hthr.santos
Contributor
I need help figuring out the correct code for the following op note. I've come up with 33475. Thoughts??
PREOPERATIVE DIAGNOSIS:
Pulmonary insufficiency, right ventricular dysfunction, status post repair of tetralogy of Fallot.
POSTOPERATIVE DIAGNOSIS:
Pulmonary insufficiency, right ventricular dysfunction, status post repair of tetralogy of Fallot.
PROCEDURE: RV to PA conduit, pulmonary valve replacement, RV muscle resection.
FINDINGS:
This is a 17-year-old who was born with complex congenital heart disease as well asprematurity. He was diagnosed at birth with complex congenital heart disease with tetralogy of Fallot and pulmonary atresia, as well as prematurity weighing 1 kg. He was initially palliated with a right ventricular outflow tract stent which was placed in a hybrid technique. He did well from that procedure and then underwent a complete repair of his tetralogy of Fallot at 9 months of age in a bloodless fashion including a transannular patch in that repair. Over the years, he has done well and has grown and thrived and has been an active young man. Along the way, he required a left pulmonary artery stent. He is now developing important right ventricular dilation with mild dysfunction and some symptoms of fatigue. He was also deemed not to be a suitable candidate for a transcatheter pulmonary valve replacement. Therefore, he was referred forsurgical pulmonary valve replacement. The patient was pretreated with erythropoietin
DESCRIPTION OF PROCEDURE:
After the induction of general endotracheal anesthesia using appropriate monitoring by the anesthesia team, the patient was positioned, padded, prepped and draped in the usual fashion. A reoperative median sternotomy was performed. Adhesions were taken down sharply. Preparation for cardiopulmonary bypass included cannulation of the ascending aorta and the right atrial appendage. The patient was then placed on total cardiopulmonary bypass using a bloodless prime and cooled to a temperature of 33 degrees centigrade. During cooling, further dissection was carried out. The right heart was dissected free including the area of the previously placed transannular patch as well as the branch pulmonary arteries. Now, the main pulmonary artery was divided. Looking into the left branch pulmonary artery, there was a nicely positioned stent with a nice wide open left pulmonary artery. Short-segment of the proximal end of the stent extended into the main pulmonary artery and confluence. These approximate 1-zig were gently bent backwards to create a better conforming to the branch pulmonary artery and to facilitate any future transcatheter manipulations. The right pulmonary artery was of normal caliber with no ostial stenosis. Now a 26 mm Hancock valved conduit was trimmed to a short length and then rinsed appropriately. The distal anastomosis was then performed as an end conduit to the confluence of the branch pulmonary arteries with a running 5-0 Prolene.
Once completed, looking through the conduit, both the left and right branch pulmonary arteries were nice and a wide open. Now, proximally a portion of the previous transannular patch was excised. Looking into the right ventricular outflow tract, there were a couple muscle bundles that were crossing which were excised nicely opening the right ventricular outflow tract and now the proximal anastomosis as an end valve conduit to right ventricular outflow tract was performed with a running 4-0 Prolene. Prior to completing the suture line, the right heart was allowed to fill and de-air appropriately, and the suture line was secured. While the patient was being rewarmed, a #28 anterior mediastinal chest tube was placed. The patient was then loaded with milrinone empirically, and once he was completely rewarmed, he was weaned from cardiopulmonary bypass without difficulty. He was in normal sinus rhythm with normal hemodynamics. The transesophageal echocardiogram at this point revealed normal left and right ventricular function, a nice open right ventricular outflow tract with no gradient and no pulmonary valve insufficiency or stenosis. This was felt to be quite adequate. Now,postbypass modified ultrafiltration was performed. Once completed, the protamine was given and the cannulae were removed. Once hemostasis was assured, the sternum was closed with interrupted wires. The skin was closed in layers. Sterile dressings were placed and the childwas returned to the Cardiothoracic Intensive Care Unit in stable condition. Cardiopulmonary bypass data includes a bypass time of 72 minutes. There was no crossclamp time, core temperature 33 degrees centigrade, and no blood products were given.
PREOPERATIVE DIAGNOSIS:
Pulmonary insufficiency, right ventricular dysfunction, status post repair of tetralogy of Fallot.
POSTOPERATIVE DIAGNOSIS:
Pulmonary insufficiency, right ventricular dysfunction, status post repair of tetralogy of Fallot.
PROCEDURE: RV to PA conduit, pulmonary valve replacement, RV muscle resection.
FINDINGS:
This is a 17-year-old who was born with complex congenital heart disease as well asprematurity. He was diagnosed at birth with complex congenital heart disease with tetralogy of Fallot and pulmonary atresia, as well as prematurity weighing 1 kg. He was initially palliated with a right ventricular outflow tract stent which was placed in a hybrid technique. He did well from that procedure and then underwent a complete repair of his tetralogy of Fallot at 9 months of age in a bloodless fashion including a transannular patch in that repair. Over the years, he has done well and has grown and thrived and has been an active young man. Along the way, he required a left pulmonary artery stent. He is now developing important right ventricular dilation with mild dysfunction and some symptoms of fatigue. He was also deemed not to be a suitable candidate for a transcatheter pulmonary valve replacement. Therefore, he was referred forsurgical pulmonary valve replacement. The patient was pretreated with erythropoietin
DESCRIPTION OF PROCEDURE:
After the induction of general endotracheal anesthesia using appropriate monitoring by the anesthesia team, the patient was positioned, padded, prepped and draped in the usual fashion. A reoperative median sternotomy was performed. Adhesions were taken down sharply. Preparation for cardiopulmonary bypass included cannulation of the ascending aorta and the right atrial appendage. The patient was then placed on total cardiopulmonary bypass using a bloodless prime and cooled to a temperature of 33 degrees centigrade. During cooling, further dissection was carried out. The right heart was dissected free including the area of the previously placed transannular patch as well as the branch pulmonary arteries. Now, the main pulmonary artery was divided. Looking into the left branch pulmonary artery, there was a nicely positioned stent with a nice wide open left pulmonary artery. Short-segment of the proximal end of the stent extended into the main pulmonary artery and confluence. These approximate 1-zig were gently bent backwards to create a better conforming to the branch pulmonary artery and to facilitate any future transcatheter manipulations. The right pulmonary artery was of normal caliber with no ostial stenosis. Now a 26 mm Hancock valved conduit was trimmed to a short length and then rinsed appropriately. The distal anastomosis was then performed as an end conduit to the confluence of the branch pulmonary arteries with a running 5-0 Prolene.
Once completed, looking through the conduit, both the left and right branch pulmonary arteries were nice and a wide open. Now, proximally a portion of the previous transannular patch was excised. Looking into the right ventricular outflow tract, there were a couple muscle bundles that were crossing which were excised nicely opening the right ventricular outflow tract and now the proximal anastomosis as an end valve conduit to right ventricular outflow tract was performed with a running 4-0 Prolene. Prior to completing the suture line, the right heart was allowed to fill and de-air appropriately, and the suture line was secured. While the patient was being rewarmed, a #28 anterior mediastinal chest tube was placed. The patient was then loaded with milrinone empirically, and once he was completely rewarmed, he was weaned from cardiopulmonary bypass without difficulty. He was in normal sinus rhythm with normal hemodynamics. The transesophageal echocardiogram at this point revealed normal left and right ventricular function, a nice open right ventricular outflow tract with no gradient and no pulmonary valve insufficiency or stenosis. This was felt to be quite adequate. Now,postbypass modified ultrafiltration was performed. Once completed, the protamine was given and the cannulae were removed. Once hemostasis was assured, the sternum was closed with interrupted wires. The skin was closed in layers. Sterile dressings were placed and the childwas returned to the Cardiothoracic Intensive Care Unit in stable condition. Cardiopulmonary bypass data includes a bypass time of 72 minutes. There was no crossclamp time, core temperature 33 degrees centigrade, and no blood products were given.