MVR, TVR,with Closure of PFO and Maze Proc.


Weston, FL
Best answers
1. Severe mitral regurgitation.
2. Rheumatic mitral valve disease.
3. Tricuspid regurgitation.
4. Atrial fibrillation.
5. Coronary artery disease.
6. Hybrid procedure status post angioplasty.
7. Patent foramen ovale.


1. Minimally invasive mitral valve replacement utilizing a 29 mm EPIC
porcine mitral valve.
2. Tricuspid valve repair utilizing a 28-mm 3-D Contour annuloplasty
3. Closure of patent foramen ovale.
4. Maze procedure utilizing radiofrequency energy.
5. Ligation left atrial appendage.
6. Direct repair of the left femoral artery.






The patient was taken to the operating room and placed in the supine
position, prepped and draped in the usual. A two-team approach was
utilized; one team exposing the left femoral artery and vein while
the other team performed the mini thoracotomy approach. Once the
patient was heparinized and a Seldinger technique was utilized to
cannulate both left femoral and left femoral vein. Thereafter a 5 cm
skin incision was performed over the right inframammary fold.
Incision was taken down through skin, subcu tissue, entering the
fourth-fifth interspace. Thereafter a soft tissue retractor was
placed and a rib spreader. The pericardium was opened over the
phrenic nerve and tacked to the skin. Thereafter, a retrograde
cardioplegia cannula was inserted. We then instituted full
cardiopulmonary bypass. Both superior and inferior vena cavae were
encircled with vessels loops. The aorta was then crossclamped and
cold blood cardioplegia was given both in antegrade and retrograde
fashion until obtaining adequate electrical mechanical arrest of the
heart. Of note, every 20 minutes further doses of cardioplegia were
given throughout the operation. A left lateral atriotomy was
performed exposing the mitral valve, and then the patent foramen
ovale was identified and this was oversewn with a 5-0 Prolene suture
in two-layer closure. Atrial lift retractor was then placed and
exposure of the mitral valve was obtained. Then a left-sided maze
procedure was performed with lesion patterns created around the left
and right pulmonary veins and communicating with each of the
pulmonary veins in a box fashion. Thereafter, the left atrial
appendage was oversewn with a 4-0 Prolene suture two-layer closure.
Then, at this point, we directed our attention to the mitral valve
where it was noted to be rheumatic in nature, so the decision was
made to resect the anterior leaf. The posterior leaflet was left
intact. Then 2-0 Tevdek pledgeted sutures were placed
circumferentially around the annulus, leaving the pledgets in the
infra-annular position. The valve sized and noted to accommodate a 29
mm EPIC porcine St. Jude mitral valve. The valve was washed, the
sutures placed through the sewing cuff and the valve was seated in a
supra-annular position. The sutures were tied down and transected.
Thereafter, the left atrium was closed with 4-0 Prolene suture
two-layer closure. Then the two vessel loops were pulled up. The cava
was snared, the venous cannula was pulled into the inferior vena
cava. The right atrium was immediately opened, then a pump suction
was placed in the superior vena cava to drain the superior vena cava.
Thereafter, a 4-0 Tevdek suture was placed circumferentially around
the tricuspid annulus, and a 28 mm 3D annuloplasty ring was passed
onto the operative field, and the suture was placed through the ring,
the ring was seated onto the annulus and the sutures tied down and
transected. Thereafter, the right atrium was closed with 4-0 Prolene
suture two-layer closure. The patient was placed in Trendelenburg
position. The left atrium was completely closed and de-aired then the
aortic cross-clamp was removed and multiple de-airing maneuvers were
performed utilizing a THI needle in the root of the aorta. After
adequate de-airing and adequate function of the valve, which was
evident by intraoperative TEE, the patient was weaned from bypass,
the venous cannula was removed. The pursestring suture was tied down.
The patient given protamine which she tolerated well. Then the
arterial was removed and direct repair of the right and left femoral
artery was performed, proximal intima adventitia in two-layer
closure. An On-Q system was placed. The pacing wire was exited
through a chest tube incision as well as the Blake chest tube and a
right angle chest tube. Further hemostasis was obtained. Thereafter a
figure-of-eight suture was placed around the ribs to approximate the
ribs, and muscle, subcutaneous tissues and skin were all closed in a
routine fashion.

Can someone please help me with this report.


Best answers
HI! I skimmed over the report Please double check with what I am coding.

33430 - Mitral valve replacment
33464 - Tricuspid Valve repair with Ring
33641 - Repair of atrial septal defect
33257 - Maze proc modified; if he did extensive it would be 33259..normally box lesion are not extensive but check with your surgeon..Also these are add on codes.

Now the Ligation left atrial appendage is included in the Maze and the MVR as is the
Direct repair of the left femoral artery.

Hope This Helps! :eek: