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Question thoracotomy with complete decortication

Best answers
Would these be correct?

#1 urgent tricuspid valve replacement with a 29 mm bioprosthetic magna ease valve
#2 excision of tricuspid valve with vegetations
#3 drainage of right ventricular subendocardial abscess with debridement of free wall the right ventricular endocardium
#4 cardiopulmonary bypass
#5 epi-aortic ultrasound visualization and interpretation
#6 TEE with visualization and interpretation ×2

Intraoperative findings:
Pre-bypass TEE revealed large tricuspid valve vegetation with rupture of multiple coronary tendonae and severe tricuspid regurgitation. There was a ventricular abscess located on the free wall the right ventricle, just posterior to the tricuspid leaflet. Left ventricular function was normal. There was no vegetations identified on the mitral valve. There was normal mitral valve function. Aortic valve was a trileaflet valve with no insufficiency or stenosis. There was no vegetation on the aortic valve. Pulmonary valve had trace insufficiency, but no evidence of involvement with endocarditis.

Post-bypass TEE showed the tricuspid valve prosthesis well-seated. There was trace insufficiency, likely related to the Swan catheter crossing the valve. The ventricular abscess was found to be completely drained and removed during the surgery. There was no alteration in biventricular function. There was no other abnormalities identified with the native valvular function. There was no air within the left ventricle.

Epi-aortic ultrasound revealed no evidence of intramural or intraluminal disease that would alter cannulation or cross clamp strategies. Image was saved for permanent records.

Other intraoperative findings:
Direct evaluation of the tricuspid valve revealed a massive vegetation involving all leaflets of the valve. There are numerous ruptured cords. After excision of the valve, a large subendocardial abscess was identified on the free wall the right ventricle which was opened, drained, then debrided. It was extensive endocardial necrosis of the free wall the right ventricle which was also debrided.

Procedure in detail:
The patient had her history and physical updated prior to the procedure. She was transferred to the operating suite and placed on the operating table where she underwent general anesthesia with endotracheal intubation. Monitoring lines were placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the procedure to be performed. The patient is on long-term antibiotics for known MRSA endocarditis.

Pre-bypass TEE was performed with my interpretation described above. Once this was completed, midline sternal incision was made. The soft tissues were divided with cautery. Sternotomy was performed in the standard fashion. After the sternum was cauterized and hemostasis was achieved, the retractor was placed. The mediastinal soft tissues were divided. The pericardium was opened and teed off along the diaphragm. Stay sutures placed create a pericardial well.

Epi-aortic ultrasound was then used to evaluate the ascending aorta with findings as described. Once this was completed, the image was saved. The patient was heparinized and ACT was found be therapeutic for cannulation and bypass. Central cannulation of the heart was performed with the 18 French aortic cannula, and bicaval cannulation. Reverse autologous priming of the pump was performed. The patient was then placed on full bypass and systemically cooled to 32°C.

With my PA assisting, the superior vena cava was encircled with umbilical tape. The oblique sinus was then opened with Metzenbaum scissors. ASSISTANT suctioned and provided visualization for passing of a umbilical tape for IVC isolation. Antegrade needle was then placed in the mid ascending aorta. The cross-clamp was placed and cold sanguinous antegrade cardioplegia was delivered to achieve full diastolic cardiac arrest. After probe was placed in the septum and ice was placed over the right ventricle. Next

The pericardial well was filled with CO2. The superior and inferior vena cava were then isolated. The free wall the right atriotomy extending from the AV groove towards the Waterston's groove was then performed and extended with Metzenbaum scissors. Pledgeted Ethibond stay sutures were placed to assist with retraction of the wall and exposure. ASSISTANT used a vein retractor to further assist with exposure.

The tricuspid valve was then identified and Metzenbaum scissors used to excise the entirety of the valve, subvalvular apparatus extending to the papillary heads. Once the tricuspid valve was removed, a large subendocardial abscess was identified on the right ventricle, opened and drained. Portions of the valve were submitted for cultures (routine, AFB, fungal). The remainder of the valve was submitted for pathology. The abscess was collected in a trap and submitted for cultures. There was extensive endocardial necrosis involving the free wall the right ventricle. This was all carefully debrided using Metzenbaum scissors back to normal myocardial tissue. Once this was completed, the right ventricle was irrigated and then the tricuspid annulus was then treated with Betadine.

Everting 2-0 pledgeted Ethibond sutures were then placed circumferentially around the annulus of the tricuspid valve. During this time, ASSISTANT was responsible for removal of blood, improving exposure, as well as organizing the sutures. The sutures had to be placed fairly close to the expected area in which the bundle of His would run. The annulus was then sized to a 29 mm magna ease valve. The sutures then placed through the sewing cuff of the valve, with ASSISTANT continuing his organization of the sutures. Once this was completed, the valve was parachuted into the supra-annular position and seated without difficulty. It was then secured with the cor-knot device. The patient was systemically rewarmed during this time.

The right atriotomy was then closed in a 2 layered fashion using 4-0 Prolene. The patient was placed in steep Trendelenburg and de-airing maneuvers performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. Pacing wires were placed on the right ventricle. The atriotomy was found to be hemostatic. The heart was paced at 80 bpm. Lungs were ventilated. The heart was then weaned from bypass without difficulty. Final TEE was performed with my findings as described. Throughout this time, the patient would regain sinus rhythm, but have intermittent heart block. Secondary to this, atrial pacing wires were placed and the patient was maintained on AV pacing.

The patient did receive blood products to control postoperative hemorrhage. Once hemostasis was achieved and protamine had been delivered, the heart was decannulated with all cannulation sites oversewn with 4-0 Prolene. A 28 French right angle chest tube was placed on the diaphragmatic surface of the mediastinum and a 32 French straight chest tube was placed in the mediastinum.

Secondary the patient's protein malnutrition, decision was made to perform rigid fixation of the sternum. With the assistance of ASSISTANT preparing the wires, the sternum was reapproximated with #7 wires. At the midsternal body, a single cable pioneer X plate was placed and secured with 8, 10 mm anchoring screws. ASSISTANT was responsible for reapproximating the fascia with 0 Ethibond, the soft tissue with 0 Vicryl, and the skin with 4 Monocryl running subcuticular manner. The patient tolerated procedure well was transferred to CVRU.

- Tricuspid valve with vegetations for pathology and cultures
- right ventricular subendocardial abscess for cultures
estimated blood loss: 50 mL's
blood replaced: FFP, cryo-, platelets
drains: Chest tubes as described
implants: Sternal plating with anchoring screws
condition the completion of procedure: Guarded


Columbus, Ohio
Best answers
Good morning TWilliam2019, I think you have the wrong op report for the decortication...
For this procedure though I would code:
33465: Tricuspid valve replacement with CPB
76998-26: Epiaortic ultrasound
93314-26: TEE- not sure if you can bill for both (FYI: to report TEE the surgeon must 1.) Perform the professional component of TEE 2.) reports the portion of the service with modifier 26 to indicate the professional component of the service. 3.) Making sure no other physician (eg. cardiologist, radiologist, etc) has billed or will bill for the service. 4.)Includes an appropriate indication in the op report supporting medical necessity for the TEE.

The only thing I'm not sure about is billing for the abscess and debridment of the right ventricular endocardium...

It looks as though your surgeon has completed the documentation for billing the TEE.

Don't forget to bill for the PA with AS modifier. The documentation he has for the PA is really great by the way. Insurance companies are now auditing PA billing more often and will pull back any payments if not appropriately documented in op report, so if he continues that type of documenting, he's good!

If you want to seen the report for the decort....I'll take a look at that! :)

Best answers
Thanks I do. sorry

#1 right thoracotomy with complete decortication
#2 drainage/marsupialization of right lower lobe abscess ×3
#3 therapeutic wedge resection of right lower lobe pulmonary infarct
#4 multilevel intercostal nerve block with cryo-freeze
#5 placement of left chest tube via open incision, 32 French straight
#6 therapeutic bronchoscopy with evacuation of mucous plugging

30-year-old Caucasian female with known IV drug abuse presenting with septic shock. Workup revealed tricuspid valve endocarditis. She subsequently had DIC with profound thrombocytopenia. In order to optimize the patient for a dressing the empyema and pulmonary abscesses, the patient received packed RBCs, platelets, as well as cryoprecipitate leading up to surgery. She now presents for definitive management of her right pleural infection.

Intraoperative findings:
On bronchoscopy, the tracheobronchial tree was anatomically normal. There was some mucous plugging extending into the left upper lobe which was evacuated. There was no gross lesions identified. There was no endobronchial lesions. No other evidence of infectious process identified.

Upon evacuating the left pleural effusion, there was a moderate-sized serous effusion removed.

Upon entering the right pleural cavity, the lung was adherent to the pleura. There was then rind primarily involving the right lower lobe as well as the right middle lobe which was removed. 3 separate abscess cavities were identified, 2 in the right lower lobe. One of these had surrounding necrotic pulmonary tissue consistent with infarction. The larger cavity was found to have old bloody material, consistent with necrosis. A third abscess cavity was identified within the greater oblique fissure. During decortication, there were patchy areas on the right lower lobe consistent with necrotizing pleuritis. These were debrided during the process. After complete decortication and evacuation of the abscesses, the lung was fully reexpanded with the pleural cavity drained.

Procedure in detail:
The patient had her history and physical updated prior to the procedure. She was transferred to the operating suite and placed on the operating table where she underwent general anesthesia with endotracheal intubation. Monitoring lines were placed by anesthesia. Timeout was used confirm patient identity as well as the surgery to be performed. The patient is on multiple long-term antibiotics secondary to her known tricuspid valve endocarditis.

Flexible bronchoscope was placed through the endotracheal tube. The distal trachea was normal. The carina was sharp. The right bronchial tree was anatomically normal with no infectious processes or endobronchial lesions identified. The scope was then retracted and advanced in the left mainstem bronchus. Mucous plugging was removed extending from the bronchus into the left upper lobe. There was no endobronchial lesions or mucosal changes identified. The scope was then removed.

The left chest was then prepped and draped ChloraPrep solution. At approximately the fifth intercostal space, anterior axillary line, a 10 mm incision was made. The soft tissues were bluntly divided. Access into the left pleural cavity was achieved using blunt dissection. A moderate-sized serous effusion was evacuated with placement of a 32 French straight chest tube. Chest tube was secured with 0 silk.

The single-lumen tube was then exchanged for a double-lumen endotracheal tube. The patient was placed in the lateral recumbent position with the right chest facing up. The right chest was prepped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used confirm patient identity for a second time as well as laterality of the procedure be performed.

A posterolateral thoracotomy incision was then made. The deep dermis and soft tissues were divided with left cautery. The latissimus muscle was divided. The serratus muscle was spared and reflected anteriorly. The avascular subscapular plane was developed. Ribs were counted down in the fifth intercostal space was entered into by dividing the intercostal muscles with left cautery. Accidents into the left pleural cavity was achieved. At this time, using blunt dissection, the lung was mobilized off of the parietal pleura, the mediastinum, the diaphragm.

Decortication of the lung was then undertaken. Rind was removed from the right lower lobe as well as the right middle lobe. During decortication the right lower lobe, 3 separate abscesses were identified, one posteriorly which was the largest abscess cavity. This was marsupialized by using Metzenbaum scissors to excise the visceral pleura. This pleura was submitted to pathology as a permanent specimen. A second abscess was identified along the oblique fissure which had surrounding pulmonary infarction. Using thick tissue stapling loads, a wedge resection was performed and submitted for pathology. Finally, an abscess was identified within the oblique fissure which was completely opened and drained. During the decortication, was evident that the patient had patchy areas of necrotizing pleuritis. These areas had most of purulent material and cultures were taken. After debridement of the necrotizing pleuritis, the pleural cavity was copiously irrigated with antibiotic solution and suctioned out. Next

A multilevel intercostal nerve block was then performed by using the cryoprobe and applied and to the thoracotomy interspace, one interspace above, and one interspace below at -60°C for 2 minutes. The interspaces were then injected with half percent Marcaine with epinephrine for regional anesthesia.

The ribs were reapproximated with #1 Vicryl after placement of a 32 French straight chest tube and a 32 French right angle chest tube. The serratus was brought back to its native position and secured with 0 Vicryl running fashion. The latissimus muscle was reapproximated with 0 Vicryl running fashion. Soft tissues reapproximated with 2-0 Vicryl. Skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound. The patient tolerated procedure well, was asked made, then transferred recovery.

- Visceral pleura for pathology
- right lower lobe wedge resection for pathology
- pleural rind for cultures
- right lower lobe abscess for cultures
estimated blood loss: 15 mL's
blood replaced: None
drains: Chest tubes as described
implants: None
condition at completion of procedure: Guarded