This is driving me crazy. I have a surgical case that has been coded by 6 different coders and we have 5 different answers. I would like to get some feed back on this portion of the case.
"Now with the heart cooled and arrested, the right coronary system was inspected. It was found to be heavily calcified and diseased and not suitable for grafting. The lateral wall was inspected and the obtuse marginals were not suitable for grafting. Next, the aorta was opened obliquely just above the old graft just below the old graft sites and aortic valve exposed. Direct infusion of cardioplegia via the left main coronary was administered and after completing this, the aortic valve was then excised. The annulus was debrided of all calcium by a pulverizing the calcium with a rongeur and sharply excising. After the annulus was fully debrided, the root was copiously irrigated with cold saline to evacuate any small debris that may have accumulated. Now with this completed, the annulus was sized and fount to be appropriate for a 23 mm mosaic bioprosthetic valve which provided an excellent index effective orifice area for this patient. Fifteen 2-0 Tevdek stitches were placed in a mattress formation with the pledgets on the ventricular side in a shoulder to shoulder fashion. After the stitches were placed, they were then seated sequentially in the aortic valve also in a shoulder to shoulder fashion and this was then easily seated at the level of the annulus and all stitches tied down.
During the couse of valve replacement, the patient was fully cooled for hypothermic circulatory arrest. Now with the valve well seated, all stitches were cut and the valve was inspected and found to be in excellent position wiht good leaflet function. Next, the aorta was resected back to the proximal arch where a suitable neck was obtained. A 26mm Dacron tube graft was selected. a bevelled cut with a cuff was fashioned to bevel on to the mid arch along the lesser curve and incorporating the orifice of the inominate artery. The tube graft was dunked into the lumen of the aorta. Once the patient was drained and circulatory arrest initiated with the clamp off and the graft in place, it was then anastomosed in 2 layers. An inner running mattress with Teflon strip reinforcement using 3-0 Prolene was first performed followed by a simple running outer layer with a 3-0 Prolene. Once this was completed, flow on the pump was reinitiated solely to fill the root. Once full, the crossclamp was then applied to the Dacron tube graft and full flow obtained. Total circulatory arrest time was 18 minutes.
Next, a piece of the Dacron tube graft cut prior and saved was then used to created a cuff and dunked into the sinotubular junction where an appropriate neck of the aorta was sized appropriate for this 26mm graft. It was then anastomosed at the level of the sinotubular junction in a similar fashion with a two layer anastomosis using a running mattress 3-0 Prolene inner layer with Teflon strip reinforcement in a simple 3-0 Prolene running outer layer. Once this anasomosis was completed, the graft was pressurized by administering cardioplegia into the graft and inspected. It was hemostatic and an addition dose cardioplegia was administered in this manner.
During the course fo vlave replacement and replacement of the aortic aneursym, cardioplegia was administered directly in the left main coronary every 15-20minutes. The patient was now initiated on full rewarming. The proximal and distal limbs of the Dacron graft were then cut to appropriate size and then anastomosed together using a running 3-0 Prolene. Once this was completed prior to tying the Prolene, the ______ aorta was allowed to fill and fully deair and the Prolene was then tied down. Now with the aortic reconstruction complete all full rewarming was continued until the patient reached 36.3 degrees. During this time the cross clamp was removed and the eart was allowed to beat empty for reperfusion. "
All opinions are greatly appreciated
Thanks
Laura, CPC
"Now with the heart cooled and arrested, the right coronary system was inspected. It was found to be heavily calcified and diseased and not suitable for grafting. The lateral wall was inspected and the obtuse marginals were not suitable for grafting. Next, the aorta was opened obliquely just above the old graft just below the old graft sites and aortic valve exposed. Direct infusion of cardioplegia via the left main coronary was administered and after completing this, the aortic valve was then excised. The annulus was debrided of all calcium by a pulverizing the calcium with a rongeur and sharply excising. After the annulus was fully debrided, the root was copiously irrigated with cold saline to evacuate any small debris that may have accumulated. Now with this completed, the annulus was sized and fount to be appropriate for a 23 mm mosaic bioprosthetic valve which provided an excellent index effective orifice area for this patient. Fifteen 2-0 Tevdek stitches were placed in a mattress formation with the pledgets on the ventricular side in a shoulder to shoulder fashion. After the stitches were placed, they were then seated sequentially in the aortic valve also in a shoulder to shoulder fashion and this was then easily seated at the level of the annulus and all stitches tied down.
During the couse of valve replacement, the patient was fully cooled for hypothermic circulatory arrest. Now with the valve well seated, all stitches were cut and the valve was inspected and found to be in excellent position wiht good leaflet function. Next, the aorta was resected back to the proximal arch where a suitable neck was obtained. A 26mm Dacron tube graft was selected. a bevelled cut with a cuff was fashioned to bevel on to the mid arch along the lesser curve and incorporating the orifice of the inominate artery. The tube graft was dunked into the lumen of the aorta. Once the patient was drained and circulatory arrest initiated with the clamp off and the graft in place, it was then anastomosed in 2 layers. An inner running mattress with Teflon strip reinforcement using 3-0 Prolene was first performed followed by a simple running outer layer with a 3-0 Prolene. Once this was completed, flow on the pump was reinitiated solely to fill the root. Once full, the crossclamp was then applied to the Dacron tube graft and full flow obtained. Total circulatory arrest time was 18 minutes.
Next, a piece of the Dacron tube graft cut prior and saved was then used to created a cuff and dunked into the sinotubular junction where an appropriate neck of the aorta was sized appropriate for this 26mm graft. It was then anastomosed at the level of the sinotubular junction in a similar fashion with a two layer anastomosis using a running mattress 3-0 Prolene inner layer with Teflon strip reinforcement in a simple 3-0 Prolene running outer layer. Once this anasomosis was completed, the graft was pressurized by administering cardioplegia into the graft and inspected. It was hemostatic and an addition dose cardioplegia was administered in this manner.
During the course fo vlave replacement and replacement of the aortic aneursym, cardioplegia was administered directly in the left main coronary every 15-20minutes. The patient was now initiated on full rewarming. The proximal and distal limbs of the Dacron graft were then cut to appropriate size and then anastomosed together using a running 3-0 Prolene. Once this was completed prior to tying the Prolene, the ______ aorta was allowed to fill and fully deair and the Prolene was then tied down. Now with the aortic reconstruction complete all full rewarming was continued until the patient reached 36.3 degrees. During this time the cross clamp was removed and the eart was allowed to beat empty for reperfusion. "
All opinions are greatly appreciated
Thanks
Laura, CPC
