ventricular pacing wires. Chest drains were placed within the pericardial well. The pericardium was* reapproximated. The sternum was reapproximated with steel wires and the soft tissues were closed with absorbable sutures.
OPERATION: *
1. Mitral Valve Replacement (29 mm St Jude Epic Porcine Valve)
2. Tricuspid Valve Repair (26 mm Medtronic Triad Ring)
3. Inspection of the Aortic Valve
4. Debridement of Vegetations on Interventricular septum
We started by performing a midline incision. This was taken through the subcutaneous tissue to expose the sternum. We then performed a median sternotomy . The sternum was gently retracted. The pericardium was opened to expose an* enlarged* heart with a dilated and dysfunctional right ventricle. We made a small laceration to the right ventricle acute margin during opening which we later repaired with a plegeted prolene suture. The patient was heparinized.
Cannulae were placed in the ascending aorta and also in the superior vena cavae. We did not manipulate the heart in this process to prevent inadvertent embolization. Cardiopulmonary bypass was instituted. The aorta was cross-clamped and the heart was protected with del Nido cardioplegia administered in the r antegrade route with redosing an hour later via the coronary sinus. With the aorta clamped we placed a second cannula in the inferior vena cava.
The interatrial groove was then dissected generously and a left atriotomy performed. Inspection of the mitral valve showed large vegetation, obscuring the valve orifice. This was mostly attached to the anterior leaflet and also there was large conglomeration of vegetation along the posterior mitral annulus spreading along the atrial wall up to 4 cm from the valve. We carefully excised the vegetation off the anterior leaflet with the tip of A2. We then debrided the anterior leaflet of vegetation material. A perforation in the A3 segment was revealed. We then debrided all the vegetations from the artial wall and posterior annulus and leaflet. This revealed normal P1 and P2 segments. However the P3 segment was retracted into the ventricle with abnormal thickened shortened chords. There was also some vegetation material which we debrided. Through the valve we observed seeding of vegetations on the interventricular septum. The ventricular septum was debrided. Once we had all the infected material debrided, I had Dr Adams evaluate for reparability. While the anterior leaflet pathology was potentially repairable, the heavily retracted P3 (this could not be mobilized even after division of the thick chordae) could not allow a valve repair without potentially losing this area for valve coaptation, which would result in stenosis. Additionally this would be a long complex repair with unpredictable outcome. We felt the most appropriate strategy would be to do a valve replacement. *
The anterior leaflet was partly excised and chordal attachments reattached to the annulus. The posterior leaflet was left intact. We then placed 2-0 Ethibond sutures with pledgets through the mitral valve annulus with the pledgets on the ventricular side. These were passed through a 29 mm Epic* heart valve and the valve was then lowered into the atrium and tied securely. The atriotomy was closed with running Prolene sutures.
An aortotomy was performed. The aortic valve was inspected and found to be free of vegetations. The aortotomy was closed. Of note the aortotomy is close to the right coronary ostium so if need for repeat aortotomy then this should be done distal to the existing suture line to avoid the right coronary artery.
A hot-shot was administered. The patient was placed in the Trendelenburg position and the cross-clamp was removed.
A right atriotomy was performed.* Inspection of the tricuspid valve revealed mild annular dilatation. No vegetations were seen. We then placed 2-0 Ethibond sutures around the tricuspid valve annulus and then through a 26 mm Triad* Ring. This was tied down securely. The right atriotomy was closed.
The heart was de-aired. Following a period of re-perfusion, cardiopulmonary bypass was discontinued with aid of moderate dose inotropes. Echocardiography showed no significant mitral regurgitation or stenosis. The Heparin was reversed and the patient was de-cannulated. Hemostasis was secured on all the surgical sites. We placed atrial and ventricular pacing wires. Chest drains were placed within the pericardial well. The pericardium was* reapproximated. The sternum was reapproximated with steel wires and the soft tissues were closed with absorbable sutures.