mush69
Contributor
I need advice on what code to use for this procedure. Would I use 33414?
1. REPAIR OF LEFT VENTRICULAR OUTFLOW TRACT PSEUDOANEURYSM.
2. REDO STERNOTOMY.
INDICATIONS: J is an infant who underwent a Ross procedure as a
newborn. He had an uneventful recovery and was doing well at home. He was
seen in the Cardiology office for routine followup when he was noted to have
the appearance of a mass within his left upper chest which by echo appeared
to have communication with his left ventricular outflow tract. A CT scan of
the chest confirmed the presence of a pseudoaneurysm originating from the
left ventricular outflow tract. The patient was intubated and invasive
lines were inserted to assist with monitoring in preparation for going to
the operating room.
FINDINGS: A 1.5 mm fistulous tract from the autograft anastomotic site in
the left ventricular flow tract was found at the base of a large
pseudoaneurysm. This was controlled with interrupted pledgeted suture and a
figure-of-eight suture. The aortic cross-clamp time was 16 minutes,
cardiopulmonary bypass time 137 minutes. A CorMatrix was placed over the
pulmonary homograft in the aorta shielding them from the overlying sternum.
TECHNICAL DESCRIPTION: The patient was brought to the Operating Room and
placed on the table in supine position. Following induction of general
anesthesia, the chest, abdomen and groins were prepped and draped in a
routine sterile fashion. A redo median sternotomy was performed. The
previous midline scar was excised and soft tissue divided with
electrocautery down to the level of sternum. The sternum was then divided.
The right ventricle and right atrium were dissected free from the
surrounding tissues. The right-sided descending aorta was likewise
dissected free from the surrounding tissues up to the level of the arch. We
were able to get adequate access for cannulation without entering the
pseudoaneurysm. The patient was then systemically anticoagulated with
heparin. A pursestring was placed at the base of the innominate artery and
an arterial cannula was inserted. A venous cannula was placed through a
pursestring into the right atrial appendage and secured. The patient was
then placed on cardiopulmonary bypass. At this point the dissection was
carried to the left side of the autograft where the pulmonary SynerGraft was
noted. Further dissection revealed a very thick encapsulated aneurysm
emanating from beneath the homograft and extending to the left upper lobe.
It was contained by the pericardium and pleura. The heart was arrested
using cold blood antegrade cardioplegia and the pseudoaneurysm capsule was
incised with scissors. At the base of the pseudoaneurysm beneath the
pulmonary homograft was a 1.5 mm fistulous tract into the left ventricular
outflow tract. CorMatrix was hydrated and utilized as a pledget. A 5-0
Prolene horizontal mattress pledgeted suture was then placed to close the
fistulous tract. An additional figure-of-eight 5-0 Prolene suture was also
placed. The heart was then deaired and the aortic cross-clamp was removed.
The patient was then warmed and weaned from cardiopulmonary bypass. Under
direct vision, there was no continued bleeding noted in the fistulous tract.
Transesophageal echo was also obtained which showed complete resolution of
the fistulous tract with excellent function and residual ventricular septal
defect. Protamine was administered and the cannulas were removed.
Mediastinal drains were inserted, one extending from the right pleural space
across the mediastinum and into the pseudoaneurysm pocket. The second drain
entered into the left pleural space. Once hemostasis was adequate, the
sternum was reapproximated with interrupted stainless steel wires. The soft
tissues were closed with two layers of running Vicryl and the skin was
closed with running monofilament suture. Benzoin and Steri-Strips were
applied. The baby remained intubated, was taken directly to the Pediatric
Cardiac Intensive Care Unit in stable condition.
1. REPAIR OF LEFT VENTRICULAR OUTFLOW TRACT PSEUDOANEURYSM.
2. REDO STERNOTOMY.
INDICATIONS: J is an infant who underwent a Ross procedure as a
newborn. He had an uneventful recovery and was doing well at home. He was
seen in the Cardiology office for routine followup when he was noted to have
the appearance of a mass within his left upper chest which by echo appeared
to have communication with his left ventricular outflow tract. A CT scan of
the chest confirmed the presence of a pseudoaneurysm originating from the
left ventricular outflow tract. The patient was intubated and invasive
lines were inserted to assist with monitoring in preparation for going to
the operating room.
FINDINGS: A 1.5 mm fistulous tract from the autograft anastomotic site in
the left ventricular flow tract was found at the base of a large
pseudoaneurysm. This was controlled with interrupted pledgeted suture and a
figure-of-eight suture. The aortic cross-clamp time was 16 minutes,
cardiopulmonary bypass time 137 minutes. A CorMatrix was placed over the
pulmonary homograft in the aorta shielding them from the overlying sternum.
TECHNICAL DESCRIPTION: The patient was brought to the Operating Room and
placed on the table in supine position. Following induction of general
anesthesia, the chest, abdomen and groins were prepped and draped in a
routine sterile fashion. A redo median sternotomy was performed. The
previous midline scar was excised and soft tissue divided with
electrocautery down to the level of sternum. The sternum was then divided.
The right ventricle and right atrium were dissected free from the
surrounding tissues. The right-sided descending aorta was likewise
dissected free from the surrounding tissues up to the level of the arch. We
were able to get adequate access for cannulation without entering the
pseudoaneurysm. The patient was then systemically anticoagulated with
heparin. A pursestring was placed at the base of the innominate artery and
an arterial cannula was inserted. A venous cannula was placed through a
pursestring into the right atrial appendage and secured. The patient was
then placed on cardiopulmonary bypass. At this point the dissection was
carried to the left side of the autograft where the pulmonary SynerGraft was
noted. Further dissection revealed a very thick encapsulated aneurysm
emanating from beneath the homograft and extending to the left upper lobe.
It was contained by the pericardium and pleura. The heart was arrested
using cold blood antegrade cardioplegia and the pseudoaneurysm capsule was
incised with scissors. At the base of the pseudoaneurysm beneath the
pulmonary homograft was a 1.5 mm fistulous tract into the left ventricular
outflow tract. CorMatrix was hydrated and utilized as a pledget. A 5-0
Prolene horizontal mattress pledgeted suture was then placed to close the
fistulous tract. An additional figure-of-eight 5-0 Prolene suture was also
placed. The heart was then deaired and the aortic cross-clamp was removed.
The patient was then warmed and weaned from cardiopulmonary bypass. Under
direct vision, there was no continued bleeding noted in the fistulous tract.
Transesophageal echo was also obtained which showed complete resolution of
the fistulous tract with excellent function and residual ventricular septal
defect. Protamine was administered and the cannulas were removed.
Mediastinal drains were inserted, one extending from the right pleural space
across the mediastinum and into the pseudoaneurysm pocket. The second drain
entered into the left pleural space. Once hemostasis was adequate, the
sternum was reapproximated with interrupted stainless steel wires. The soft
tissues were closed with two layers of running Vicryl and the skin was
closed with running monofilament suture. Benzoin and Steri-Strips were
applied. The baby remained intubated, was taken directly to the Pediatric
Cardiac Intensive Care Unit in stable condition.