conleyclan
Guru
This patient had a heart transplant three days prior to rejection. Any help on how to code this, or a price point for an unlisted code, would be great.
PREOPERATIVE DIAGNOSIS: Dysfunctional donor cardiac allograft.
POSTOPERATIVE DIAGNOSIS: Dysfunctional donor cardiac allograft.
PROCEDURES PERFORMED:
1. Complete removal of donor heart.
2. Creation of right atrial and left atrial chambers.
3. Placement of biventricular assist devices using Levitronix Centrifugal
pump with Berlin Heart Cannulas.
donor heart shows no signs of
activity. On echocardiogram, there appears to be a clot inside the heart.
---- comes to the OR for surgical exploration and possible explantation of
the donor heart with placement of ventricular assist devices.
OPERATIVE FINDINGS: The patient was found to have a thrombose inside all
chambers of the heart. The heart itself looked dead.
OPERATIVE TECHNIQUE: With the patient in supine position under excellent
general anesthesia, the chest and abdomen were prepped and draped in the
standard fashion. The Silastic patch membrane was removed. We then
proceeded to switch from ECMO support to cardiopulmonary bypass using the
existing cannulas. Once on cardiopulmonary bypass, I took a very close
look at the heart, which appeared to be dead. The heart was dark in color
and had no activity. The right atrium was clearly thrombosed. The
superior vena cava also appeared to contain clot. I then felt that the
heart needed to be removed since it was clearly dead. I clamped the
ascending aorta just proximal to the aortic cannula. I then proceeded to
undo all the suture lines that kept the donor heart in the mediastinum.
The donor heart was completely removed. I found clot on the main pulmonary
artery, which was removed. I used a Fogarty catheter to make sure that
there was no clot distally. There was backflow of blood from both the
right and left LPA. There was also clot in the superior vena cava which
was also removed using a Fogarty catheter. At this time, in order to
provide a biventricular support, I had to create left atrial and right
atrial chambers. Therefore, I used an 18-mm Gore-Tex tube, which was sewn
to the left atrial cuff in an end-to-end fashion in order to create a
larger capacitance chamber. A 5-0 Prolene was used in a running fashion.
I had placed superior vena cannula once we went on bypass to decompress the
upper body. I then placed a Berlin Heart atrial cannula through the
abdominal wall into the mediastinum and the cannula was sewn in to the open
end of the conduit after plicating the opening of the conduit so that it
would match the sewn ring of the atrial cannula. The cannula was sewn in
place using a 5-0 Prolene in a running fashion. I then opted to use,
again, a similar Gore-Tex conduit for the right atrial reconstruction. I
performed end-to-end anastomosis between the Gore-Tex conduit and the
inferior vena cava using a 5-0 Prolene in a running fashion. The native
superior vena cava was sewn to the side of the tube after creating a hole
in the tube and the anastomosis was performed using interrupted 6-0 Prolene
sutures. An atrial cannula was again tunneled through the abdominal wall
and brought into the mediastinum and sewn to the open end of the tube in a
similar fashion as the left atrial anastomosis. I then proceeded to place
2 arterial cannulas through the abdominal wall into the mediastinum and I
placed interposition graft between the main pulmonary artery and its
respective cannula using an 8-mm Gore-Tex tube which was sewn in one end to
the open end of the main pulmonary artery and at the other end to the sewn
ring of the arterial cannula. Similar type of connection was created in
the aorta. We then primed 2 Levitronix Centrifugal pumps, which were then
connected to the primed cannulas. Cardiopulmonary bypass support was then
discontinued. We proceeded to establish biventricular support. We did
notice that we could not flow as well through the LVAD. It looked like the
left atrial chamber needed a little more stability. Thus, I proceeded to
go back on cardiopulmonary bypass and placed a patch of ring Gore-Tex
anteriorly on the left atrial chamber where the open end of the atrial
cannula was sewn to the Gore-Tex tube. This prevented complete collapse of
the chamber. We again proceeded to come off cardiopulmonary bypass, and
this time, we had much improved flows through the left ventricular assist
device. Intravenous protamine was given. Careful hemostasis was obtained.
Mediastinal chest tube was placed. The incision was then closed using a
patch of Silastic material. A sterile dressing was applied.
PREOPERATIVE DIAGNOSIS: Dysfunctional donor cardiac allograft.
POSTOPERATIVE DIAGNOSIS: Dysfunctional donor cardiac allograft.
PROCEDURES PERFORMED:
1. Complete removal of donor heart.
2. Creation of right atrial and left atrial chambers.
3. Placement of biventricular assist devices using Levitronix Centrifugal
pump with Berlin Heart Cannulas.
donor heart shows no signs of
activity. On echocardiogram, there appears to be a clot inside the heart.
---- comes to the OR for surgical exploration and possible explantation of
the donor heart with placement of ventricular assist devices.
OPERATIVE FINDINGS: The patient was found to have a thrombose inside all
chambers of the heart. The heart itself looked dead.
OPERATIVE TECHNIQUE: With the patient in supine position under excellent
general anesthesia, the chest and abdomen were prepped and draped in the
standard fashion. The Silastic patch membrane was removed. We then
proceeded to switch from ECMO support to cardiopulmonary bypass using the
existing cannulas. Once on cardiopulmonary bypass, I took a very close
look at the heart, which appeared to be dead. The heart was dark in color
and had no activity. The right atrium was clearly thrombosed. The
superior vena cava also appeared to contain clot. I then felt that the
heart needed to be removed since it was clearly dead. I clamped the
ascending aorta just proximal to the aortic cannula. I then proceeded to
undo all the suture lines that kept the donor heart in the mediastinum.
The donor heart was completely removed. I found clot on the main pulmonary
artery, which was removed. I used a Fogarty catheter to make sure that
there was no clot distally. There was backflow of blood from both the
right and left LPA. There was also clot in the superior vena cava which
was also removed using a Fogarty catheter. At this time, in order to
provide a biventricular support, I had to create left atrial and right
atrial chambers. Therefore, I used an 18-mm Gore-Tex tube, which was sewn
to the left atrial cuff in an end-to-end fashion in order to create a
larger capacitance chamber. A 5-0 Prolene was used in a running fashion.
I had placed superior vena cannula once we went on bypass to decompress the
upper body. I then placed a Berlin Heart atrial cannula through the
abdominal wall into the mediastinum and the cannula was sewn in to the open
end of the conduit after plicating the opening of the conduit so that it
would match the sewn ring of the atrial cannula. The cannula was sewn in
place using a 5-0 Prolene in a running fashion. I then opted to use,
again, a similar Gore-Tex conduit for the right atrial reconstruction. I
performed end-to-end anastomosis between the Gore-Tex conduit and the
inferior vena cava using a 5-0 Prolene in a running fashion. The native
superior vena cava was sewn to the side of the tube after creating a hole
in the tube and the anastomosis was performed using interrupted 6-0 Prolene
sutures. An atrial cannula was again tunneled through the abdominal wall
and brought into the mediastinum and sewn to the open end of the tube in a
similar fashion as the left atrial anastomosis. I then proceeded to place
2 arterial cannulas through the abdominal wall into the mediastinum and I
placed interposition graft between the main pulmonary artery and its
respective cannula using an 8-mm Gore-Tex tube which was sewn in one end to
the open end of the main pulmonary artery and at the other end to the sewn
ring of the arterial cannula. Similar type of connection was created in
the aorta. We then primed 2 Levitronix Centrifugal pumps, which were then
connected to the primed cannulas. Cardiopulmonary bypass support was then
discontinued. We proceeded to establish biventricular support. We did
notice that we could not flow as well through the LVAD. It looked like the
left atrial chamber needed a little more stability. Thus, I proceeded to
go back on cardiopulmonary bypass and placed a patch of ring Gore-Tex
anteriorly on the left atrial chamber where the open end of the atrial
cannula was sewn to the Gore-Tex tube. This prevented complete collapse of
the chamber. We again proceeded to come off cardiopulmonary bypass, and
this time, we had much improved flows through the left ventricular assist
device. Intravenous protamine was given. Careful hemostasis was obtained.
Mediastinal chest tube was placed. The incision was then closed using a
patch of Silastic material. A sterile dressing was applied.