jessicaeason
New
PROCEDURES:
Right femoral and arterial cannulation using Heartport access, right mini
thoracotomy, this would be considered a redo mediastinum to enter, complex
mitral valve repair with a small triangular resection in the P3 and also
closure of the gap in between P1 and P2 and annuloplasty using Simulus #31.
FINDINGS:
Height 178, weight 76.4, pump time 126, cross-clamp time 76, perfusion
temperature 32. This procedure was at least 30% tougher than usual
considering the fact that this patient had enormously dense adhesions. It
took longer time and added at least 2 hours to our operation time. The
patient definitely had prolapse of the P3 with elongation of the chords,
also had a gap between P1 and P2.
INDICATIONS FOR SURGERY:
This is an 85-year-old gentleman status post aortic valve replacement and
ascending aortic aneurysm repair done by Dr. Rosenberg a few years ago.
The patient recently underwent echocardiogram, and due to congestive heart
failure, it was noted that the patient had severe mitral valve
regurgitation, also had coronary artery disease. Dr. Kadura spoke with me
and we decided that the best thing is to also do stenting of the LAD.
Therefore, we could go through the right chest by doing a median sternotomy
to make that a safe approach for the patient. The patient has a history of
active lymphoma currently, also has renal dysfunction. The patient was
considered highly risky, but the patient wanted to have the surgery.
Therefore, we decided to plan . The patient and his wife fully
understood that the patient is at high risk and accepted to do whatever we
instruct the patient postop to get him back on his feet.
DESCRIPTION OF PROCEDURE:
After the patient was brought to the OR, endotracheal general anesthesia
was induced. Prep and drape was done in routine fashion. Right mini
thoracotomy incision was made. We entered the pleural space. There were
severely dense adhesions. We had to go through within the lung and the
pericardium. This took a long time. Then, we identified the pericardium.
Intrapericardial adhesions were very much more denser. We meticulously
dissected around the right atrium. We noticed that for trying to get
around the aorta we may have to go on cardiopulmonary bypass to make the
dissection less risky. Therefore, we already had exposed the right femoral
artery and vein. Heparin was given. Pursestring sutures were applied.
The right femoral also had very dense adhesion due to previous cannulation
of the site, but we were able to dissect both vein and artery and then we
placed 5-0 Prolene pursestring sutures. Then, after heparin was given,
femoral venous stick was applied. Then, wire was passed through the wire
in the stick. The stick was removed, and dilators were used and finally
#25 venous cannula was advanced all the way to the superior vena cava on
the guidewire. The introducer was removed, and the cannula was connected
to the venous side of the cardiopulmonary bypass machine. Then, femoral
arterial stick was applied. Guidewire was inserted. Then, dilators were
used. A #17 arterial cannula was advanced on the guidewire and introducer,
and then introducer and guidewire were removed and they connected to the
arterial side after complete de-aeration was done. They were secured to
the patient. Then, we placed the patient on cardiopulmonary bypass, and we
dissected around the right atrium and we identified the left atrium and
finally the aorta. We did a very meticulous job to make sure we do not
damage anything, and particularly it is worth mentioning that the patient
has been on aspirin, Plavix, and Eliquis recently and that is why we
admitted the patient to the hospital first and placed the patient on
heparin to be able to diminish the effect of all of these factors to a
certain point and find a balance between the problem with thrombosis and
anticoagulation, and this job was done very meticulously. We made sure
that we had good hemostasis as we continued to dissect around the heart.
After we had enough and safe dissection around the aorta, which showed very
dense adhesions, antegrade cardioplegic cannula was inserted. Then,
cross-clamp was applied as we cooled down the patient and we gave 1000 mL
of cold del Nido cardioplegia and we brought the perfusion temperature to
32. We entered the left atrium and Cardio Vision retractor was applied.
We injected cold saline, and as the TEE showed that we had prolapse and
elongation of the chords in the P3 area, there were 2 chords that were
completely elongated and causing the regurgitation. Those chords were
removed and the triangular resection in that territory was done.
Reapproximation of the 2 edges was done with 5-0 sutures in a
figure-of-eight, multiple of them until reapproximation of the triangular
resection was done. Then, we injected saline and we also identified a gap
between P1 and P2. We did place 3 figure-of-eight 5-0 Prolene sutures in
that gap, and then after injection of the cold saline in the ventricle, we
noticed that the repair was perfect, no leak whatsoever. At the same time,
no stenosis. We sized the annulus. We chose #31 Simulus band. We applied
2-0 Ti-Cron sutures, and then the needles were applied on #31 Simulus band
and the valve was tied down using Cor-Knots. We checked again. We had
perfect repair. No regurgitation was at all. We placed the sump inside of
the ventricle. The atriotomy was closed with 3-0 Prolene in running
fashion. We placed the patient in Trendelenburg position and we continued
to de-air the system. We had CO2 in the field at all time. We made sure
there was no embolization of any kind through the whole procedure. In
Trendelenburg position, we de-aired the system more. Cross-clamp was
removed and we continued to de-air the LV and the root. Because of the
adhesions, we had no chance to place any ventricular wire. Therefore, we
already had intravenous ventricular pacing through the jugular vein. I
should mention this is very . I was planning to do cryoablation, but
then I decided against it because the exposure was very difficult and that
would not be a satisfactory cryoablation and I could not also close the
left atrial appendage considering the fact that due to the adhesions from
previous surgery, the anatomy was sucked in this to the scars and I did not
want to jeopardize the patient's life and I thought the best thing was to
repair the mitral valve, which I think we were fortunate to repair and not
bother with extra work for this patient's life. Therefore, we did not
do any cryoablation, and we did not close the left atrial appendage. After
closure of the left atrium and continued de-airing the system, we
ventricularly paced the patient, and at some point, we did not have to pace
the patient anymore and the patient's previous rhythm came back. We placed
a straight 32 chest tube and a right angle 28 in the right chest, brought
out through separate stab wounds, and secured. At 37 degree, after we made
sure there was no air in the system proven by TEE, we removed the LV vent
and site was secured, and the patient was taken off the bypass and TEE
showed perfect repair and trivial if any regurgitation. Ventricular
function preserved. Protamine was started. Decannulation of the venous
line was done and site was secured, and then decannulation of the arterial
cannula also was done from the groin and the site was secured. We had
great pulse after removal of the cannula. Copious irrigation of antibiotic
solution was done, and the sites of the cannulations were closed in layer
standard fashion. Skin was closed with 4-0 Monocryl. I should mention
that the aortic cardioplegic cannula also was removed and site was secured.
We had good hemostasis. Copious irrigation was done for the thoracotomy,
and the ribs were approximated with heavy Vicryl, and muscle was closed
with 2-0 Vicryl. Soft tissue was closed with 2-0 Vicryl. Skin was closed
with 4-0 Monocryl. We applied the On-Q in place. The dressing was
applied. The patient was transferred to Intensive Care Unit in stable
condition.
Coded as 33427, 33530, 34714-RT but the 33427 is being denied stating it was not mentioned (dictated) in the above report and a different CPT should be coded. Would a 33430-22 be more appropriate? Any help is greatly appreciated.
Right femoral and arterial cannulation using Heartport access, right mini
thoracotomy, this would be considered a redo mediastinum to enter, complex
mitral valve repair with a small triangular resection in the P3 and also
closure of the gap in between P1 and P2 and annuloplasty using Simulus #31.
FINDINGS:
Height 178, weight 76.4, pump time 126, cross-clamp time 76, perfusion
temperature 32. This procedure was at least 30% tougher than usual
considering the fact that this patient had enormously dense adhesions. It
took longer time and added at least 2 hours to our operation time. The
patient definitely had prolapse of the P3 with elongation of the chords,
also had a gap between P1 and P2.
INDICATIONS FOR SURGERY:
This is an 85-year-old gentleman status post aortic valve replacement and
ascending aortic aneurysm repair done by Dr. Rosenberg a few years ago.
The patient recently underwent echocardiogram, and due to congestive heart
failure, it was noted that the patient had severe mitral valve
regurgitation, also had coronary artery disease. Dr. Kadura spoke with me
and we decided that the best thing is to also do stenting of the LAD.
Therefore, we could go through the right chest by doing a median sternotomy
to make that a safe approach for the patient. The patient has a history of
active lymphoma currently, also has renal dysfunction. The patient was
considered highly risky, but the patient wanted to have the surgery.
Therefore, we decided to plan . The patient and his wife fully
understood that the patient is at high risk and accepted to do whatever we
instruct the patient postop to get him back on his feet.
DESCRIPTION OF PROCEDURE:
After the patient was brought to the OR, endotracheal general anesthesia
was induced. Prep and drape was done in routine fashion. Right mini
thoracotomy incision was made. We entered the pleural space. There were
severely dense adhesions. We had to go through within the lung and the
pericardium. This took a long time. Then, we identified the pericardium.
Intrapericardial adhesions were very much more denser. We meticulously
dissected around the right atrium. We noticed that for trying to get
around the aorta we may have to go on cardiopulmonary bypass to make the
dissection less risky. Therefore, we already had exposed the right femoral
artery and vein. Heparin was given. Pursestring sutures were applied.
The right femoral also had very dense adhesion due to previous cannulation
of the site, but we were able to dissect both vein and artery and then we
placed 5-0 Prolene pursestring sutures. Then, after heparin was given,
femoral venous stick was applied. Then, wire was passed through the wire
in the stick. The stick was removed, and dilators were used and finally
#25 venous cannula was advanced all the way to the superior vena cava on
the guidewire. The introducer was removed, and the cannula was connected
to the venous side of the cardiopulmonary bypass machine. Then, femoral
arterial stick was applied. Guidewire was inserted. Then, dilators were
used. A #17 arterial cannula was advanced on the guidewire and introducer,
and then introducer and guidewire were removed and they connected to the
arterial side after complete de-aeration was done. They were secured to
the patient. Then, we placed the patient on cardiopulmonary bypass, and we
dissected around the right atrium and we identified the left atrium and
finally the aorta. We did a very meticulous job to make sure we do not
damage anything, and particularly it is worth mentioning that the patient
has been on aspirin, Plavix, and Eliquis recently and that is why we
admitted the patient to the hospital first and placed the patient on
heparin to be able to diminish the effect of all of these factors to a
certain point and find a balance between the problem with thrombosis and
anticoagulation, and this job was done very meticulously. We made sure
that we had good hemostasis as we continued to dissect around the heart.
After we had enough and safe dissection around the aorta, which showed very
dense adhesions, antegrade cardioplegic cannula was inserted. Then,
cross-clamp was applied as we cooled down the patient and we gave 1000 mL
of cold del Nido cardioplegia and we brought the perfusion temperature to
32. We entered the left atrium and Cardio Vision retractor was applied.
We injected cold saline, and as the TEE showed that we had prolapse and
elongation of the chords in the P3 area, there were 2 chords that were
completely elongated and causing the regurgitation. Those chords were
removed and the triangular resection in that territory was done.
Reapproximation of the 2 edges was done with 5-0 sutures in a
figure-of-eight, multiple of them until reapproximation of the triangular
resection was done. Then, we injected saline and we also identified a gap
between P1 and P2. We did place 3 figure-of-eight 5-0 Prolene sutures in
that gap, and then after injection of the cold saline in the ventricle, we
noticed that the repair was perfect, no leak whatsoever. At the same time,
no stenosis. We sized the annulus. We chose #31 Simulus band. We applied
2-0 Ti-Cron sutures, and then the needles were applied on #31 Simulus band
and the valve was tied down using Cor-Knots. We checked again. We had
perfect repair. No regurgitation was at all. We placed the sump inside of
the ventricle. The atriotomy was closed with 3-0 Prolene in running
fashion. We placed the patient in Trendelenburg position and we continued
to de-air the system. We had CO2 in the field at all time. We made sure
there was no embolization of any kind through the whole procedure. In
Trendelenburg position, we de-aired the system more. Cross-clamp was
removed and we continued to de-air the LV and the root. Because of the
adhesions, we had no chance to place any ventricular wire. Therefore, we
already had intravenous ventricular pacing through the jugular vein. I
should mention this is very . I was planning to do cryoablation, but
then I decided against it because the exposure was very difficult and that
would not be a satisfactory cryoablation and I could not also close the
left atrial appendage considering the fact that due to the adhesions from
previous surgery, the anatomy was sucked in this to the scars and I did not
want to jeopardize the patient's life and I thought the best thing was to
repair the mitral valve, which I think we were fortunate to repair and not
bother with extra work for this patient's life. Therefore, we did not
do any cryoablation, and we did not close the left atrial appendage. After
closure of the left atrium and continued de-airing the system, we
ventricularly paced the patient, and at some point, we did not have to pace
the patient anymore and the patient's previous rhythm came back. We placed
a straight 32 chest tube and a right angle 28 in the right chest, brought
out through separate stab wounds, and secured. At 37 degree, after we made
sure there was no air in the system proven by TEE, we removed the LV vent
and site was secured, and the patient was taken off the bypass and TEE
showed perfect repair and trivial if any regurgitation. Ventricular
function preserved. Protamine was started. Decannulation of the venous
line was done and site was secured, and then decannulation of the arterial
cannula also was done from the groin and the site was secured. We had
great pulse after removal of the cannula. Copious irrigation of antibiotic
solution was done, and the sites of the cannulations were closed in layer
standard fashion. Skin was closed with 4-0 Monocryl. I should mention
that the aortic cardioplegic cannula also was removed and site was secured.
We had good hemostasis. Copious irrigation was done for the thoracotomy,
and the ribs were approximated with heavy Vicryl, and muscle was closed
with 2-0 Vicryl. Soft tissue was closed with 2-0 Vicryl. Skin was closed
with 4-0 Monocryl. We applied the On-Q in place. The dressing was
applied. The patient was transferred to Intensive Care Unit in stable
condition.
Coded as 33427, 33530, 34714-RT but the 33427 is being denied stating it was not mentioned (dictated) in the above report and a different CPT should be coded. Would a 33430-22 be more appropriate? Any help is greatly appreciated.
