sandy06
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PREOPERATIVE DIAGNOSES:
1. Critical aortic stenosis.
2. Severely calcified ascending aorta.
3. Poststenotic aortic dilatation.
PREOPERATIVE DIAGNOSES:
1. Critical aortic stenosis.
2. Severely calcified ascending aorta.
3. Poststenotic aortic dilatation.
PROCEDURE PERFORMED:
1. Replacement of the aortic root.
2. Aortic valve with a 21 mm freestyle stentless aortic mini-root,
with 20 mm freestyle stentless aortic mini root reimplantation of
left main.
3. Tailoring ascending aortoplasty.
4. Aortic endarterectomy.
5. Exploration repair left femoral artery.
6. Coronary artery bypass grafting x1 utilizing a saphenous vein graft
to the right coronary artery.
SURGEON:
Dr. L.
ASSISTANT:
Dr. A and Dr. M.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed in the supine
position, prepped and draped in usual fashion. A two-team approach was
utilized. One team exposing the left femoral artery. A Seldinger
technique was utilized to cannulate the left femoral artery. Of note,
vein was taken initially from the left thigh although this was not
deemed to be adequate due the varicosities. There was a lesion in the
obtuse marginal branch which did not appear to be critical, although
consideration was given to bypass this vessel and ultimately this was
not bypassed. A median sternotomy incision was performed. The incision
was taken down through skin and subcutaneous tissues, down to the
midportion of sternum. An electrical saw was utilized for median
sternotomy. Thereafter, a sternal retractor was placed. The
pericardium was opened in midline, tacked to the skin. Then venous and
retrograde cardioplegia cannulations were performed in routine
fashion. We instituted a full cardiopulmonary bypass and a left
ventricular vent was inserted through the right superior pulmonary
vein. Of note, the aorta was cross clamped extremely distal and at a
point where it appeared to be free of plaque. This was not evident by
angiogram which appeared to show significant amount of calcium. Once
the aorta was cross clamped, cold blood cardioplegia was given, both
in antegrade and retrograde fashion. Once the aortotomy was performed,
it was noted that there was calcium extending into the ascending aorta
up to the cross-clamp and extensive endarterectomy of the aorta was
performed. This aggressive amount of calcium extend into the root and
it appeared that the decalcification would lead to the aorta becoming
extremely thin and a potential tearing postoperatively, so a decision
was made to perform an aortic root replacement. The aortic valve was
severely calcified. The leaflets were resected down to the anulus.
Then a rongeur was utilized to dbride any remaining calcium. A button
was cut around the left main ostia. Of note, the right coronary ostia
could not be found and appeared angiographically that there was a
common ostia from both left and right. There was calcium around the
ostium so a felt strip was placed around the left main coronary ostia
to reinforce the suture line. Once the leaflets were resected down to
the anulus, 4-0 Tevdek sutures were placed in one linear plane. A 21
mm freestyle stentless aortic mini root was passed onto the operative
field. The sutures were placed through the inflow aspect of the mini
root and each of the sutures were tied over a felt strip as well.
Thereafter, the right coronary aspect of the mini root was oversewn
with a 5-0 Prolene suture. Then an opening was cut posteriorly to
accommodate the left main. Of note, a felt strip was left on the
outside of the of the left main and this was reattached onto the mini
root with a 5-0 Prolene suture in a continuous over fashion. Once this
was completed, the ascending aorta was then sutured in an end-to-end
fashion to the mini root. Of note, the ascending aorta was much larger
than the mini root so a longitudinal segment of the anterior aspect of
the aorta was performed and then a plication of the aorta was
performed in order for this to be of the appropriate sized match to
the mini root. This was sutured with a 5-0 Prolene suture in two-layer
closure. The patient was placed in Trendelenburg position. The aortic
cross-clamp was removed. Then multiple deairing maneuvers were
performed. It was noted that the right heart appeared to be sluggish
and at this point, after coming off pump with multiple drips, the
decision was made to reinstitute full cardiopulmonary bypass. A
segment of vein was harvested from the right thigh, which was noted to
be adequate. A decision was made to bypass the right coronary artery.
The aorta was then re-clamped and antegrade cardioplegia was given. An
arteriotomy was made in the distal right coronary artery. This also
had a 2 mm intraluminal diameter. A segment of vein was anastomosed
end-to-side fashion utilizing a 7-0 Prolene suture. Upon injecting
this right coronary graft, it was noted that there was a cardioplegia
evident in the base of the aortic root and the fat pad above where the
right coronary artery is, so in careful inspection of the aortic wall,
it was truly another ostium to the right coronary which was extremely
close to the commissure between the left and right, and this was not
seen because it was covered with a dense amount of calcium. This was
ligated with a 5-0 Prolene suture and then the vein graft was measured
to the right lateral aspect of the tailoring aortoplasty on the actual
native aorta and a 4 mm punch was utilized to perform aortotomy. The
vein graft was measured and sutured in end-to-side fashion with a 6-0
Prolene suture. With this completed, the patient was placed in
Trendelenburg position again, and multiple deairing maneuvers were
performed. The patient was then subsequently weaned from
cardiopulmonary bypass without difficulty. The right heart appeared to
be contracting perfectly well. At this point the patient was weaned.
The venous cannula was removed. The purse suture tied down. The
patient protamine which she tolerated well. Then the arterial cannula
was removed. Repair of the femoral artery was performed. Thereafter,
a substernal chest tube and a right pleural chest tube were inserted
as well as a ventricular pacing wire and atrial pacing wire.
Hemostasis was obtained. Thereafter, number 5 steel sternal wires were
placed, three in the manubrium, four in the intercostal space beneath.
The wires were proximally twisted and bent. The muscle, subcutaneous
tissue, and skin were all closed in routine fashion.
Can someone please give some insight on how to code this Report please, I'm a little bit
Thanks.......
1. Critical aortic stenosis.
2. Severely calcified ascending aorta.
3. Poststenotic aortic dilatation.
PREOPERATIVE DIAGNOSES:
1. Critical aortic stenosis.
2. Severely calcified ascending aorta.
3. Poststenotic aortic dilatation.
PROCEDURE PERFORMED:
1. Replacement of the aortic root.
2. Aortic valve with a 21 mm freestyle stentless aortic mini-root,
with 20 mm freestyle stentless aortic mini root reimplantation of
left main.
3. Tailoring ascending aortoplasty.
4. Aortic endarterectomy.
5. Exploration repair left femoral artery.
6. Coronary artery bypass grafting x1 utilizing a saphenous vein graft
to the right coronary artery.
SURGEON:
Dr. L.
ASSISTANT:
Dr. A and Dr. M.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed in the supine
position, prepped and draped in usual fashion. A two-team approach was
utilized. One team exposing the left femoral artery. A Seldinger
technique was utilized to cannulate the left femoral artery. Of note,
vein was taken initially from the left thigh although this was not
deemed to be adequate due the varicosities. There was a lesion in the
obtuse marginal branch which did not appear to be critical, although
consideration was given to bypass this vessel and ultimately this was
not bypassed. A median sternotomy incision was performed. The incision
was taken down through skin and subcutaneous tissues, down to the
midportion of sternum. An electrical saw was utilized for median
sternotomy. Thereafter, a sternal retractor was placed. The
pericardium was opened in midline, tacked to the skin. Then venous and
retrograde cardioplegia cannulations were performed in routine
fashion. We instituted a full cardiopulmonary bypass and a left
ventricular vent was inserted through the right superior pulmonary
vein. Of note, the aorta was cross clamped extremely distal and at a
point where it appeared to be free of plaque. This was not evident by
angiogram which appeared to show significant amount of calcium. Once
the aorta was cross clamped, cold blood cardioplegia was given, both
in antegrade and retrograde fashion. Once the aortotomy was performed,
it was noted that there was calcium extending into the ascending aorta
up to the cross-clamp and extensive endarterectomy of the aorta was
performed. This aggressive amount of calcium extend into the root and
it appeared that the decalcification would lead to the aorta becoming
extremely thin and a potential tearing postoperatively, so a decision
was made to perform an aortic root replacement. The aortic valve was
severely calcified. The leaflets were resected down to the anulus.
Then a rongeur was utilized to dbride any remaining calcium. A button
was cut around the left main ostia. Of note, the right coronary ostia
could not be found and appeared angiographically that there was a
common ostia from both left and right. There was calcium around the
ostium so a felt strip was placed around the left main coronary ostia
to reinforce the suture line. Once the leaflets were resected down to
the anulus, 4-0 Tevdek sutures were placed in one linear plane. A 21
mm freestyle stentless aortic mini root was passed onto the operative
field. The sutures were placed through the inflow aspect of the mini
root and each of the sutures were tied over a felt strip as well.
Thereafter, the right coronary aspect of the mini root was oversewn
with a 5-0 Prolene suture. Then an opening was cut posteriorly to
accommodate the left main. Of note, a felt strip was left on the
outside of the of the left main and this was reattached onto the mini
root with a 5-0 Prolene suture in a continuous over fashion. Once this
was completed, the ascending aorta was then sutured in an end-to-end
fashion to the mini root. Of note, the ascending aorta was much larger
than the mini root so a longitudinal segment of the anterior aspect of
the aorta was performed and then a plication of the aorta was
performed in order for this to be of the appropriate sized match to
the mini root. This was sutured with a 5-0 Prolene suture in two-layer
closure. The patient was placed in Trendelenburg position. The aortic
cross-clamp was removed. Then multiple deairing maneuvers were
performed. It was noted that the right heart appeared to be sluggish
and at this point, after coming off pump with multiple drips, the
decision was made to reinstitute full cardiopulmonary bypass. A
segment of vein was harvested from the right thigh, which was noted to
be adequate. A decision was made to bypass the right coronary artery.
The aorta was then re-clamped and antegrade cardioplegia was given. An
arteriotomy was made in the distal right coronary artery. This also
had a 2 mm intraluminal diameter. A segment of vein was anastomosed
end-to-side fashion utilizing a 7-0 Prolene suture. Upon injecting
this right coronary graft, it was noted that there was a cardioplegia
evident in the base of the aortic root and the fat pad above where the
right coronary artery is, so in careful inspection of the aortic wall,
it was truly another ostium to the right coronary which was extremely
close to the commissure between the left and right, and this was not
seen because it was covered with a dense amount of calcium. This was
ligated with a 5-0 Prolene suture and then the vein graft was measured
to the right lateral aspect of the tailoring aortoplasty on the actual
native aorta and a 4 mm punch was utilized to perform aortotomy. The
vein graft was measured and sutured in end-to-side fashion with a 6-0
Prolene suture. With this completed, the patient was placed in
Trendelenburg position again, and multiple deairing maneuvers were
performed. The patient was then subsequently weaned from
cardiopulmonary bypass without difficulty. The right heart appeared to
be contracting perfectly well. At this point the patient was weaned.
The venous cannula was removed. The purse suture tied down. The
patient protamine which she tolerated well. Then the arterial cannula
was removed. Repair of the femoral artery was performed. Thereafter,
a substernal chest tube and a right pleural chest tube were inserted
as well as a ventricular pacing wire and atrial pacing wire.
Hemostasis was obtained. Thereafter, number 5 steel sternal wires were
placed, three in the manubrium, four in the intercostal space beneath.
The wires were proximally twisted and bent. The muscle, subcutaneous
tissue, and skin were all closed in routine fashion.
Can someone please give some insight on how to code this Report please, I'm a little bit
Thanks.......