Opt Report

sandy06

Networker
Messages
61
Location
Weston, FL
Best answers
0
PREOPERATIVE DIAGNOSES:
1. Severe mitral regurgitation and mitral stenosis.
2. Coronary artery disease.

PROCEDURE:
1. Coronary artery bypass grafting x2 utilizing the left internal
mammary artery to left anterior descending artery, and saphenous
vein graft to the ramus intermediate.
2. Mitral valve replacement utilizing a 29 mm Hancock porcine mitral
valve.
3. Extensive debridement and decalcification of the mitral valve
annulus.
4. Harvesting of left and right greater saphenous veins.

SURGEON:
, M.D.

ASSISTANT:
, M.D.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed in supine
position, prepped and draped in the usual fashion.

A 2-team approach was utilized. One team harvesting both left and
right greater saphenous veins in order to obtain adequate venous
conduit.

A median sternotomy incision was performed. Electrical saw was
utilized to perform a median sternotomy. Thereafter the left internal
mammary artery was harvested free from the chest in the routine
fashion. The IMA was ligated distally and transected. Adequate flow
was noted through the IMA. The IMA was flushed with papaverine
solution, clipped and left in the left thoracic cavity for
utilization later in the operative procedure.

A sternal retractor was placed. The pericardium was opened in the
midline and tacked to the skin. Thereafter aortic venous antegrade
and retrograde cardioplegia cannulations were performed in routine
fashion. We then instituted a full cardiopulmonary bypass. The aorta
was cross clamped. Cold blood cardioplegia was given both in
antegrade and retrograde fashions until obtaining adequate
electromechanical arrest of the heart. The cardioplegia was delivered
after each anastomosis or every 15 to 20 minutes throughout the
operation.

The ramus intermediate was identified. An arteriotomy was made. This
vessel had a 1.5 mm intraluminal diameter. A segment of vein was then
anastomosed in end-to-side fashion utilizing a 7-0 Prolene suture.

We then directed attention to the left anterior descending artery. It
was identified at its mid segment. This vessel had a 1.5 mm
intraluminal diameter. Then the IMA was anastomosed in end-to-side
fashion utilizing a 7-0 Prolene suture.

We then directed attention to the mitral valve where a left lateral
atriotomy was performed. Exposing the mitral valve was almost
impossible. So a decision was made to bicaval cannulate and encircle
both cavae. Then the right atrium was opened, and then the septum was
opened as well. Then retractors were placed for exposure of the
mitral valve. The anterior leaflet was resected and a significant
amount of posterior mitral annular calcification was evident. So an
extensive debridement of the mitral annulus was required. Thereafter
2-0 Tevdek pledgeted sutures were placed circumferentially around the
annulus. The valve was sized for a 29 mm Hancock porcine valve. This
was then washed. The sutures were placed through the sewing cuff and
the valve was seated in the supra-annular position. The sutures were
tied down and transected. Thereafter the septum, the right atrium and
the left atrium were all closed in a routine fashion with a 4-0
Prolene suture, in a continuous over-and-over fashion.

One aortotomy was performed at the root of the aorta. Then the ramus
vein graft was measured to the aortotomy. This was anastomosed in
end-to-side fashion utilizing a 6-0 Prolene suture.

The patient was then placed in Trendelenburg position. 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, the patient
was placed on inotropic vasopressor supports then weaned from
cardiopulmonary bypass. The venous cannula was removed. Purse string
suture was tied down. The patient was given Protamine, which he
tolerated well. Then the arterial cannula was removed and the purse
suture was tied down. Further hemostasis was obtained. Thereafter
substernal and pleural chest tubes were inserted, as well as pacing
wires. Then the sternum was approximated with number 5 steel sternal
wires. Then the muscle, subcutaneous tissue, and skin were closed in
the routine fashion.

Can someone please give me your insight on this report.

Thanks,
 

jewlz0879

True Blue
Messages
823
Location
Richardson, TX
Best answers
0
PREOPERATIVE DIAGNOSES:
1. Severe mitral regurgitation and mitral stenosis.
2. Coronary artery disease.

PROCEDURE:
1. Coronary artery bypass grafting x2 utilizing the left internal
mammary artery to left anterior descending artery, and saphenous
vein graft to the ramus intermediate.
2. Mitral valve replacement utilizing a 29 mm Hancock porcine mitral
valve.
3. Extensive debridement and decalcification of the mitral valve
annulus.
4. Harvesting of left and right greater saphenous veins.

SURGEON:
, M.D.

ASSISTANT:
, M.D.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed in supine
position, prepped and draped in the usual fashion.

A 2-team approach was utilized. One team harvesting both left and
right greater saphenous veins in order to obtain adequate venous
conduit.

A median sternotomy incision was performed. Electrical saw was
utilized to perform a median sternotomy. Thereafter the left internal
mammary artery was harvested free from the chest in the routine
fashion. The IMA was ligated distally and transected. Adequate flow
was noted through the IMA. The IMA was flushed with papaverine
solution, clipped and left in the left thoracic cavity for
utilization later in the operative procedure.

A sternal retractor was placed. The pericardium was opened in the
midline and tacked to the skin. Thereafter aortic venous antegrade
and retrograde cardioplegia cannulations were performed in routine
fashion. We then instituted a full cardiopulmonary bypass. The aorta
was cross clamped. Cold blood cardioplegia was given both in
antegrade and retrograde fashions until obtaining adequate
electromechanical arrest of the heart. The cardioplegia was delivered
after each anastomosis or every 15 to 20 minutes throughout the
operation.

The ramus intermediate was identified. An arteriotomy was made. This
vessel had a 1.5 mm intraluminal diameter. A segment of vein was then
anastomosed in end-to-side fashion utilizing a 7-0 Prolene suture.

We then directed attention to the left anterior descending artery. It
was identified at its mid segment. This vessel had a 1.5 mm
intraluminal diameter. Then the IMA was anastomosed in end-to-side
fashion utilizing a 7-0 Prolene suture.

We then directed attention to the mitral valve where a left lateral
atriotomy was performed. Exposing the mitral valve was almost
impossible. So a decision was made to bicaval cannulate and encircle
both cavae. Then the right atrium was opened, and then the septum was
opened as well. Then retractors were placed for exposure of the
mitral valve. The anterior leaflet was resected and a significant
amount of posterior mitral annular calcification was evident. So an
extensive debridement of the mitral annulus was required. Thereafter
2-0 Tevdek pledgeted sutures were placed circumferentially around the
annulus. The valve was sized for a 29 mm Hancock porcine valve. This
was then washed. The sutures were placed through the sewing cuff and
the valve was seated in the supra-annular position. The sutures were
tied down and transected. Thereafter the septum, the right atrium and
the left atrium were all closed in a routine fashion with a 4-0
Prolene suture, in a continuous over-and-over fashion.

One aortotomy was performed at the root of the aorta. Then the ramus
vein graft was measured to the aortotomy. This was anastomosed in
end-to-side fashion utilizing a 6-0 Prolene suture.

The patient was then placed in Trendelenburg position. 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, the patient
was placed on inotropic vasopressor supports then weaned from
cardiopulmonary bypass. The venous cannula was removed. Purse string
suture was tied down. The patient was given Protamine, which he
tolerated well. Then the arterial cannula was removed and the purse
suture was tied down. Further hemostasis was obtained. Thereafter
substernal and pleural chest tubes were inserted, as well as pacing
wires. Then the sternum was approximated with number 5 steel sternal
wires. Then the muscle, subcutaneous tissue, and skin were closed in
the routine fashion.

Can someone please give me your insight on this report.

Thanks,
CABG - 33533, 33517
Tip: if the physician endoscopically harvests the Saphenous vein (he must say this in his report) then you can also bill 33508; allowed with codes 33510-33523.

Mitral Valve replacement - 33430

You could consider 22 for the 'extensive debridement' of the annulus so the new valve could be seated.

HTH
 
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