conleyclan
Guru
Good Morning. I am struggling to code this report. I have the aortic valve, balloon pump and VSD repair. It is the RVOT augmentation along with the pulmonic root replacement that is stumping me. Thanks for any help.
PREOPERATIVE DIAGNOSES: Severe pulmonic insufficiency, a history of
tetralogy of Fallot status post RVOT patch augmentation and VSD closure,
severe right ventricular dysfunction, moderate tricuspid regurgitation,
moderate aortic insufficiency.
POSTOPERATIVE DIAGNOSES: Severe pulmonic insufficiency, a history of
tetralogy of Fallot status post RVOT patch augmentation and VSD closure,
severe right ventricular dysfunction, moderate tricuspid regurgitation,
moderate aortic insufficiency.
PROCEDURES PERFORMED: Reoperative pulmonic root replacement (32 mm
homograft), right ventricular outflow tract augmentation (Vascutek patch),
VSD repair (Vascutek patch), aortic valve replacement (25-mm St. Jude
Medical Regent). Placement of intraaortic balloon pump.
ANESTHESIA: General endotracheal.
BRIEF HISTORY: The patient is a 67-year-old male with a history of
tetralogy of Fallot and 3 prior cardiac surgeries. His first was in the
early 1960s who performed Blalock shunt.
Subsequently, he underwent tetralogy of Fallot repair that included closure
of the VSD and RVOT patch augmentation and ultimately underwent a second
operation that included homograft pulmonic root replacement. He has not
required surgery for many years; however, he has developed quite severe
right ventricular dysfunction in the setting of torrential pulmonic
insufficiency. He had a markedly dilated right ventricle with essentially
very little systolic function remaining. He has an indwelling permanent
pacemaker and ICD, and he has been evaluated by multiple other surgical
team's and deemed to be at very high risk for reoperation. He was referred
to me for a second opinion. I felt that he was an operative candidate
despite the severity of his RV dysfunction. He also has chronic renal
insufficiency compounding the risk; however, his options beyond attempted
reconstruction and pulmonic root replacement are limited to
transplantation. I felt that he was a candidate for reconstruction at this
time and he strongly desired that we proceed. He presents today for
elective re-intervention.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. Central line
and radial arterial line were placed by the Anesthesia team for
intraoperative monitoring. Transesophageal echocardiogram was performed
and confirmed the above-noted findings with relatively preserved left
ventricular function, but severe RV dysfunction and severe RV dilatation,
there was torrential pulmonic insufficiency, moderate tricuspid
insufficiency, and mild-to-moderate aortic insufficiency.
The patient was prepped and draped in the usual sterile fashion from the
chin to the toes. A reoperative midline sternotomy was made in the usual
fashion using an oscillating saw for the anterior sternal table and
straight Mayo scissors for the posterior table. There were extraordinarily
dense adhesions throughout the mediastinum, which were carefully lysed. Of
note, the patient had undergone prior patch defibrillator placement with
anterior patch and posterior patch. These patches had completely calcified
making a mediastinal dissection of the right ventricle and left ventricle
areas in particular quite tedious. Nonetheless, the aortic arch, ascending
aorta, both superior and inferior vena cava and the right ventricle and a
portion of the anterior and inferior walls of the left ventricle were
dissected out. After adequate exposure, the patient was heparinized and
then cannulated for cardiopulmonary bypass via the aortic arch and
bicavally. We initially planned on reconstructing the entire right
ventricle and pulmonic root with a beating heart on cardiopulmonary bypass
and this was our initial progression. The patient was placed on
cardiopulmonary bypass and then we began with the right ventricular and the
pulmonic root reconstruction. We noted that the previous patch
augmentation of the RVOT was completely calcified. We opened the pulmonary
artery just at the junction of the left and right and confirmed that the
entire previously placed homograft pulmonic root was completely calcified.
Carefully it was excised and after separating it from the root, we
confirmed that the entire patch augmentation was completely calcified such
that it would not accept any suture and required that we completely replace
that whole patch augmentation. It was explanted to adjacent noncalcified
right ventricle. We also noted that the VSD patch that had been placed
over 40 years ago was completely calcified and a portion of it was at the
right ventricular outflow tract and it would require that we pass suture
through it or the coroner it to allow for placement of the pulmonic
homograft, and therefore, I elected to also remove and redo the VSD repair.
In order to this, we elected to cannulate the ascending aorta and then
arrest the heart with antegrade cardioplegia, so an ascending aortic
catheter was placed and an aortic crossclamp applied and initial induction
cold blood high potassium cardioplegia was delivered antegrade to achieve a
ventricular fibrillatory arrest and subsequent asystolic arrest. We then
carefully excised the previously placed VSD patch, which was about 1.5 cm
in diameter, it was completely calcified. We carefully removed it leaving
a VSD, this VSD was then repaired with Vascutek Gelweave patch, it was
trimmed to a circular shape and then it was implanted from the right
ventricular aspect using running 4-0 Prolene suture. Great care was taken
to avoid getting too close to the aortic valve. The VSD defect was well
repaired with this technique. Following completion, we then administered a
hotshot in an antegrade fashion and then removed the cross clamp to
reperfuse the heart in an antegrade fashion. We then proceeded with
reconstruction of the RVOT. We made a large football shaped patch with a
Vascutek Gelweave. It was sewn to augment the entire right ventricular
outflow tract down to the near apical right ventricle and it was sewn to
the RV with running 3-0 Prolene suture. This effectively reconstructed the
RVOT with a VSD patch on the right lateral wall, the patch augmentation
anteriorly, and the native RVOT laterally and posteriorly. We then thawed
a 32 mm pulmonic homograft root that was trimmed proximally and distally to
the appropriate length and then it was implanted using a running 3-0
Prolene suture for the annular anastomosis to the RVOT and 5-0 Prolene
suture for the pulmonary arterial anastomosis distally. Following
completion, we de-aired the left ventricle and then carefully filled the
heart and inspected the aortic valve. We noted that there appeared to be a
little worse aortic insufficiency now clearly in the moderate range and
this was deemed to be unacceptable, and therefore, I replaced the cross
clamp delivered antegrade cold blood high potassium cardioplegia in an
antegrade fashion and then made an oblique aortotomy to expose the aortic
valve. We inspected that there were no sutures through the valve, but it
appeared that there was some tethering of the noncoronary annulus with the
reconstruction and this in combination with the preoperative degree of
aortic insufficiency precluded valve preservation. The valve was excised
and the annulus sounded to 25 mm. We gave additional antegrade
cardioplegia directly to the right and left coronary ostia to complete
induction and maintenance cardioplegia was administered in an antegrade
fashion intermittently to the ostia. After debriding the aortic annulus,
we then sounded the LVOT and annulus to 25 mm and a 25 mm St. Jude Medical
Regent mechanical valve was implanted using running 2-0 Prolene suture, a
total of 3 sutures were utilized, each covering one third of the
circumference of the annular anastomosis. Following seating of the valve,
the aortotomy was closed with running 4-0 Prolene suture. A hot shot was
administered in an antegrade fashion, the left heart deaired, the cross
clamp removed, and a period of reperfusion allowed. The patient was
subsequently weaned from cardiopulmonary bypass after placement of an
intraaortic balloon pump in the right common femoral artery. The balloon
pump was placed using a Seldinger technique with TEE guidance. The tip was
positioned approximately 1 cm distal to the takeoff of the left subclavian
and descending thoracic aorta. With a combination of intraaortic balloon
pump and both low-dose epinephrine and low-dose milrinone, we were able to
wean the patient from cardiopulmonary bypass. He had persistent right
ventricular dysfunction, which was expected. His left ventricular function
was preserved relative to the preoperative state. The mechanical aortic
valve was well seated with no perivalvular leak and no gradient across it.
There was no pulmonic insufficiency. There was persistent moderate
tricuspid insufficiency; however, there was an ICD lead going through the
tricuspid. The tricuspid annulus itself was not dilated, in fact it was
small in caliber, and therefore, I did not believe that tricuspid valve
repair would yield any better degree of tricuspid insufficiency than
currently present given the small size of the annulus and the fact that
there was an indwelling ICD pacer lead. I felt that the degree of
tricuspid regurgitation would be tolerable and that tricuspid valve
replacement given the size of the annulus, which was small, would be
suboptimal. Therefore, we proceeded with decannulation. The heparin was
then reversed with IV protamine. Meticulous hemostasis was confirmed after
a lengthy period of time drying the patient up due to coagulopathy, likely
secondary to hepatic congestion from longstanding severe RV failure. We
were able to achieve hemostasis to an adequate degree. Two Blake drains
were placed in the mediastinum and then temporary atrial and ventricular
pacing leads were secured. The patient had an indwelling permanent
pacemaker that was functioning well. The sternum was then reapproximated
with interrupted heavy gauge wire. The pectoralis fascia, subcutaneous
tissues, and skin were all approximated with running absorbable sutures.
The patient tolerated the procedure well and was sent to the CT ICU instable condition.
PREOPERATIVE DIAGNOSES: Severe pulmonic insufficiency, a history of
tetralogy of Fallot status post RVOT patch augmentation and VSD closure,
severe right ventricular dysfunction, moderate tricuspid regurgitation,
moderate aortic insufficiency.
POSTOPERATIVE DIAGNOSES: Severe pulmonic insufficiency, a history of
tetralogy of Fallot status post RVOT patch augmentation and VSD closure,
severe right ventricular dysfunction, moderate tricuspid regurgitation,
moderate aortic insufficiency.
PROCEDURES PERFORMED: Reoperative pulmonic root replacement (32 mm
homograft), right ventricular outflow tract augmentation (Vascutek patch),
VSD repair (Vascutek patch), aortic valve replacement (25-mm St. Jude
Medical Regent). Placement of intraaortic balloon pump.
ANESTHESIA: General endotracheal.
BRIEF HISTORY: The patient is a 67-year-old male with a history of
tetralogy of Fallot and 3 prior cardiac surgeries. His first was in the
early 1960s who performed Blalock shunt.
Subsequently, he underwent tetralogy of Fallot repair that included closure
of the VSD and RVOT patch augmentation and ultimately underwent a second
operation that included homograft pulmonic root replacement. He has not
required surgery for many years; however, he has developed quite severe
right ventricular dysfunction in the setting of torrential pulmonic
insufficiency. He had a markedly dilated right ventricle with essentially
very little systolic function remaining. He has an indwelling permanent
pacemaker and ICD, and he has been evaluated by multiple other surgical
team's and deemed to be at very high risk for reoperation. He was referred
to me for a second opinion. I felt that he was an operative candidate
despite the severity of his RV dysfunction. He also has chronic renal
insufficiency compounding the risk; however, his options beyond attempted
reconstruction and pulmonic root replacement are limited to
transplantation. I felt that he was a candidate for reconstruction at this
time and he strongly desired that we proceed. He presents today for
elective re-intervention.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. Central line
and radial arterial line were placed by the Anesthesia team for
intraoperative monitoring. Transesophageal echocardiogram was performed
and confirmed the above-noted findings with relatively preserved left
ventricular function, but severe RV dysfunction and severe RV dilatation,
there was torrential pulmonic insufficiency, moderate tricuspid
insufficiency, and mild-to-moderate aortic insufficiency.
The patient was prepped and draped in the usual sterile fashion from the
chin to the toes. A reoperative midline sternotomy was made in the usual
fashion using an oscillating saw for the anterior sternal table and
straight Mayo scissors for the posterior table. There were extraordinarily
dense adhesions throughout the mediastinum, which were carefully lysed. Of
note, the patient had undergone prior patch defibrillator placement with
anterior patch and posterior patch. These patches had completely calcified
making a mediastinal dissection of the right ventricle and left ventricle
areas in particular quite tedious. Nonetheless, the aortic arch, ascending
aorta, both superior and inferior vena cava and the right ventricle and a
portion of the anterior and inferior walls of the left ventricle were
dissected out. After adequate exposure, the patient was heparinized and
then cannulated for cardiopulmonary bypass via the aortic arch and
bicavally. We initially planned on reconstructing the entire right
ventricle and pulmonic root with a beating heart on cardiopulmonary bypass
and this was our initial progression. The patient was placed on
cardiopulmonary bypass and then we began with the right ventricular and the
pulmonic root reconstruction. We noted that the previous patch
augmentation of the RVOT was completely calcified. We opened the pulmonary
artery just at the junction of the left and right and confirmed that the
entire previously placed homograft pulmonic root was completely calcified.
Carefully it was excised and after separating it from the root, we
confirmed that the entire patch augmentation was completely calcified such
that it would not accept any suture and required that we completely replace
that whole patch augmentation. It was explanted to adjacent noncalcified
right ventricle. We also noted that the VSD patch that had been placed
over 40 years ago was completely calcified and a portion of it was at the
right ventricular outflow tract and it would require that we pass suture
through it or the coroner it to allow for placement of the pulmonic
homograft, and therefore, I elected to also remove and redo the VSD repair.
In order to this, we elected to cannulate the ascending aorta and then
arrest the heart with antegrade cardioplegia, so an ascending aortic
catheter was placed and an aortic crossclamp applied and initial induction
cold blood high potassium cardioplegia was delivered antegrade to achieve a
ventricular fibrillatory arrest and subsequent asystolic arrest. We then
carefully excised the previously placed VSD patch, which was about 1.5 cm
in diameter, it was completely calcified. We carefully removed it leaving
a VSD, this VSD was then repaired with Vascutek Gelweave patch, it was
trimmed to a circular shape and then it was implanted from the right
ventricular aspect using running 4-0 Prolene suture. Great care was taken
to avoid getting too close to the aortic valve. The VSD defect was well
repaired with this technique. Following completion, we then administered a
hotshot in an antegrade fashion and then removed the cross clamp to
reperfuse the heart in an antegrade fashion. We then proceeded with
reconstruction of the RVOT. We made a large football shaped patch with a
Vascutek Gelweave. It was sewn to augment the entire right ventricular
outflow tract down to the near apical right ventricle and it was sewn to
the RV with running 3-0 Prolene suture. This effectively reconstructed the
RVOT with a VSD patch on the right lateral wall, the patch augmentation
anteriorly, and the native RVOT laterally and posteriorly. We then thawed
a 32 mm pulmonic homograft root that was trimmed proximally and distally to
the appropriate length and then it was implanted using a running 3-0
Prolene suture for the annular anastomosis to the RVOT and 5-0 Prolene
suture for the pulmonary arterial anastomosis distally. Following
completion, we de-aired the left ventricle and then carefully filled the
heart and inspected the aortic valve. We noted that there appeared to be a
little worse aortic insufficiency now clearly in the moderate range and
this was deemed to be unacceptable, and therefore, I replaced the cross
clamp delivered antegrade cold blood high potassium cardioplegia in an
antegrade fashion and then made an oblique aortotomy to expose the aortic
valve. We inspected that there were no sutures through the valve, but it
appeared that there was some tethering of the noncoronary annulus with the
reconstruction and this in combination with the preoperative degree of
aortic insufficiency precluded valve preservation. The valve was excised
and the annulus sounded to 25 mm. We gave additional antegrade
cardioplegia directly to the right and left coronary ostia to complete
induction and maintenance cardioplegia was administered in an antegrade
fashion intermittently to the ostia. After debriding the aortic annulus,
we then sounded the LVOT and annulus to 25 mm and a 25 mm St. Jude Medical
Regent mechanical valve was implanted using running 2-0 Prolene suture, a
total of 3 sutures were utilized, each covering one third of the
circumference of the annular anastomosis. Following seating of the valve,
the aortotomy was closed with running 4-0 Prolene suture. A hot shot was
administered in an antegrade fashion, the left heart deaired, the cross
clamp removed, and a period of reperfusion allowed. The patient was
subsequently weaned from cardiopulmonary bypass after placement of an
intraaortic balloon pump in the right common femoral artery. The balloon
pump was placed using a Seldinger technique with TEE guidance. The tip was
positioned approximately 1 cm distal to the takeoff of the left subclavian
and descending thoracic aorta. With a combination of intraaortic balloon
pump and both low-dose epinephrine and low-dose milrinone, we were able to
wean the patient from cardiopulmonary bypass. He had persistent right
ventricular dysfunction, which was expected. His left ventricular function
was preserved relative to the preoperative state. The mechanical aortic
valve was well seated with no perivalvular leak and no gradient across it.
There was no pulmonic insufficiency. There was persistent moderate
tricuspid insufficiency; however, there was an ICD lead going through the
tricuspid. The tricuspid annulus itself was not dilated, in fact it was
small in caliber, and therefore, I did not believe that tricuspid valve
repair would yield any better degree of tricuspid insufficiency than
currently present given the small size of the annulus and the fact that
there was an indwelling ICD pacer lead. I felt that the degree of
tricuspid regurgitation would be tolerable and that tricuspid valve
replacement given the size of the annulus, which was small, would be
suboptimal. Therefore, we proceeded with decannulation. The heparin was
then reversed with IV protamine. Meticulous hemostasis was confirmed after
a lengthy period of time drying the patient up due to coagulopathy, likely
secondary to hepatic congestion from longstanding severe RV failure. We
were able to achieve hemostasis to an adequate degree. Two Blake drains
were placed in the mediastinum and then temporary atrial and ventricular
pacing leads were secured. The patient had an indwelling permanent
pacemaker that was functioning well. The sternum was then reapproximated
with interrupted heavy gauge wire. The pectoralis fascia, subcutaneous
tissues, and skin were all approximated with running absorbable sutures.
The patient tolerated the procedure well and was sent to the CT ICU instable condition.