conleyclan
Guru
The op note states the patient had previous truncus arteriosus total repair. I think this time he had partial repair along with RV to PA conduit replacment, and RVOT muscle bundle reseciton. I am not sure how to code the truncal valve repair. Thanks 
Cardiothoracic Surgery Operative Report
PREOPERATIVE DIAGNOSES: Right ventricle to pulmonary artery conduit
obstruction, truncal valve insufficiency, status post truncus arteriosus
repair.
POSTOPERATIVE DIAGNOSES: Right ventricle to pulmonary artery conduit
obstruction, truncal valve insufficiency, status post truncus arteriosus
repair.
PROCEDURES PERFORMED:
1. Redo sternotomy with lysis of adhesions and removal of deep-seated
sternal wires.
2. Truncal valve repair.
3. RV to PA conduit replacement using a 20 mm PTFE trileaflet conduit.
4. Right ventricular outflow tract muscle bundle resection.
INDICATIONS FOR THE PROCEDURE: ------- is an old patient of mine who
underwent repair of truncus arteriosus as a newborn. He now presents for
RV to PA conduit replacement and repair of his insufficient truncal valve.
OPERATIVE FINDINGS: The patient had a quadricuspid truncal valve. The
smallest cusp was the coronary cusp. The valve itself did not look that
abnormal. There was some central insufficiency. The RV to PA conduit was
stenotic. There were some large muscle bundles in the distal right
ventricular outflow tract.
OPERATIVE TECHNIQUE: With the patient in supine position under excellent
general anesthesia, the chest and abdomen were prepped and draped in the
standard fashion. The chest was entered through a median sternotomy
incision. The previous sternal wires were deeply embedded in the sternum.
The wires were cut and removed. The sternum was then divided using the
oscillating saw. The undersurface of each hemisternum was then carefully
dissected from the underlying mediastinal structures. The chest retractor
was then placed and opened. The epicardium of the heart was then carefully
dissected from the pericardium circumferentially. Pursestring sutures were
placed in the distal ascending aorta, SVC, and IVC. Intravenous heparin
was given. The heart was then cannulated in standard fashion.
Cardiopulmonary bypass was instituted and the patient was cooled down to 35
degrees Centigrade. The RV to PA conduit was carefully dissected. An
antegrade cardioplegia catheter was placed in the proximal ascending aorta.
The aorta was then cross-clamped and the heart arrested using cold
antegrade blood cardioplegia. I then opened the proximal aorta through a
transverse aortotomy. I then looked at the truncal valve, which was
quadricuspid. The patient had a single coronary, which originated from the
left sinus. The left cusp was a small of 4 cusps. The leaflets themselves
were relatively normal. There was central insufficiency. I proceeded to
place commissural annuloplasty sutures circumferentially using 4-0
pledgeted sutures. An LV vent was placed through the right superior
pulmonary vein. The valve appeared to have much better coaptation. I
therefore proceeded to close the aortotomy using a 4-0 Prolene in a 2-layer
fashion. Cardioplegia was again given. I then proceeded to excise the
existing RV to PA conduit, which was homograft that was calcified and
stenotic. I then noted in the distal right ventricular outflow tract.
There were very thick obstructive muscle bundles, which I proceeded to
resect. I then placed a 20-mm PTFE trileaflet valve conduit in the RV to
PA position. The pulmonary arteries themselves appeared to be of
reasonable size. The distal anastomosis was performed using a 4-0 Prolene
in a running fashion. The proximal anastomosis was performed using a 4-0
Prolene in a running fashion. CoSeal glue was applied to all suture lines.
The patient was placed in the Trendelenburg position. The antegrade
cardioplegia catheter was used as an aortic root vent. The aortic
cross-clamp was then removed. The heart resumed a normal sinus rhythm.
Temporary atrial and ventricular pacing wires were placed. Once fully
warmed, the patient was weaned from cardiopulmonary bypass without any
difficulty. The heart was then decannulated. The pursestring sutures were
tied and the cannulation sites reinforced using 4-0 Prolene suture.
Careful hemostasis was obtained. At the end of the procedure, the patient
still had mild aortic insufficiency. I did not believe that the
insufficiency was sufficient to require replacement of the truncal valve.
A mediastinal chest tube was placed. The incision was then closed in
layers. A sterile dressing was applied. The patient tolerated the
procedure well.
Cardiothoracic Surgery Operative Report
PREOPERATIVE DIAGNOSES: Right ventricle to pulmonary artery conduit
obstruction, truncal valve insufficiency, status post truncus arteriosus
repair.
POSTOPERATIVE DIAGNOSES: Right ventricle to pulmonary artery conduit
obstruction, truncal valve insufficiency, status post truncus arteriosus
repair.
PROCEDURES PERFORMED:
1. Redo sternotomy with lysis of adhesions and removal of deep-seated
sternal wires.
2. Truncal valve repair.
3. RV to PA conduit replacement using a 20 mm PTFE trileaflet conduit.
4. Right ventricular outflow tract muscle bundle resection.
INDICATIONS FOR THE PROCEDURE: ------- is an old patient of mine who
underwent repair of truncus arteriosus as a newborn. He now presents for
RV to PA conduit replacement and repair of his insufficient truncal valve.
OPERATIVE FINDINGS: The patient had a quadricuspid truncal valve. The
smallest cusp was the coronary cusp. The valve itself did not look that
abnormal. There was some central insufficiency. The RV to PA conduit was
stenotic. There were some large muscle bundles in the distal right
ventricular outflow tract.
OPERATIVE TECHNIQUE: With the patient in supine position under excellent
general anesthesia, the chest and abdomen were prepped and draped in the
standard fashion. The chest was entered through a median sternotomy
incision. The previous sternal wires were deeply embedded in the sternum.
The wires were cut and removed. The sternum was then divided using the
oscillating saw. The undersurface of each hemisternum was then carefully
dissected from the underlying mediastinal structures. The chest retractor
was then placed and opened. The epicardium of the heart was then carefully
dissected from the pericardium circumferentially. Pursestring sutures were
placed in the distal ascending aorta, SVC, and IVC. Intravenous heparin
was given. The heart was then cannulated in standard fashion.
Cardiopulmonary bypass was instituted and the patient was cooled down to 35
degrees Centigrade. The RV to PA conduit was carefully dissected. An
antegrade cardioplegia catheter was placed in the proximal ascending aorta.
The aorta was then cross-clamped and the heart arrested using cold
antegrade blood cardioplegia. I then opened the proximal aorta through a
transverse aortotomy. I then looked at the truncal valve, which was
quadricuspid. The patient had a single coronary, which originated from the
left sinus. The left cusp was a small of 4 cusps. The leaflets themselves
were relatively normal. There was central insufficiency. I proceeded to
place commissural annuloplasty sutures circumferentially using 4-0
pledgeted sutures. An LV vent was placed through the right superior
pulmonary vein. The valve appeared to have much better coaptation. I
therefore proceeded to close the aortotomy using a 4-0 Prolene in a 2-layer
fashion. Cardioplegia was again given. I then proceeded to excise the
existing RV to PA conduit, which was homograft that was calcified and
stenotic. I then noted in the distal right ventricular outflow tract.
There were very thick obstructive muscle bundles, which I proceeded to
resect. I then placed a 20-mm PTFE trileaflet valve conduit in the RV to
PA position. The pulmonary arteries themselves appeared to be of
reasonable size. The distal anastomosis was performed using a 4-0 Prolene
in a running fashion. The proximal anastomosis was performed using a 4-0
Prolene in a running fashion. CoSeal glue was applied to all suture lines.
The patient was placed in the Trendelenburg position. The antegrade
cardioplegia catheter was used as an aortic root vent. The aortic
cross-clamp was then removed. The heart resumed a normal sinus rhythm.
Temporary atrial and ventricular pacing wires were placed. Once fully
warmed, the patient was weaned from cardiopulmonary bypass without any
difficulty. The heart was then decannulated. The pursestring sutures were
tied and the cannulation sites reinforced using 4-0 Prolene suture.
Careful hemostasis was obtained. At the end of the procedure, the patient
still had mild aortic insufficiency. I did not believe that the
insufficiency was sufficient to require replacement of the truncal valve.
A mediastinal chest tube was placed. The incision was then closed in
layers. A sterile dressing was applied. The patient tolerated the
procedure well.