bennieyoung
Guru
My auditor wants me to use I42.1 instead of I42.2. I chose I42.2 because in the note it says she was more of a circumferential hypertrophic than a true outflow tract obstruction.
PREOPERATIVE DIAGNOSIS:
1. Mitral insufficiency.
2. Patent foramen ovale.
3. Hypertrophic cardiomyopathy with outflow tract obstruction.
4. Mild to moderate aortic insufficiency.
5. Persistent atrial fibrillation.
POSTOPERATIVE DIAGNOSIS:
1. Mitral insufficiency.
2. Patent foramen ovale.
3. Hypertrophic cardiomyopathy with outflow tract obstruction.
4. Mild to moderate aortic insufficiency.
5. Persistent atrial fibrillation.
PROCEDURE PERFORMED:
1. Mitral valve replacement with a 29 Mitris bioprosthetic valve.
2. Biatrial Cox-Maze IV procedure with radiofrequency and cryoablation.
3. Closure of patent foramen ovale.
4. A 40 mm atrial clip to the base of the left atrial appendage.
FINDINGS:
DESCRIPTION OF PROCEDURE: The patient was consented for surgery, brought to the operating room, intubated, and monitoring lines were placed. She was prepped and draped in a sterile classical manner. Sternotomy was performed. She was heparinized and cannulated in the ascending aorta and bicaval cannulas. Cardiopulmonary bypass was begun and radiofrequency ablation was performed on the right pulmonary vein per protocol. We then arrested the heart using Del Nido protocol. The aortic insufficiency was mild and we were able to maintain adequate aortic pressure without LV distention and excellent myocardial protection. Topical hypothermia in the form of slush was also utilized. I then exposed the left pulmonary veins and ablated that per protocol. We then opened the left atrial appendage and ablated across into the left superior pulmonary vein per protocol. A 40 mm atrial clip was placed at the base of the left atrial appendage. We then marked the terminus of the right and left coronary systems on the coronary sinus, opened the left atrium through the right superior pulmonary vein, and performed the cryoablation from the inferior pole of the right inferior pulmonary vein to and across the coronary sinus for 3 minutes. I then exposed the mitral valve. The anterior leaflet was quite thickened and relatively noncompliant. The chordae were fused somewhat below the anterior leaflet. The posterior anulus had a large bar of MAC. For that reason, I felt it would be unsuitable for repair, particularly given her outflow tract obstruction with septal hypertrophy. I then excised the entire anterior leaflet down to the papillary muscle head. Because of her hyperdynamic and obliterated ventricle, I felt that she was more of a circumferential hypertrophic than a true outflow tract obstruction with HOCM. I then placed a 29 mm Mitris valve in a supra-annular position with the pledgets on the ventricular side in order to increase the distance between the struts and the ventricular septum. These were secured with Cor-Knots with without difficulty. I then performed a cryoablation on the dome lesion and radiofrequency on the floor lesion. The left atrium was then closed in the LV sump across the valve to prevent ventricular distention when removing the cross-clamp. We then opened the right atrium with a vertical atriotomy, performed the free wall lesion, and the superior and inferior vena caval lesions. I then I identified a 1 cm in diameter PFO, which was closed with a two-layer closure of Prolene. We then removed the cross-clamp with suction on the LV sump and aortic vent in Trendelenburg, de-airing through the apex intermittently. I then cryo ablated across the isthmus of the tricuspid valve with flow in the right coronary artery. The right atrium was closed in a 2-layer fashion. The patient was rewarmed and de-aired until no further air was identified, easily weaned from bypass with the loss of the anterior leaflet. There was no longer outflow tract obstruction despite having a thick septum and extremely thick circumferential ventricle. I felt that septal myectomy was not warranted, also hoping to avoid pacemaker placement. The patient was weaned from bypass. Biventricular function was preserved. She was in sinus rhythm. Heparin was reversed with protamine. The cannula was removed and oversewn. Four pacing wires were placed. Two mediastinal drains were placed. The thymic fat and pericardium were closed. The sternum was closed in a standard fashion. The patient was returned to Intensive Care Unit in stable condition.
I had a hard time finding out if circumferential hypertrophy causes outflow obstruction, even this article says it might be associated with it so? Am I right using I42.2 instead of I42.1? Or did I in fact make the wrong choice?
Associations
Concentric hypertrophic cardiomyopathy might be also associated with left ventricular outflow obstruction 5.
Pathology
In concentric hypertrophic cardiomyopathy, myocardial wall thickness is increased in a fairly symmetrical and circumferential fashion and the left ventricular cavity is decreased.
PREOPERATIVE DIAGNOSIS:
1. Mitral insufficiency.
2. Patent foramen ovale.
3. Hypertrophic cardiomyopathy with outflow tract obstruction.
4. Mild to moderate aortic insufficiency.
5. Persistent atrial fibrillation.
POSTOPERATIVE DIAGNOSIS:
1. Mitral insufficiency.
2. Patent foramen ovale.
3. Hypertrophic cardiomyopathy with outflow tract obstruction.
4. Mild to moderate aortic insufficiency.
5. Persistent atrial fibrillation.
PROCEDURE PERFORMED:
1. Mitral valve replacement with a 29 Mitris bioprosthetic valve.
2. Biatrial Cox-Maze IV procedure with radiofrequency and cryoablation.
3. Closure of patent foramen ovale.
4. A 40 mm atrial clip to the base of the left atrial appendage.
FINDINGS:
DESCRIPTION OF PROCEDURE: The patient was consented for surgery, brought to the operating room, intubated, and monitoring lines were placed. She was prepped and draped in a sterile classical manner. Sternotomy was performed. She was heparinized and cannulated in the ascending aorta and bicaval cannulas. Cardiopulmonary bypass was begun and radiofrequency ablation was performed on the right pulmonary vein per protocol. We then arrested the heart using Del Nido protocol. The aortic insufficiency was mild and we were able to maintain adequate aortic pressure without LV distention and excellent myocardial protection. Topical hypothermia in the form of slush was also utilized. I then exposed the left pulmonary veins and ablated that per protocol. We then opened the left atrial appendage and ablated across into the left superior pulmonary vein per protocol. A 40 mm atrial clip was placed at the base of the left atrial appendage. We then marked the terminus of the right and left coronary systems on the coronary sinus, opened the left atrium through the right superior pulmonary vein, and performed the cryoablation from the inferior pole of the right inferior pulmonary vein to and across the coronary sinus for 3 minutes. I then exposed the mitral valve. The anterior leaflet was quite thickened and relatively noncompliant. The chordae were fused somewhat below the anterior leaflet. The posterior anulus had a large bar of MAC. For that reason, I felt it would be unsuitable for repair, particularly given her outflow tract obstruction with septal hypertrophy. I then excised the entire anterior leaflet down to the papillary muscle head. Because of her hyperdynamic and obliterated ventricle, I felt that she was more of a circumferential hypertrophic than a true outflow tract obstruction with HOCM. I then placed a 29 mm Mitris valve in a supra-annular position with the pledgets on the ventricular side in order to increase the distance between the struts and the ventricular septum. These were secured with Cor-Knots with without difficulty. I then performed a cryoablation on the dome lesion and radiofrequency on the floor lesion. The left atrium was then closed in the LV sump across the valve to prevent ventricular distention when removing the cross-clamp. We then opened the right atrium with a vertical atriotomy, performed the free wall lesion, and the superior and inferior vena caval lesions. I then I identified a 1 cm in diameter PFO, which was closed with a two-layer closure of Prolene. We then removed the cross-clamp with suction on the LV sump and aortic vent in Trendelenburg, de-airing through the apex intermittently. I then cryo ablated across the isthmus of the tricuspid valve with flow in the right coronary artery. The right atrium was closed in a 2-layer fashion. The patient was rewarmed and de-aired until no further air was identified, easily weaned from bypass with the loss of the anterior leaflet. There was no longer outflow tract obstruction despite having a thick septum and extremely thick circumferential ventricle. I felt that septal myectomy was not warranted, also hoping to avoid pacemaker placement. The patient was weaned from bypass. Biventricular function was preserved. She was in sinus rhythm. Heparin was reversed with protamine. The cannula was removed and oversewn. Four pacing wires were placed. Two mediastinal drains were placed. The thymic fat and pericardium were closed. The sternum was closed in a standard fashion. The patient was returned to Intensive Care Unit in stable condition.
I had a hard time finding out if circumferential hypertrophy causes outflow obstruction, even this article says it might be associated with it so? Am I right using I42.2 instead of I42.1? Or did I in fact make the wrong choice?
Associations
Concentric hypertrophic cardiomyopathy might be also associated with left ventricular outflow obstruction 5.
Pathology
In concentric hypertrophic cardiomyopathy, myocardial wall thickness is increased in a fairly symmetrical and circumferential fashion and the left ventricular cavity is decreased.
