Ascending aortic replacement with hemi arch

mkndevh@msn.com

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Could someone please help me with a CPT for a cardio procedure? I code for anesthesia and normally don't code for complex cardio procedures.
I'm thinking in the 33860 series? Any direction you can give would be very helpful. Thank you!

POSTOPERATIVE DIAGNOSIS
Ruptured ascending aortic aneurysm.
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OPERATIVE PROCEDURE
Ascending aortic replacement with hemi arch and selective antegrade
cardioplegia with open repair via right axillary artery cannulation.
*
CLINICAL SITUATION
The patient is a 78-year-old male followed with an aneurysm which has
been unchanged between 4.6 to 4.7 cm for the last few years. He
presents from acute onset of chest pain earlier today, and was being
worked up for a musculoskeletal disorder when a CT scan was done which
showed a ruptured ascending aorta with blood in the pericardium and a
large hematoma compressing the right pulmonary artery. The tear
appeared to extend up the left lateral wall of the ascending aorta, but
the arch and the distal appeared intact. He was brought to the
operating room for emergent repair.
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OPERATIVE NOTE
Patient brought to the operating room, placed on the operating room
table in supine position. After satisfactory placement of lines and
general endotracheal anesthesia, was sterilely prepped and draped in the
usual manner. A right subclavicular skin incision was made and carried
down to mobilize the axillary artery. Patient was then systemically
heparinized and a Satinsky clamp placed and an 8 mm Hemashield graft was
sewn end-to-side onto the axillary artery to allow for arterial
perfusion. Once this was completed, the sternum was opened and a large
amount of clot was evacuated from the mediastinum with an extremely
large hematoma of the ascending aorta. Venous cannulation was then
accomplished and the cooling began. As this was in process the aorta
ruptured on the left lateral wall adjacent to the PA. This was
controlled as cooling was completed and left subclavian artery were
clamped with antegrade circulation restored. A circulatory arrest was
accomplished. This allowed for the remainder of the aortic dissection.
The direct ostial cannulation was used to arrest the heart and a
retrograde coronary sinus catheter was used as was a left ventricular
vent via the right superior pulmonary vein. This showed that the aortic
valve was intact proximally. The right coronary and part of the non
coronary sinus adventitia was taken up by the dissection but this was
felt to be salvageable. Distally the lesser curve of the arch is where
the tear ended and this was all completely resected. Some Bio-glue was
placed to allow for salvage of the distal part of the arch and this
appeared to set up for hemi arch replacement. A running 4-0 Prolene
suture was used for the end-to-end anastomosis with an outer stripper
felt constructing hemi arch replacement. The Bio-glue was then placed
and the circulation was restarted with what appeared to be good
hemostasis distally. The proximal anastomosis was then constructed in
the end-to-end fashion similarly with a light coat of Bio-glue from the
dissected adventitia around the right coronary, but this appeared to set
up nicely and the valve appeared intact. An end-to-end anastomosis was
performed with a running 4-0 Prolene suture and now a strip of felt, a
light coat of Bio-glue was placed. Warm blood was given in retrograde
fashion as the usual de-airing was accomplished and the clamp was
removed. Temporary pacing wires were placed in the right ventricle and
right atrium. An anterior mediastinal chest tube was placed as well as
a posterior Jackson-Pratt drain. He then was completely rewarmed and
uneventfully weaned from cardiopulmonary bypass. The usual coagulopathy
was present, but appeared to be reasonable and once cannula was removed
and heparin reversed with protamine, the chest was closed with #7 wires
to approximate the sternum and running Vicryl suture to approximate
linea alba, presternal fascia, and deep subcutaneous tissues. 3-0 Vicryl
was used for subcuticular skin closure. The infraclavicular incision
was then opened and the graft was stapled at its origin on the axillary
artery and that wound also closed with running Vicryl suture and a
Vicryl subcuticular skin closure. With reasonably good hemodynamics and
improving coagulopathy the patient was then transported to open heart
recovery in critical, but stable condition on no pressor support in
sinus rhythm.
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