TWilliam2019
Guru
Operation:
#1. Coronary artery bypass grafting × 3 with internal mammary artery graft to the left anterior descending coronary artery and individual saphenous vein grafts to the obtuse marginal artery and PDA
#2. Endoscopic vein harvesting x 2 segments left leg
#3. Closure of left atrial appendage
#4. Temporary cardiopulmonary bypass with mild systemic hypothermia and cold sanguineous cardioplegia
#5. Transesophageal echocardiography independent interpretation ×2 (pre-bypass and post-bypass )
#6. Doppler ultrasound bypass graft interrogation × 3
#7. Drainage of right pleural effusion with placement of right tube thoracostomy
#8. Drainage of left pleural effusion with left tube thoracostomy
#9. Rigid internal sternal fixation with Sternal Lock Blue (manubrial 4 screws, proximal body left straight plate-5 screws, proximal right body-4 screws) IS THIS CODABLE? AND IF SO WHAT WOULD I USE?
33533
33518
33508
93314 26
Preoperative note:
Patient is a 40 y.o. Caucasian female with severe three-vessel coronary artery disease, unstable angina pectoris, recent non-STEMI now being taken to the operating room for high risk myocardial revascularization.
Operative findings:
#1. TEE independent interpretation-pre bypass: The left ventricular size was increased and the ejection fraction was significantly reduced at 30-35%. The right ventricular size and function was mildly reduced. There was moderate central mitral valve insufficiency with normal mitral valve leaflets. Aortic valve was a tricuspid valve with no incompetence in the long or short axis views. The atrial septum was intact. The left atrial appendage was free of thrombi. There were bilateral pleural effusions with the right being greater than the left.
#2. TEE independent interpretation- post bypass: The left atrial appendage was noted be closed. Left ventricular ejection fraction improved to approximately 40%. The mitral valve insufficiency was rated as mild.
#3. Operative findings: The left ventricle was enlarged grade 3/6 and hypertrophied grade 3/6. Coronary arteries at the site of anastomosis: LAD-mid1.5 mm, OM -mid 1.5 mm, PDA-1.0 mm all vessels were significantly and diffusely diseased right pleural effusion had 600 mL of clear fluid, the left pleural effusion had 260 mL of clear fluid
#4. Doppler ultrasound bypass graft interrogation: IMA graft mean flow rate of 17 mL/m with a PI of 2.2, PDA saphenous vein graft mean flow rate of 54 mL/m and PI of 1.7, OM saphenous vein graft mean flow rate 60 mL/m with a PI of 2.1
Description of operation:
Patient was placed on the operating table in the supine position and adequate general anesthesia was administered monitoring the arterial pressure, pulmonary artery pressure, bladder temperature, and electrocardiogram. A transesophageal echocardiographic probe was placed by anesthesia and findings are described above. The entire chest, abdomen, and legs were prepped in a sterile manner. A primary median sternotomy was performed and the pericardium was opened and heparin was administered. The left pleural effusion was drained and the right pleural effusion was drained. Volume removed as described above. Simultaneously PA-C harvested the saphenous vein from the left leg in the usual manner utilizing the Guidant endoscopic vein harvesting device. A small transverse incision was placed directly over the saphenous vein at the level of the left knee. The vein was then dissected out and individual branches of the vein were ultimately divided using the hemo-pro unit. The vein was then doubly ligated distally, divided, excised and prepared on the back table in the usual manner. The incision was closed in layers. The left internal mammary artery was harvested and prepared in the usual manner. The pericardium was marsupialized and pursestring sutures were placed. Following satisfactory heparinization with ACT greater than 450 seconds, aortic and right atrial cannulation were effected and cardiopulmonary bypass was established. The aorta was crossclamped and cold sanguinous cardioplegia was administered via the aortic root and diastolic arrest promptly ensued. Further myocardial cooling was obtained using topical slush. The left atrial appendage was closed with a 35 mm Atricure clip. The distal anastomoses were then constructed using longitudinal arteriotomies,and end to side anastomosis of the left internal mammary artery to the left anterior descending artery using 8-0 Prolene, end-to-side anastomosis of saphenous vein to the obtuse marginal artery with 7-0 Prolene and end to side anastomosis of saphenous vein to the PDA with 7-0 Prolene. Hand injection of cardioplegia via the saphenous vein grafts was satisfactory. Following the completion of the distal anastomoses rewarming was carried out. Two proximal anastomoses were performed utilizing a 4.0 mm punch and running 6-0 Prolene to the ascending aorta. Volume was infused into the patient and air was evacuated from the left side of the heart and vein grafts. With strong suction on the needle vent the aortic cross clamp was released and the heart returned to normal sinus rhythm. Following satisfactory rewarming cardiopulmonary bypass was completely discontinued in a gradual manner under TEE surveillance and satisfactory hemodynamics and rhythm ensued. Temporary ventricular pacemaker wires were placed. Bilateral pleural chest tubes were placed. One mediastinal chest tube was placed. Protamine was administered, decannulation was effected and hemostasis was obtained. With satisfactory rhythm, hemodynamics and hemostasis the chest was closed in layers. The sternum was somewhat osteoporotic and was somewhat thin on the left hemiscrotum sternum. For this reason a Sternal Lock Blue manubrial plate was placed with a total of 4 screws and the proximal sternal body had 2 straight plates placed with 5 screws in the left hemisternum and 4 screws and right hemisternum. PA-C was responsible for the sternal wound closure. The remainder of the sternum was closed with interrupted #7 wires. Sterile dressing was applied, sponge count was correct ×2, and the patient was taken to the CVRU in stable condition.
THANKS
#1. Coronary artery bypass grafting × 3 with internal mammary artery graft to the left anterior descending coronary artery and individual saphenous vein grafts to the obtuse marginal artery and PDA
#2. Endoscopic vein harvesting x 2 segments left leg
#3. Closure of left atrial appendage
#4. Temporary cardiopulmonary bypass with mild systemic hypothermia and cold sanguineous cardioplegia
#5. Transesophageal echocardiography independent interpretation ×2 (pre-bypass and post-bypass )
#6. Doppler ultrasound bypass graft interrogation × 3
#7. Drainage of right pleural effusion with placement of right tube thoracostomy
#8. Drainage of left pleural effusion with left tube thoracostomy
#9. Rigid internal sternal fixation with Sternal Lock Blue (manubrial 4 screws, proximal body left straight plate-5 screws, proximal right body-4 screws) IS THIS CODABLE? AND IF SO WHAT WOULD I USE?
33533
33518
33508
93314 26
Preoperative note:
Patient is a 40 y.o. Caucasian female with severe three-vessel coronary artery disease, unstable angina pectoris, recent non-STEMI now being taken to the operating room for high risk myocardial revascularization.
Operative findings:
#1. TEE independent interpretation-pre bypass: The left ventricular size was increased and the ejection fraction was significantly reduced at 30-35%. The right ventricular size and function was mildly reduced. There was moderate central mitral valve insufficiency with normal mitral valve leaflets. Aortic valve was a tricuspid valve with no incompetence in the long or short axis views. The atrial septum was intact. The left atrial appendage was free of thrombi. There were bilateral pleural effusions with the right being greater than the left.
#2. TEE independent interpretation- post bypass: The left atrial appendage was noted be closed. Left ventricular ejection fraction improved to approximately 40%. The mitral valve insufficiency was rated as mild.
#3. Operative findings: The left ventricle was enlarged grade 3/6 and hypertrophied grade 3/6. Coronary arteries at the site of anastomosis: LAD-mid1.5 mm, OM -mid 1.5 mm, PDA-1.0 mm all vessels were significantly and diffusely diseased right pleural effusion had 600 mL of clear fluid, the left pleural effusion had 260 mL of clear fluid
#4. Doppler ultrasound bypass graft interrogation: IMA graft mean flow rate of 17 mL/m with a PI of 2.2, PDA saphenous vein graft mean flow rate of 54 mL/m and PI of 1.7, OM saphenous vein graft mean flow rate 60 mL/m with a PI of 2.1
Description of operation:
Patient was placed on the operating table in the supine position and adequate general anesthesia was administered monitoring the arterial pressure, pulmonary artery pressure, bladder temperature, and electrocardiogram. A transesophageal echocardiographic probe was placed by anesthesia and findings are described above. The entire chest, abdomen, and legs were prepped in a sterile manner. A primary median sternotomy was performed and the pericardium was opened and heparin was administered. The left pleural effusion was drained and the right pleural effusion was drained. Volume removed as described above. Simultaneously PA-C harvested the saphenous vein from the left leg in the usual manner utilizing the Guidant endoscopic vein harvesting device. A small transverse incision was placed directly over the saphenous vein at the level of the left knee. The vein was then dissected out and individual branches of the vein were ultimately divided using the hemo-pro unit. The vein was then doubly ligated distally, divided, excised and prepared on the back table in the usual manner. The incision was closed in layers. The left internal mammary artery was harvested and prepared in the usual manner. The pericardium was marsupialized and pursestring sutures were placed. Following satisfactory heparinization with ACT greater than 450 seconds, aortic and right atrial cannulation were effected and cardiopulmonary bypass was established. The aorta was crossclamped and cold sanguinous cardioplegia was administered via the aortic root and diastolic arrest promptly ensued. Further myocardial cooling was obtained using topical slush. The left atrial appendage was closed with a 35 mm Atricure clip. The distal anastomoses were then constructed using longitudinal arteriotomies,and end to side anastomosis of the left internal mammary artery to the left anterior descending artery using 8-0 Prolene, end-to-side anastomosis of saphenous vein to the obtuse marginal artery with 7-0 Prolene and end to side anastomosis of saphenous vein to the PDA with 7-0 Prolene. Hand injection of cardioplegia via the saphenous vein grafts was satisfactory. Following the completion of the distal anastomoses rewarming was carried out. Two proximal anastomoses were performed utilizing a 4.0 mm punch and running 6-0 Prolene to the ascending aorta. Volume was infused into the patient and air was evacuated from the left side of the heart and vein grafts. With strong suction on the needle vent the aortic cross clamp was released and the heart returned to normal sinus rhythm. Following satisfactory rewarming cardiopulmonary bypass was completely discontinued in a gradual manner under TEE surveillance and satisfactory hemodynamics and rhythm ensued. Temporary ventricular pacemaker wires were placed. Bilateral pleural chest tubes were placed. One mediastinal chest tube was placed. Protamine was administered, decannulation was effected and hemostasis was obtained. With satisfactory rhythm, hemodynamics and hemostasis the chest was closed in layers. The sternum was somewhat osteoporotic and was somewhat thin on the left hemiscrotum sternum. For this reason a Sternal Lock Blue manubrial plate was placed with a total of 4 screws and the proximal sternal body had 2 straight plates placed with 5 screws in the left hemisternum and 4 screws and right hemisternum. PA-C was responsible for the sternal wound closure. The remainder of the sternum was closed with interrupted #7 wires. Sterile dressing was applied, sponge count was correct ×2, and the patient was taken to the CVRU in stable condition.
THANKS