Wiki ECMO Removal and RVAD Insertion

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Atlanta, GA
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It has been years since I coded this specialty so I'm pretty rusty... Can someone please tell me if they agree with my codes?
33975
35271-51
34201-51
33946-51
33984-59
36556-51
93314-26
(I don't see documentation of the cardioversion in the op note)

OPERATIONS PERFORMED:
1. Right groin cutdown.
2. Open peripheral venoarterial-venous extracorporeal membrane oxygenation
decannulation.
3. Fogarty balloon thrombectomy of the right superficial femoral artery.
4. Primary repair of the right common femoral artery and right superficial
femoral artery.
5. Median sternotomy.
6. Anastomosis to 8 mm Gelweave graft to the main pulmonary artery.
7. Percutaneous insertion of the left femoral venous cannula.
8. Insertion of extracorporeal CentriMag right ventricular assist device with
oxygenator.
9. Initiation of central venovenous extracorporeal membrane oxygenation
support.
10. Transesophageal echo. I independently reviewed and interpreted the
intraoperative echo findings.
11. Sternal fixation with KLS Martin plating system.
12. Insertion of right femoral venous Vas-Cath for continuous renal replacement
therapy.
13. Synchronized cardioversion.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed under general anesthesia in
the supine position. The patient had appropriate vascular access and monitors
placed. A timeout was performed. The patient received perioperative antibiotic
within 60 minutes of the skin incision. Transesophageal echo was placed to
monitor the patient's cardiac function. I independently reviewed and
interpreted the intraoperative echo findings. Overall, it demonstrated good
left ventricular function. There was moderate to severe right ventricular
dysfunction. The right ventricle was significantly dilated. The patient was
then sterilely prepped, draped and padded appropriately.

We proceeded with a right groin cutdown. A vertical incision was made at the
level of the cannula. I follow first the path of the right common femoral
artery cannula into its insertion site into the artery. The artery was good
size and had no evidence of significant atherosclerosis. A 5-0 Prolene
pursestring was then placed around the entry site of the cannula. The previous
Perclose sutures were removed. I then followed the path of the right
superficial femoral artery distal perfusion catheter into its insertion site
into the artery. Similarly, I placed a 5-0 Prolene pursestring sutures for
control of the vessel. I then followed the path of the right common femoral
vein into its insertion site. A 5-0 Prolene pursestring was placed at the entry
site of the vein.

I then proceeded with the insertion of the extracorporeal right ventricular
assist device. Initially, we attempted to do the procedure through an upper
mini sternotomy with an inverted T incision at the level of the fifth
intercostal space. The sternotomy was performed with an oscillating saw. This
was done safely. We opened the pericardium. However, due to the very enlarged
right ventricle, the exposure to the pulmonary artery was very difficult.
Therefore, I felt that we need to complete the sternotomy. This was done with a
regular saw to complete the full sternotomy. Later, we fixed the fifth
intercostal sternal break with sternal plates.

The chest cavity was entered. The pericardium was fully opened. The right
ventricle was noted to be significantly dilated with moderate to severe
dysfunction. We opened both pleural spaces. The left lung was not fully
expanded. There was a small to moderate sized pleural effusion, which was
drained. The fluid was transudative. We entered the right pleural space. The
right lung was more significantly scarred and inflamed. It was adherent and had
a very low compliance. There was a moderate sized right pleural effusion, which
was also drained.

We proceeded with insertion of extracorporeal right ventricular assist device.
The right ventricle as noted was dilated and the pulmonary artery was enlarged.
I was able to place a small side-biting clamp on the proximal pulmonary artery.
The patient tolerated that well. An arteriotomy was performed on the main
pulmonary artery. An 8 mm Gelweave graft was then anastomosed to the main
pulmonary artery using a running 5-0 Prolene suture. The clamp was released and
we obtained hemostasis at the anastomosis. The graft was covered with BioGlue
and then tunneled to the epigastrium. I then proceeded with placement of a new
right femoral venous cannula for drainage. The reason for this was to place a
venous cannula higher into the right atrium for better drainage of the venous
circulation. The patient had previous left femoral Vas-Cath. This was
exchanged over a 0.035 inch Amplatz wire. The wire was advanced into the right
atrium under transesophageal echo guidance. Using the Seldinger technique, the
25-French femoral venous cannula was advanced to the right atrium to the level
of the superior vena cava without any problem. The cannula was then secured. I
then placed a 20-French arterial cannula into the pulmonary artery chimney
graft. We then came off venoarterial-venous extracorporeal membrane oxygenation
by clamping the current extracorporeal membrane oxygenation circuit. The tubing
was divided. The tubing from the current extracorporeal membrane oxygenation
circuit was then connected appropriately to the right ventricular assist device
cannula. The clamps were released and we initiated central venovenous
extracorporeal membrane oxygenation support with right ventricular support. The
flow was slowly increased to about 4 L per minute. This immediately improved
the patient's oxygenation status. The patient remained hemodynamically stable.
Left ventricular function remained very good. The right ventricle was mildly
decreased in size but still dysfunctional.

I then proceeded to remove the right common femoral venous cannula. The
pursestring suture was tied down. We then removed the right superficial femoral
artery distal perfusion cannula. The pursestring was tied down. We also
removed the right common femoral artery cannula. There was good antegrade and
backbleeding from the vessel. The pursestring suture was then snared down. We
then removed the right internal jugular vein cannula. A pursestring suture was
placed and manual pressure held over the right neck for more than 20 minutes to
achieve hemostasis.

I then returned my attention back to the chest cavity. Copious irrigation was
performed. Meticulous hemostasis was obtained. We placed new chest tubes. The
pericardium was partially reapproximated. The current configuration of the
right ventricular assist device with a chimney graft to the main pulmonary
artery will allow us to remove the right ventricular assist device when
appropriate without having to reopen the chest. The sternum was then closed in
the usual fashion with a combination of sternal wires and sternal plates. As
noted, we stabilized the intercostal break at the fifth intercostal space. The
rest of the incision was closed with absorbable sutures followed by subcuticular
skin stitch. Sterile dressing was applied.

I then turned my attention to the right groin. Proximal and distal control of
the right common femoral artery was obtained. There was adequate backbleeding
from the right superficial femoral artery. I used a #4 Fogarty catheter and
passed that distally and we were able to remove a long thin strand of thrombus.
The second pass did not yield any further thrombi. The specimen was sent to
pathology. I then repaired the right common femoral artery entry site with
several interrupted 5-0 Prolene suture in a transverse fashion. Prior to tying
down the sutures, we allowed for both antegrade and retrograde bleeding from the
vessel. The clamps were released. There was a good palpable pulse. We
confirmed that with good Doppler signal in the right common femoral artery and
superficial femoral artery. Meticulous hemostasis was obtained. We placed a
7-French JP drain. I also inserted a new right femoral venous Vas-Cath for
subsequent access for dialysis. The incision was then closed in several layers
with Vicryl sutures followed by skin closure. All the cannulae and tubes were
secured. Sterile dressings were applied. The patient was then transferred to
the ICU in critical condition. Final sponge, instrumentation and needle counts
were correct.
 
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