I am wondering, if anyone can assist me with coding this congential case?
POSTOPERATIVE DIAGNOSES:
1. Taussig-Bing double-outlet right ventricle, transposition type.
2. Aortic stenosis.
3. Interrupted aortic arch type B.
4. Patent foramen ovale x2.
5. Patent ductus arteriosus.
OPERATIONS:
1. Damus-Kaye-Stansel construction with aortic arch reconstruction.
2. Ventricular septal defect closure, pericardial patch.
3. Closure of patent foramen ovale.
4. Right ventricle to pulmonary artery conduit, 9-mm pulmonary homograft.
5. Lecompte maneuver.
6. Broviac catheter placement.
A midline incision was made overlying the sternum. The sternum was divided in the midline, and the left lobe of the thymus was resected, the right lobe remained intact. The pericardium was opened and the anterior pericardium was ethanol and glutaraldehyde treated for use as a patch. A Broviac catheter was placed with a tunneled course from the left subclavicular region to the subxiphoid region. Seldinger technique was then used to place it between the leads of the diaphragm and into the right atrium at the inferior vena cavoatrial junction and the tip of the catheter was confirmed at atriotomy later in the case.
A 3-mm Gore-Tex shunt was sewn to an arteriotomy on the innominate artery for use as a perfusion. A second aortic cannulation site was chosen on the main pulmonary artery. A bifid aortic cannula was prepared. Heparin was given. The cannulation was carried out with a single venous cannula in the inferior vena cava. A vent in the right atrium and a vent in the left atrium were placed through a right upper pulmonary vein. Two arterial cannulas were placed. The patient was cooled to 32 degrees. During cooling, a full mobilization of the arch and ductus arteriosus was mobilized. The branched pulmonary arteries were normal in caliber. The aorta was in fact diminutive and did not appear suitable for use as a pulmonary artery. Marking sutures were placed in a side-by-side fashion where the aorta would be anastomosed to the main pulmonary artery. The distal arch was isolated. The ductus arteriosus was ligated and divided. The proximal ascending aorta was transected. A Lecompte maneuver was performed. An onlay patch of ethanol treated autologous pericardium was placed on the spatulated descending aorta. The left subclavian artery and the left common carotid artery were anastomosed in a side-by-side fashion over a short distance that constituted the upper aspect of the arch of the main pulmonary artery. The quadriplegia was given. The aortic cross-clamp applied. The ventricular septal defect was visualized through a large valve and the VSD was closed to the pulmonary valve excluding the diminutive aorta to the right ventricle. Pledgeted VSD sutures were placed circumferentially around the ventricular septal defect with transition suture on to the right atrial side of the tricuspid annulus in the area of His bundle. The patch was then applied. The sutures were sequentially tied and cut, and the VSD was in this way closed. Tricuspid valve was tested with the infusion of saline and appeared to be competent. Two patent foramen ovales were present, a large and a small, and the larger one was closed with a running #7-0 Prolene suture. The right atriotomy was then closed. The aortic arch reconstruction was then completed with a direct anastomosis of the main pulmonary artery to the descending aorta and the transverse arch. A side-by-side anastomosis of the aorta to the main pulmonary artery was carried out and the onlay patch of ethanol treated autologous pericardium was continued to augment the ascending aorta and transverse arch completely. The heart was then evacuated of air. The cross-clamp was removed. Rewarming was begun. A right ventriculotomy was made anteriorly, and a homograft was prepared and 9-mm pulmonary homograft was used. The branched pulmonary arteries, the left pulmonary artery had an extensive amount of ductal material on it, which was resected and an onlay patch of native pulmonary artery from the main pulmonary artery remnant was used to patch the left pulmonary artery. The homograft was then sewn at the distal anastomosis after its appropriate tailoring. The proximal anastomosis onto the RV outflow tract was carried out with a running #6-0 Prolene suture. This completed the anatomic repair. Atrial and ventricular pacing wires were placed. A transthoracic double-lumen right atrial line was placed and transthoracic left atrial line was placed. Mediastinal and pleural chest tubes were placed. The patient was separated from cardiopulmonary bypass to have satisfactory hemodynamics. Transesophageal echocardiogram demonstrated a small residual ventricular septal defect, mild tricuspid regurgitation, good biventricular function, no evidence of RV or LV outflow tract obstruction, and an estimated RV pressure of one-half systemic. Modified ultrafiltration was carried out. Protamine was given. The decannulation was carried out. It was elected to leave the sternum open or into the length of the case and the new homograft on the anterior aspect of the heart. It could be compromised by chest closure and edema. Ioban was placed over the open sternum after sufficient hemostasis was achieved, and the patient was taken from the operating room in stable condition. Total pump time was 247 minutes, aortic cross-clamp time was 115 minutes, and the descending aortic cross-clamp time was 39 minutes.
POSTOPERATIVE DIAGNOSES:
1. Taussig-Bing double-outlet right ventricle, transposition type.
2. Aortic stenosis.
3. Interrupted aortic arch type B.
4. Patent foramen ovale x2.
5. Patent ductus arteriosus.
OPERATIONS:
1. Damus-Kaye-Stansel construction with aortic arch reconstruction.
2. Ventricular septal defect closure, pericardial patch.
3. Closure of patent foramen ovale.
4. Right ventricle to pulmonary artery conduit, 9-mm pulmonary homograft.
5. Lecompte maneuver.
6. Broviac catheter placement.
A midline incision was made overlying the sternum. The sternum was divided in the midline, and the left lobe of the thymus was resected, the right lobe remained intact. The pericardium was opened and the anterior pericardium was ethanol and glutaraldehyde treated for use as a patch. A Broviac catheter was placed with a tunneled course from the left subclavicular region to the subxiphoid region. Seldinger technique was then used to place it between the leads of the diaphragm and into the right atrium at the inferior vena cavoatrial junction and the tip of the catheter was confirmed at atriotomy later in the case.
A 3-mm Gore-Tex shunt was sewn to an arteriotomy on the innominate artery for use as a perfusion. A second aortic cannulation site was chosen on the main pulmonary artery. A bifid aortic cannula was prepared. Heparin was given. The cannulation was carried out with a single venous cannula in the inferior vena cava. A vent in the right atrium and a vent in the left atrium were placed through a right upper pulmonary vein. Two arterial cannulas were placed. The patient was cooled to 32 degrees. During cooling, a full mobilization of the arch and ductus arteriosus was mobilized. The branched pulmonary arteries were normal in caliber. The aorta was in fact diminutive and did not appear suitable for use as a pulmonary artery. Marking sutures were placed in a side-by-side fashion where the aorta would be anastomosed to the main pulmonary artery. The distal arch was isolated. The ductus arteriosus was ligated and divided. The proximal ascending aorta was transected. A Lecompte maneuver was performed. An onlay patch of ethanol treated autologous pericardium was placed on the spatulated descending aorta. The left subclavian artery and the left common carotid artery were anastomosed in a side-by-side fashion over a short distance that constituted the upper aspect of the arch of the main pulmonary artery. The quadriplegia was given. The aortic cross-clamp applied. The ventricular septal defect was visualized through a large valve and the VSD was closed to the pulmonary valve excluding the diminutive aorta to the right ventricle. Pledgeted VSD sutures were placed circumferentially around the ventricular septal defect with transition suture on to the right atrial side of the tricuspid annulus in the area of His bundle. The patch was then applied. The sutures were sequentially tied and cut, and the VSD was in this way closed. Tricuspid valve was tested with the infusion of saline and appeared to be competent. Two patent foramen ovales were present, a large and a small, and the larger one was closed with a running #7-0 Prolene suture. The right atriotomy was then closed. The aortic arch reconstruction was then completed with a direct anastomosis of the main pulmonary artery to the descending aorta and the transverse arch. A side-by-side anastomosis of the aorta to the main pulmonary artery was carried out and the onlay patch of ethanol treated autologous pericardium was continued to augment the ascending aorta and transverse arch completely. The heart was then evacuated of air. The cross-clamp was removed. Rewarming was begun. A right ventriculotomy was made anteriorly, and a homograft was prepared and 9-mm pulmonary homograft was used. The branched pulmonary arteries, the left pulmonary artery had an extensive amount of ductal material on it, which was resected and an onlay patch of native pulmonary artery from the main pulmonary artery remnant was used to patch the left pulmonary artery. The homograft was then sewn at the distal anastomosis after its appropriate tailoring. The proximal anastomosis onto the RV outflow tract was carried out with a running #6-0 Prolene suture. This completed the anatomic repair. Atrial and ventricular pacing wires were placed. A transthoracic double-lumen right atrial line was placed and transthoracic left atrial line was placed. Mediastinal and pleural chest tubes were placed. The patient was separated from cardiopulmonary bypass to have satisfactory hemodynamics. Transesophageal echocardiogram demonstrated a small residual ventricular septal defect, mild tricuspid regurgitation, good biventricular function, no evidence of RV or LV outflow tract obstruction, and an estimated RV pressure of one-half systemic. Modified ultrafiltration was carried out. Protamine was given. The decannulation was carried out. It was elected to leave the sternum open or into the length of the case and the new homograft on the anterior aspect of the heart. It could be compromised by chest closure and edema. Ioban was placed over the open sternum after sufficient hemostasis was achieved, and the patient was taken from the operating room in stable condition. Total pump time was 247 minutes, aortic cross-clamp time was 115 minutes, and the descending aortic cross-clamp time was 39 minutes.