Please help, 35021 & 33863???
I'm new to Cardiothoracic and need help on if I assigned the right CPTs:
Procedure: RIGHT AXILLARY ARTERY CANNULATION WITH REPLACEMENT OF AORTIC
VALVE, AND AORTIC ANEURYSM WITH REIMPLANTATION OF THE CORONARY ARTERIES
(BENTALL PROCEDURE) WITH A TISSUE COMPOSITE GRAFT.
Preoperative Diagnosis: Aortic insufficiency with aortic aneurysm.
Postoperative Diagnosis: Aortic insufficiency with aortic aneurysm.
Anesthesia: General endotracheal.
Description of Procedure: Following written informed consent and
preoperative antibiotics, the patient was taken to the operating room where
appropriate central venous and arterial monitoring lines were placed. He
was induced with a general anesthetic and a transesophageal echo was placed
which confirmed the preoperative diagnosis. After appropriate time-out, he
was draped and prepped in the usual sterile fashion. Attention was given
to the right axillary region where a several centimeter long incision was
made several centimeters inferior to the clavicle with a combination of
electrocautery and blunt dissection down to the level of the brachial
plexus which was clearly identified and retracted gently out of the way.
Further dissection revealed the axillary artery as well as several feeding
branches. Proximal and distal control of this was obtained and the patient
was heparinized with 7500 units of heparin. The artery was then opened up
sharply and an 8 mm graft was sewn in an end-to-side fashion with 5-0
Prolene. Flow was restored and there was good hemostasis. The graft was
clamped. Attention was then given back to the chest where standard median
sternotomy was performed. The chest was opened widely. The pericardium
was gently opened and the heart was suspended in a cradle revealing the
large aneurysm which clearly had an inflammatory component to it and
appeared to taper down at the level of the arch consistent with the
preoperative assessment. The patient was then heparinized to an adequate
ACT and the axillary graft was deaired and hooked up to the bypass circuit.
Similarly, a pursestring suture was placed in the right atrium which was
cannulated and hooked up to the venous circuit of the cardiopulmonary
bypass was initiated. Retrograde cardioplegia line was placed as well as a
left ventricular vent. With the heart decompressed, we started systemic
cooling to facilitate the repair. The ascending aorta was crossclamped and
the heart was arrested with a combination retrograde cardioplegia and
topical cold. Additional cardioplegia was given in 15-20 minutes intervals
and throughout the case. Once the heart was completely arrested, the
ascending aorta was opened up and debrided back to what appeared to be
healthy arch tissue. It was then debrided back also to the level of the
valve and the anulus. The valve leaflets themselves were inspected and
appeared to be very attenuated and thinned out with poor coaptation and as
I previously discussed with the patient I did not think that this was
something that was salvageable with regards to a valve sparing root
operation. The coronary buttons were dissected free without difficulty and
because of the nature of the aneurysm densely adherent to the pulmonary
artery and other mediastinal structures in that region it could not be
removed in total safely so there was still a patch left laterally which was
excluded from the circulation. The leaflets themselves from the valve were
then excised without difficulty and sent for microbiology and pathology,
and it was then sized to a 29 mm Medtronic tissue valve. The valve itself
was then sewn into a 32 mm tube graft using a running 5-0 Prolene at the
base. Cardioplegia was given and seen coming out of the coronary ostium as
circumferential pledgeted sutures were placed around the root and anulus of
the aorta. These were then passed through the valve conduit which was then
seated down without difficulty and tied. The graft was then trimmed to the
appropriate length, and using an eye cautery, holes were made for the
coronary buttons. The left main one was performed first using a running
5-0 Prolene, and this was attached in a standard fashion. Cardioplegia was
given and seen coming out of the coronary ostium that appeared to be widely
patent. The right coronary button was prepared in a similar fashion using
5-0 Prolene and again cardioplegia was given seen coming out of this is
well. 4-0 Prolene was placed in the graft and root vent was placed, and a
cross-clamp was applied as the heart was pressurized and filled with
cardioplegia which reveals good hemostasis through the aortic valve
anastomosis of the root as well as to the coronary buttons and this allowed
giving some antegrade cardioplegia as attention was then given to the
distal anastomosis. This was performed using a running 3-0 Prolene with a
reinforced felt pledgets circumferentially. Once this was completed, the
cross-clamp was removed and the heart was allowed to reperfuse.
Ventricular pacing wires were placed and after a single episode of
ventricular fibrillation requiring cardioversion. There was a return of a
normal spontaneous rhythm. The whole of the left ventricular vent was
removed and oversewn for hemostasis, and after several minutes of
reperfusion we then weaned off bypass without difficulty. Repeat
transesophageal echo showed good biventricular function. No wall motion
abnormalities. No valvular function and the valve itself appeared to be
seated with minimal gradient. The retrograde cannula was removed and
oversewn for hemostasis and once I was satisfied with the de-airing, the
root vent was also removed. Test dose of protamine was given and as the
remainder of the protamine was given the venous line was removed and
oversewn for hemostasis and the chest was then packed for control of the
coagulopathy that had developed and for administration of the protamine
blood and blood products. This then allowed attention to the axillary
graft which was clipped 4 times and divided. I left it a little bit long
as given the patient's age, this may need to be accessed again in the
future. Once all the protamine and blood products were in the chest was
irrigated with warm antibiotic solution. Topical hemostatic agents were
placed along the raw surface edges and suture line and once I was satisfied
with the hemodynamics and hemostasis, the chest was then closed with
multiple wires. The skin and fascia were closed in a standard fashion, a
sterile dressing was applied. The patient tolerated the procedure well.
There were no complications. I was present for the entire procedure and
available immediately afterwards. Needle and foreign body counts were
correct x2, as the patient was transferred to the ICU in stable but
critical condition. The right pleural tubes and 2 mediastinal tubes were
placed for drainage. Total cardiopulmonary bypass time was 183 minutes
with a cross-clamp time of 153 minutes.
CPT: 35021 & 33863
I'm new to Cardiothoracic and need help on if I assigned the right CPTs:
Procedure: RIGHT AXILLARY ARTERY CANNULATION WITH REPLACEMENT OF AORTIC
VALVE, AND AORTIC ANEURYSM WITH REIMPLANTATION OF THE CORONARY ARTERIES
(BENTALL PROCEDURE) WITH A TISSUE COMPOSITE GRAFT.
Preoperative Diagnosis: Aortic insufficiency with aortic aneurysm.
Postoperative Diagnosis: Aortic insufficiency with aortic aneurysm.
Anesthesia: General endotracheal.
Description of Procedure: Following written informed consent and
preoperative antibiotics, the patient was taken to the operating room where
appropriate central venous and arterial monitoring lines were placed. He
was induced with a general anesthetic and a transesophageal echo was placed
which confirmed the preoperative diagnosis. After appropriate time-out, he
was draped and prepped in the usual sterile fashion. Attention was given
to the right axillary region where a several centimeter long incision was
made several centimeters inferior to the clavicle with a combination of
electrocautery and blunt dissection down to the level of the brachial
plexus which was clearly identified and retracted gently out of the way.
Further dissection revealed the axillary artery as well as several feeding
branches. Proximal and distal control of this was obtained and the patient
was heparinized with 7500 units of heparin. The artery was then opened up
sharply and an 8 mm graft was sewn in an end-to-side fashion with 5-0
Prolene. Flow was restored and there was good hemostasis. The graft was
clamped. Attention was then given back to the chest where standard median
sternotomy was performed. The chest was opened widely. The pericardium
was gently opened and the heart was suspended in a cradle revealing the
large aneurysm which clearly had an inflammatory component to it and
appeared to taper down at the level of the arch consistent with the
preoperative assessment. The patient was then heparinized to an adequate
ACT and the axillary graft was deaired and hooked up to the bypass circuit.
Similarly, a pursestring suture was placed in the right atrium which was
cannulated and hooked up to the venous circuit of the cardiopulmonary
bypass was initiated. Retrograde cardioplegia line was placed as well as a
left ventricular vent. With the heart decompressed, we started systemic
cooling to facilitate the repair. The ascending aorta was crossclamped and
the heart was arrested with a combination retrograde cardioplegia and
topical cold. Additional cardioplegia was given in 15-20 minutes intervals
and throughout the case. Once the heart was completely arrested, the
ascending aorta was opened up and debrided back to what appeared to be
healthy arch tissue. It was then debrided back also to the level of the
valve and the anulus. The valve leaflets themselves were inspected and
appeared to be very attenuated and thinned out with poor coaptation and as
I previously discussed with the patient I did not think that this was
something that was salvageable with regards to a valve sparing root
operation. The coronary buttons were dissected free without difficulty and
because of the nature of the aneurysm densely adherent to the pulmonary
artery and other mediastinal structures in that region it could not be
removed in total safely so there was still a patch left laterally which was
excluded from the circulation. The leaflets themselves from the valve were
then excised without difficulty and sent for microbiology and pathology,
and it was then sized to a 29 mm Medtronic tissue valve. The valve itself
was then sewn into a 32 mm tube graft using a running 5-0 Prolene at the
base. Cardioplegia was given and seen coming out of the coronary ostium as
circumferential pledgeted sutures were placed around the root and anulus of
the aorta. These were then passed through the valve conduit which was then
seated down without difficulty and tied. The graft was then trimmed to the
appropriate length, and using an eye cautery, holes were made for the
coronary buttons. The left main one was performed first using a running
5-0 Prolene, and this was attached in a standard fashion. Cardioplegia was
given and seen coming out of the coronary ostium that appeared to be widely
patent. The right coronary button was prepared in a similar fashion using
5-0 Prolene and again cardioplegia was given seen coming out of this is
well. 4-0 Prolene was placed in the graft and root vent was placed, and a
cross-clamp was applied as the heart was pressurized and filled with
cardioplegia which reveals good hemostasis through the aortic valve
anastomosis of the root as well as to the coronary buttons and this allowed
giving some antegrade cardioplegia as attention was then given to the
distal anastomosis. This was performed using a running 3-0 Prolene with a
reinforced felt pledgets circumferentially. Once this was completed, the
cross-clamp was removed and the heart was allowed to reperfuse.
Ventricular pacing wires were placed and after a single episode of
ventricular fibrillation requiring cardioversion. There was a return of a
normal spontaneous rhythm. The whole of the left ventricular vent was
removed and oversewn for hemostasis, and after several minutes of
reperfusion we then weaned off bypass without difficulty. Repeat
transesophageal echo showed good biventricular function. No wall motion
abnormalities. No valvular function and the valve itself appeared to be
seated with minimal gradient. The retrograde cannula was removed and
oversewn for hemostasis and once I was satisfied with the de-airing, the
root vent was also removed. Test dose of protamine was given and as the
remainder of the protamine was given the venous line was removed and
oversewn for hemostasis and the chest was then packed for control of the
coagulopathy that had developed and for administration of the protamine
blood and blood products. This then allowed attention to the axillary
graft which was clipped 4 times and divided. I left it a little bit long
as given the patient's age, this may need to be accessed again in the
future. Once all the protamine and blood products were in the chest was
irrigated with warm antibiotic solution. Topical hemostatic agents were
placed along the raw surface edges and suture line and once I was satisfied
with the hemodynamics and hemostasis, the chest was then closed with
multiple wires. The skin and fascia were closed in a standard fashion, a
sterile dressing was applied. The patient tolerated the procedure well.
There were no complications. I was present for the entire procedure and
available immediately afterwards. Needle and foreign body counts were
correct x2, as the patient was transferred to the ICU in stable but
critical condition. The right pleural tubes and 2 mediastinal tubes were
placed for drainage. Total cardiopulmonary bypass time was 183 minutes
with a cross-clamp time of 153 minutes.
CPT: 35021 & 33863
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