Am I missing a code with 33405, 33510, 33508 and 33530? I feel like there was more going on here. (Dr. lists R heart cath and TEE in name of operation.) I'm more concerned with the AVR.
I know it's long, but anyone willing to take a look and weigh in, is appreciated.
After placement of the Swan-Ganz in the floating end of the pulmonary artery, the pulmonary artery pressures were noted they elevated with PA pressures of 48/22 and with a CVP of approximately 12. Cardiac function appeared adequate with a normal cardiac index of approximately 2.3 on no inotropic agents.
After carefully entering the sternum without violating the cardiac structures,
blunt and sharp dissection was utilized to free the planes in the retrosternal position with great care being taken to protect the left internal mammary artery, which was accomplished. Simultaneously, a saphenous vein segment was harvested from the lower extremities by endoscopic technique.
Dissection was began on the right side and the right atrium was dissected free of the rather dense adhesions with one entry the right atrium corrected with the 4-0 Prolene suture. The rather calcified aorta was identified and dissection along its length allowed us to place sutures for the aortic cannula site high upon the aorta in reasonable safe side. similarly, a dissection was carried down until the right atrial wall was identified in toto and purse-string sutures were placed in that for allowing for venous drainage. At that point, it was decided to place the patient on cardiopulmonary bypass and with the heart decompressed, beating and warm, then complete the dissections.
Accordingly, the aortic cannula was placed through the previously placed purse-string sutures and was tied and place with good hemostasis. The two-stage venous cannula was inserted in the right atrium down into the vena cava and was confirmed and secured. The patient was then placed on cardiopulmonary bypass. With the heart decompressed, dissection enabled us to free up the remainder of the right atrium and the aorta, and the plane between the aorta and pulmonary artery. In addition, dissection was carried out over the anterior ventricle with eventual visualization of the mammary into the left anterior descending, such that we could identify the mammary and place an appropriate temporary bulldog clip across it during the time of the operation.
Eventually immobilization was adequate to place additional purse-string sutures into the ascending aorta and into the right atrium to allow for the antegrade and retrograde cardioplegia lines to be introduced and advanced. Once these were in place, gentle cooling was began and a cross-clamp was applied and cardioplegia was instituted through the ascending aorta, which was not entirely successful given the patient's aortic insufficiency, but some relaxation occurred without distention of the ventricle. We rapidly shifted to retrograde cardioplegia for the completion of the cardioplegia dose and this was accomplished.
Dissection was then continued on the ascending aorta until down to the area where the possible aortotomy. It was noted that the aorta had calcified plates in its layers at this site, but it was decided that was the best entering point. The aorta was then opened and the incision was extended down towards the noncoronary cusps to allow for visualization as well as to extend it to the left side. with the aorta open, exposure of the failed prosthesis was identified and there was clearly tear and one of the cusps had a side of calcification. We then used the handheld perfusor and reestablished cardioplegia using antegrade technique down the left main coronary, which was patent. We gave an additional 800 mL of cardioplegia solution this way as well as down the right coronary artery, which was little more difficult to uncover.
Once we were satisfied with a complete cardioplegia, it was decided to resect the current damaged tissue prosthesis and then proceed with revascularization of lateral wall. Accordingly, a knife was brought into the field and we began cutting the sutures and the interface between sewing ring in the annulus circumferentially. This was completed with scissors in some areas and eventually the entire valve intact was able to be excised from the valve annul us intact. We then carefully inspected the valve annulus for any residual pledgets and none were found. We then inspected the ring noted that there were areas of partial denuding of the wall particularly laterally near the non-commissure cusp and that these would need reconstruction by deep placement of pledget with sutures in the ventricle, which should be accomplished at the time of placing the valve. The remainder of the annulus was satisfactory for holding stitches, although there was calcium that needed to be rongeured particularly over the left coronary cusp and this was accomplished. We then incised the valve ring and it was decided to place a 23-mm Medtronic porcine graft yet again.
Attention was then turned to the lateral wait where dissection ultimately revealed the lateral obtuse marginal vessel of approximately 2.2 mm in size, which was identified by angiogram. This vessel was opened and a satisfactory end-to-side anastomosis with 7-0 Prolene sutures was fashioned and tested and secured and probed prior to completion. With the graft in place, this was then hooked into the cardioplegia system for antegrade cardioplegia as appropriate.
We then turned our attention back to the aortic valve. We then began to place circumferentially pledgetted sutures with the pledget on the ventricular surface and used the pledgets literally to reconstruct and reef up the annular tissues to provide re-support at the actual sewing annulus, which had been thinned at the non-commissure cusp. Approximately 16 of these sutures were placed circumferentially, these were 2-0 pledgeted Tycron sutures of alternating colors. Once these were placed circumferentially, the valves have been washed and the sutures were then passed to the sewing annulus, which was then slid into place and sat well just slightly in the supraannular position and free from the left and right coronary arteries. The sutures were then tied securely without breakage. The valve was tested and was competent.
With the valve seated in place, it was time to close the aorta. Two double-piedgetted 4-0 Prolene sutures were then brought in a mattress fashion at the left and right edges of the aortotomy. The right side of the aortotomy was very close to the actual annular sewing ring and the valve proper. The stitches were placed carefully and with adequate margin very dose to the sewing ring and the reinforcing pledgets were slid into place and suture was tied. The aorta was then closed using a running continuous as well as over-and-over double layer suture towards the midline. Similarly, the left side was closed with a double-layered pledgetted 4-0 Prolene suture.
The patient continued in stable state and the blood volume was adjusted through the arterial cannula using the TEE probe to evaluate cardiac fullness. It should be noted that the TEE showed good left ventricular function without evidence of new mitral regurgitation and with aortic prosthesis working well without paravalvular leak. When we were satisfied with the volume, the arterial cannula was withdrawn and hemostasis was satisfactory. The patient was using only atrial pacing at this point and interrupted external wires were placed with closure and remaining layers were closed with vicryl.
At the conclusion of the operation, the patient was atrially paced at approximately 88 with a cardiac index approaching 3 and reduced filling pressures on the right side with PA pressures running in the mid to low 40s
over approximately 19 to 20. The patient's cardiac function was thought to be improved by TEE.
I know it's long, but anyone willing to take a look and weigh in, is appreciated.
After placement of the Swan-Ganz in the floating end of the pulmonary artery, the pulmonary artery pressures were noted they elevated with PA pressures of 48/22 and with a CVP of approximately 12. Cardiac function appeared adequate with a normal cardiac index of approximately 2.3 on no inotropic agents.
After carefully entering the sternum without violating the cardiac structures,
blunt and sharp dissection was utilized to free the planes in the retrosternal position with great care being taken to protect the left internal mammary artery, which was accomplished. Simultaneously, a saphenous vein segment was harvested from the lower extremities by endoscopic technique.
Dissection was began on the right side and the right atrium was dissected free of the rather dense adhesions with one entry the right atrium corrected with the 4-0 Prolene suture. The rather calcified aorta was identified and dissection along its length allowed us to place sutures for the aortic cannula site high upon the aorta in reasonable safe side. similarly, a dissection was carried down until the right atrial wall was identified in toto and purse-string sutures were placed in that for allowing for venous drainage. At that point, it was decided to place the patient on cardiopulmonary bypass and with the heart decompressed, beating and warm, then complete the dissections.
Accordingly, the aortic cannula was placed through the previously placed purse-string sutures and was tied and place with good hemostasis. The two-stage venous cannula was inserted in the right atrium down into the vena cava and was confirmed and secured. The patient was then placed on cardiopulmonary bypass. With the heart decompressed, dissection enabled us to free up the remainder of the right atrium and the aorta, and the plane between the aorta and pulmonary artery. In addition, dissection was carried out over the anterior ventricle with eventual visualization of the mammary into the left anterior descending, such that we could identify the mammary and place an appropriate temporary bulldog clip across it during the time of the operation.
Eventually immobilization was adequate to place additional purse-string sutures into the ascending aorta and into the right atrium to allow for the antegrade and retrograde cardioplegia lines to be introduced and advanced. Once these were in place, gentle cooling was began and a cross-clamp was applied and cardioplegia was instituted through the ascending aorta, which was not entirely successful given the patient's aortic insufficiency, but some relaxation occurred without distention of the ventricle. We rapidly shifted to retrograde cardioplegia for the completion of the cardioplegia dose and this was accomplished.
Dissection was then continued on the ascending aorta until down to the area where the possible aortotomy. It was noted that the aorta had calcified plates in its layers at this site, but it was decided that was the best entering point. The aorta was then opened and the incision was extended down towards the noncoronary cusps to allow for visualization as well as to extend it to the left side. with the aorta open, exposure of the failed prosthesis was identified and there was clearly tear and one of the cusps had a side of calcification. We then used the handheld perfusor and reestablished cardioplegia using antegrade technique down the left main coronary, which was patent. We gave an additional 800 mL of cardioplegia solution this way as well as down the right coronary artery, which was little more difficult to uncover.
Once we were satisfied with a complete cardioplegia, it was decided to resect the current damaged tissue prosthesis and then proceed with revascularization of lateral wall. Accordingly, a knife was brought into the field and we began cutting the sutures and the interface between sewing ring in the annulus circumferentially. This was completed with scissors in some areas and eventually the entire valve intact was able to be excised from the valve annul us intact. We then carefully inspected the valve annulus for any residual pledgets and none were found. We then inspected the ring noted that there were areas of partial denuding of the wall particularly laterally near the non-commissure cusp and that these would need reconstruction by deep placement of pledget with sutures in the ventricle, which should be accomplished at the time of placing the valve. The remainder of the annulus was satisfactory for holding stitches, although there was calcium that needed to be rongeured particularly over the left coronary cusp and this was accomplished. We then incised the valve ring and it was decided to place a 23-mm Medtronic porcine graft yet again.
Attention was then turned to the lateral wait where dissection ultimately revealed the lateral obtuse marginal vessel of approximately 2.2 mm in size, which was identified by angiogram. This vessel was opened and a satisfactory end-to-side anastomosis with 7-0 Prolene sutures was fashioned and tested and secured and probed prior to completion. With the graft in place, this was then hooked into the cardioplegia system for antegrade cardioplegia as appropriate.
We then turned our attention back to the aortic valve. We then began to place circumferentially pledgetted sutures with the pledget on the ventricular surface and used the pledgets literally to reconstruct and reef up the annular tissues to provide re-support at the actual sewing annulus, which had been thinned at the non-commissure cusp. Approximately 16 of these sutures were placed circumferentially, these were 2-0 pledgeted Tycron sutures of alternating colors. Once these were placed circumferentially, the valves have been washed and the sutures were then passed to the sewing annulus, which was then slid into place and sat well just slightly in the supraannular position and free from the left and right coronary arteries. The sutures were then tied securely without breakage. The valve was tested and was competent.
With the valve seated in place, it was time to close the aorta. Two double-piedgetted 4-0 Prolene sutures were then brought in a mattress fashion at the left and right edges of the aortotomy. The right side of the aortotomy was very close to the actual annular sewing ring and the valve proper. The stitches were placed carefully and with adequate margin very dose to the sewing ring and the reinforcing pledgets were slid into place and suture was tied. The aorta was then closed using a running continuous as well as over-and-over double layer suture towards the midline. Similarly, the left side was closed with a double-layered pledgetted 4-0 Prolene suture.
The patient continued in stable state and the blood volume was adjusted through the arterial cannula using the TEE probe to evaluate cardiac fullness. It should be noted that the TEE showed good left ventricular function without evidence of new mitral regurgitation and with aortic prosthesis working well without paravalvular leak. When we were satisfied with the volume, the arterial cannula was withdrawn and hemostasis was satisfactory. The patient was using only atrial pacing at this point and interrupted external wires were placed with closure and remaining layers were closed with vicryl.
At the conclusion of the operation, the patient was atrially paced at approximately 88 with a cardiac index approaching 3 and reduced filling pressures on the right side with PA pressures running in the mid to low 40s
over approximately 19 to 20. The patient's cardiac function was thought to be improved by TEE.
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