Coding Valvuloplasty for Extensive Debridement?

Alfaro33

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Provider coding 33464: Valvuloplasty, tricuspid valve; with ring insertion

I don't believe the documentation supports the repair of the valve nor a ring insertion and cannot find a code that describe what the provider actually did in the atrium and around and a segment of the tri annular. Pleeease help!

Preoperative Diagnosis:
Prosthetic aortic valvular endocarditis, tricuspid valvular endocarditis, heart block, sepsis

Postoperative Diagnosis
As above

Operation
Reoperative sternotomy, aortic valve replacement, debridement of sub annular aortic abscess, patch repair of aorto right ventricular septal defect, debridement of tricuspid annulus and right atrial tissue, tricuspid annuloplasty with reconstruction of tricuspid annulus and patch of right atrial aortic defect transesophageal echocardiography, placement of left ventricular and right atrial epicardial pacing wires

Anesthesia
General

Technique
The patient was placed on the operating table in supine position the operative site prepped and draped sterilely. Hemodynamic parameters were monitored using a Swan-Ganz catheter and radial arterial catheter. General endotracheal anesthesia was administered. Transesophageal echocardiogram was performed which revealed as noted in the preoperative studies large vegetations on the aortic bioprosthetic valve, a perivalvular leak, what appeared to be a large abscess cavity in the subvalvular area, evidence of possible vegetations in the annular area of the tricuspid valve.

The chest was entered through a reoperative sternotomy incision. The adhesions surrounding the heart and mediastinal structures were lysed sharply. The patient was heparinized systemically. Arterial and venous cannula were inserted into the ascending aorta and superior and inferior vena cava respectively. When the arterial venous lines had been inspected to be certain that there are no emboli bubbles present cardiopulmonary bypass was instituted. The patient was then allowed to drift to 34° centigrade. The aorta was crossclamped with a soft jaw vascular clamp and the heart arrested by injection of cold blood cardioplegia solution into the aortic root. The EKG was monitored continuously during the period of cross-clamping and additional injections of cardioplegia were given via direct injection into the coronary ostia as necessary to maintain a flaccid diastolic arrest of the heart. A vent was inserted into position in the left ventricle via the right superior pulmonary vein. An aortotomy was made approximately 2 mm above the prior aortic suture line. It was extended approximately 5-7 mm in either direction. The bioprosthetic valve was inspected. It was noted to have vegetations on it. A systematic removal of the prior sutures holding the valve in place was completed in the 0 prosthetic valve was then removed. Should be noted that there was an area of dehiscence of the valve along the right coronary commissure. When the prosthetic valve was removed it was cultured and these were sent for microbiologic analysis. The removed valve was sent to pathology. Inspection of the this area now showed that there was extensive destruction of tissue in the sub annular area which extended into the tissues of the right ventricular muscle. This was completely debrided. There was also extension of infected tissue into the right atrium up to the area of the tricuspid valve. The right atrium was opened and inspected. There was no vegetations noted on the actual tricuspid valve. Extensive debridement of the infected tissue in the right atrium and a segment of the tricuspid annular area was also completed. This was reconstructed with a patch in the right atrium of a PeriGard tissue and reapproximation of the tissue near the tricuspid annulus. Insufflation of saline into the right ventricle revealed a competent tricuspid valve. Complete debridement of the abscess tissue in the sub aortic area into the right ventricular tissue was completed there was a defect noted into the right ventricle. This area was also cultured and then reconstructed using AP periGard patch. The lower aspect of the patch was reanastomosed using 4-0 Prolene suture. The upper rim of the patch served as the buttress for the annular portion of the new bioprosthetic valve. Interrupted sutures of 2-0 Ethibond were now placed around the reconstructed annulus through the patch. These sutures were then placed that he quit distant points through 823 Edwards bioprosthetic valve. The bioprosthetic valve was then lowered into position over the annulus and tied down. It was then inspected to be certain that the struts did not obstruct the main coronary ostia in any way, and also probed on the outer aspect of the sewing ring to be certain there were no loose areas of perivalvular leakage. When this had been completed the aortotomy was closed in 2 layer technique using 4-0 Prolene suture. The atrium a was also then closed using a 4-0 Prolene suture in a running fashion. Given the extensive debridement of this patient's tissue in the region of the conduction system was felt that he would be a likely candidate for complete heart block. In view of this epicardial pacing wires were placed on the left ventricular surface on the inferior wall, and also on the right atrium. These were brought out through a separate incision on the lower pole of the incision into a pocket fashion down the anterior abdominal wall. The heart Was then allowed to fill with blood so that air could be evacuated from within the cardiac chambers. Event needle was inserted into the aortic root for de-airing of the heart. Cardiac de-airing maneuvers were completed using transesophageal echocardiography as a visual guide. When all air was completely removed from the heart the aorta was unclamped and systemic rewarming to normothermia completed. Following the resumption of normal serum me a now with the paced AV sequential rhythm the patient was weaned from cardiopulmonary bypass. Aortic and venous cannula in vents removed and heparin reversed with intravenous protamine. Total cardiopulmonary bypass time was 200 minutes, total aortic cross-clamp time was 167 minutes. Epicardial wires were placed pacing wires were placed on the right atrium and the right ventricle and brought on the anterior chest wall. Ground wire was also placed on the anterior chest wall. A single chest tube was inserted through a separate stab incision on the anterior chest wall and I could in place. This was positioned in the anterior mediastinum. All suture lines were inspected and hemostasis achieved. The sternum was reapproximated using interrupted stainless steel wires. The sternal incision was irrigated with antibiotic solution. Muscle and subcutaneous tissue over the sternum were reapproximated using continuous sutures of 1. Vicryl. Skin edges reapproximated using a subcuticular stitch of 3-0 Vicryl suture. The sponge instrument needle counts were determined to correct. Postoperative transesophageal echocardiography showed that the new bioprosthetic valve was working well, there was no evidence of any perivalvular leakage. The tricuspid valve appeared to be competent. Sterile dressings were applied over the incisions and the patient was now prepared for transport back to the intensive care unit in critical but stable condition.
 
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