jtb57chevy
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This case is more complex than I'm used to and I will greatly appreciate any recommendations.
PREOPERATIVE DIAGNOSIS: Aortic insufficiency and ascending aortic aneurysm.
POSTOPERATIVE DIAGNOSIS: Aortic insufficiency and ascending aortic aneurysm, right subclavian artery dissection.
OPERATION: Aortic valve replacement with a #23 millimeter Bovine pericardial valve, supracoronary ascending aortic replacement with a 34 millimeter tube graft, aorto right subclavian bypass with an 8 millimeter tube graft and transesophageal echocardiography.
DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the operating room table . Antibiotics were administered according to SCIP protocols and will be discontinued within 24 hours. After general endotracheal intubation, a transesophageal echocardiogram probe was passed by Dr. Z and showed evidence of good biventricular function, 1-2+ tricuspid regurgitation. There as severe aortic insufficiency. The sinotubular junction appeared to be approximately 3.2 centimeters in size where as the ascending aorta was approximately 4.9 centimeters in size. With these findings, I first proceeded to perform a right axillary cannulation. The right axillary artery was exposed. It was snared with vessel loops. 5000 units Heparin was delivered. The vessel was clamped and was entered. There was evidence of dissection in this vessel. The dissection extended both proximally and distally. I exposed the artery further, however, I had to ligate the proximal axillary to obtain hemostasis. The distal end, I anastomosed to the end of the 8 millimeter tube graft. There was good back bleeding. I left this in the pocket. I then performed sternotomy incision and centrally cannulated the proximal arch with a #24 straight aortic cannula. A two-stage venous cannula was placed and a retrograde cardioplegia cannula was placed in the coronary sinus. The ACT was greater than 400, the patient was placed on cardiopulmonary bypass. An LV vent was passed through the right superior pulmonary vein. Aortic cross clamp was applied and cold blood cardioplegia was delivered in a retrograde fashion. The heart was promptly arrested. A transverse aortotomy incision was made. The ascending aorta was resected from the sinotubular junction from just proximal to our cross clamp. The dimension of the artery was approximately 3.4 centimeters by the cross clamp as was the sinotubular junction. The aortic valve was tricommisural. There was calcification of the left coronary cusp. The valve was completely excised. The annulus was d?brided and it was sized to a #23 millimeter Bovine pericardial vavle. Ethibond suture was placed about the valve annulus, was passed through the vavle cuff. The valve was seated and conformed to the annular sutures and tied in place. A 34 millimeter tube graft was selected and it was sewn in a running fashion with 4-0 Prolene suture proximally and then distally. An 8 mm tube graft was taken off of the mid-ascending aortic tube graft. It was tunneled through the right chest and through the third interspace and into the incision to perform an end to end anastomosis to the right axillary artery. A hot shot had been delivered prior to cross clamp removal. Then deairing maneuvers had been undertaken successfully and vents were removed. Retrograde cardioplegia cannula sites were all removed. Patient developed spontaneous NSR. Echocardiography showed evidence of normal biventricular function with 2+ tricuspid regurgitation, no evidence of aortic insufficiency with good biventricular function. 50% of the protamine dose was given to maintain the ACT slightly elevated at 180 at this point. There was evidence of good hemostasis. Attention was then drawn to the axillary artery repair. Dr. X was consulted intraoperatively for assistance with this portion of the procedure. The vessel was quite friable, however, we dissected the vessel distally to a point where there was no further dissection and an end to end anastomosis was performed using 5-0 Prolene suture in a running fashion. Flow was then established to the right arm, Doppler done intraoperatively demonstrated flow. The remaining Protamine dose was administered without any adverse effects. Chest tubes were placed. Paired atrial and ventricular pacing wires were placed. The wound was thoroughly irrigated with antibiotic irrigation. Chest was closed in a normal fashion over chest tubes. The right axillary incision was closed in a normal fashion.
OPERATIVE FINDINGS: There was severe aortic insufficiency, 4.9 centimeter ascending aorta with friable right axillary artery which was dissected after manipulation, normal left ventricular function with a 2+ tricuspid regurgitation, no residual aortic insufficiency post-operatively.
SPECIMENS: Aorta and aortic valve.
COMPLICATIONS: Right axillary artery dissection, transfusion of one unit of packed cells. No drips. The patient was in stable condition and was taken to the open heart recovery room in stable condition. I'm thinking 33405 for the valve, 33860 for the aorto tube graft, but not sure what to do with the aorto-axillary bypass....Maybe 37799 and price it similar to 35626?
PREOPERATIVE DIAGNOSIS: Aortic insufficiency and ascending aortic aneurysm.
POSTOPERATIVE DIAGNOSIS: Aortic insufficiency and ascending aortic aneurysm, right subclavian artery dissection.
OPERATION: Aortic valve replacement with a #23 millimeter Bovine pericardial valve, supracoronary ascending aortic replacement with a 34 millimeter tube graft, aorto right subclavian bypass with an 8 millimeter tube graft and transesophageal echocardiography.
DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the operating room table . Antibiotics were administered according to SCIP protocols and will be discontinued within 24 hours. After general endotracheal intubation, a transesophageal echocardiogram probe was passed by Dr. Z and showed evidence of good biventricular function, 1-2+ tricuspid regurgitation. There as severe aortic insufficiency. The sinotubular junction appeared to be approximately 3.2 centimeters in size where as the ascending aorta was approximately 4.9 centimeters in size. With these findings, I first proceeded to perform a right axillary cannulation. The right axillary artery was exposed. It was snared with vessel loops. 5000 units Heparin was delivered. The vessel was clamped and was entered. There was evidence of dissection in this vessel. The dissection extended both proximally and distally. I exposed the artery further, however, I had to ligate the proximal axillary to obtain hemostasis. The distal end, I anastomosed to the end of the 8 millimeter tube graft. There was good back bleeding. I left this in the pocket. I then performed sternotomy incision and centrally cannulated the proximal arch with a #24 straight aortic cannula. A two-stage venous cannula was placed and a retrograde cardioplegia cannula was placed in the coronary sinus. The ACT was greater than 400, the patient was placed on cardiopulmonary bypass. An LV vent was passed through the right superior pulmonary vein. Aortic cross clamp was applied and cold blood cardioplegia was delivered in a retrograde fashion. The heart was promptly arrested. A transverse aortotomy incision was made. The ascending aorta was resected from the sinotubular junction from just proximal to our cross clamp. The dimension of the artery was approximately 3.4 centimeters by the cross clamp as was the sinotubular junction. The aortic valve was tricommisural. There was calcification of the left coronary cusp. The valve was completely excised. The annulus was d?brided and it was sized to a #23 millimeter Bovine pericardial vavle. Ethibond suture was placed about the valve annulus, was passed through the vavle cuff. The valve was seated and conformed to the annular sutures and tied in place. A 34 millimeter tube graft was selected and it was sewn in a running fashion with 4-0 Prolene suture proximally and then distally. An 8 mm tube graft was taken off of the mid-ascending aortic tube graft. It was tunneled through the right chest and through the third interspace and into the incision to perform an end to end anastomosis to the right axillary artery. A hot shot had been delivered prior to cross clamp removal. Then deairing maneuvers had been undertaken successfully and vents were removed. Retrograde cardioplegia cannula sites were all removed. Patient developed spontaneous NSR. Echocardiography showed evidence of normal biventricular function with 2+ tricuspid regurgitation, no evidence of aortic insufficiency with good biventricular function. 50% of the protamine dose was given to maintain the ACT slightly elevated at 180 at this point. There was evidence of good hemostasis. Attention was then drawn to the axillary artery repair. Dr. X was consulted intraoperatively for assistance with this portion of the procedure. The vessel was quite friable, however, we dissected the vessel distally to a point where there was no further dissection and an end to end anastomosis was performed using 5-0 Prolene suture in a running fashion. Flow was then established to the right arm, Doppler done intraoperatively demonstrated flow. The remaining Protamine dose was administered without any adverse effects. Chest tubes were placed. Paired atrial and ventricular pacing wires were placed. The wound was thoroughly irrigated with antibiotic irrigation. Chest was closed in a normal fashion over chest tubes. The right axillary incision was closed in a normal fashion.
OPERATIVE FINDINGS: There was severe aortic insufficiency, 4.9 centimeter ascending aorta with friable right axillary artery which was dissected after manipulation, normal left ventricular function with a 2+ tricuspid regurgitation, no residual aortic insufficiency post-operatively.
SPECIMENS: Aorta and aortic valve.
COMPLICATIONS: Right axillary artery dissection, transfusion of one unit of packed cells. No drips. The patient was in stable condition and was taken to the open heart recovery room in stable condition. I'm thinking 33405 for the valve, 33860 for the aorto tube graft, but not sure what to do with the aorto-axillary bypass....Maybe 37799 and price it similar to 35626?