conleyclan
Guru
I have the hardest time coding these. Could someone please take a look at this and see how they would code it. Thanks!!
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PREOPERATIVE DIAGNOSES: Acute type A aortic dissection, mild-to-moderate
aortic insufficiency.
POSTOPERATIVE DIAGNOSES: Acute type A aortic dissection, mild-to-moderate
aortic insufficiency.
PROCEDURES PERFORMED: Repair of type A aortic dissection, aortic valve
resuspension and aortic root repair, ascending aortic replacement (28 mm
Vascutek graft), total aortic arch replacement (26 mm Vascutek graft, 14 mm
graft for a bovine trunk replacement).
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. A Swan-Ganz
catheter and radial arterial line were placed by the anesthesia team for
intraoperative monitoring. A transesophageal echocardiogram was performed,
and this demonstrated an acute type A aortic dissection. There was mild to
moderate aortic insufficiency, and right and left ventricular function was
preserved.
The patient was prepped and draped in the usual sterile fashion from chin to
toes. A midline sternotomy was made, and then a pericardial cradle created
to expose the heart and great vessels. The patient was heparinized and then
cannulated for cardiopulmonary bypass essentially using a Seldinger
technique. A needle was introduced into the true lumen and a guidewire
advanced under TEE guidance in the true lumen. The guidewire was then
serially dilated up, and a 20-French femoral type Edwards catheter was placed
in the true lumen of the aortic arch to serve as primary inflow. The right
atrial appendage was cannulated with a dual stage and the superior vena cava
cannulated with a 26-French soft angled cannula to facilitate retrograde
cerebral perfusion. A coronary sinus catheter was placed for retrograde
cardioplegia, and then, the patient placed on cardiopulmonary bypass and was
systemically cooled to deep hypothermia. We were monitoring the patient with
continuous EEG and SSEPs throughout the procedure to help direct a safe
period of deep hypothermic circulatory arrest. During systemic cooling, an
aortic crossclamp was applied, and initial induction cold blood high
potassium cardioplegia was delivered retrograde while the ascending aorta was
transected. We identified the primary tear site in the proximal ascending
aorta at the sinotubular junction. Upon transecting the aorta, we then
delivered direct ostial antegrade cold blood high potassium cardioplegia to
the left and right coronary arteries to complete myocardial protection. From
that point forward, we maintained myocardial protection using a combination
of intermittent retrograde and intermittent antegrade cardioplegia. Next we
carefully inspected the aortic valve. The cusps themselves were of normal
quality and were deemed acceptable for preservation. Dissection itself
extended into the noncoronary sinus and portions of the right coronary sinus
but only halfway down the sinus segment. Consequently, we resuspended the
aortic valve and repaired the sinus segments using a neo medial
reconstruction technique with tailored pieces of Teflon felt placed within
the dissected plane. We then sandwiched the native intima adventitia in neo
planes around the Teflon felt for a neo medial reconstruction. There was no
felt internally or externally, only within the aortic wall. It was tacked
into place using 4-0 Prolene sutures as well as a few pledgeted 4-0 Prolene
sutures for additional support. This resuspended the valve well. We then
took a 28 mm Vascutek graft and anastomosed it end-to-end to the aortic root
for creation of a neo-sinotubular junction. This anastomosis was completed
with running 4-0 Prolene suture taking care to intussuscept graft into the
native root for hemostatic suture line. We then connected that graft to the
cardioplegia circuit and confirmed competency of the valve and gave
additional antegrade cardioplegia. All the while we were systemically
rewarming. Upon achieving electrocerebral silence for greater than 4
minutes, we brief period of deep hypothermic circulatory arrest was
initiated. The aortic arch was transected obliquely from the takeoff of the
innominate artery to the distal lesser curve and then we inspected the
dissected aorta. We then identified a very large distal re-entry tear in the
distal arch just opposite the level of left subclavian arterial takeoff and
extending into the descending thoracic aorta. This was quite concerning as
there was a large secondary tear and in order to exclude it, this mandated a
total arch replacement. Of note, the patient had a bovine arch anatomy and
the bovine trunk itself was dissected homing in its very proximal most
aspect. We replaced the bovine trunk with a 14 mm Vascutek graft. This was
done first. 14 mm graft was then trimmed to an appropriate length and then
anastomosed end-to-end to the bovine trunk using running 4-0 Prolene suture
taking care to intussuscept graft into the bovine trunk. We then connected
that 14 mm graft to the cardiopulmonary bypass circuit via separate side arm
and then began antegrade cerebral perfusion to both carotids via this bovine
trunk, and we completed the rest of the arch reconstruction with continuous
antegrade cerebral perfusion through this graft. Next we cut the distal arch
in somewhat of a beveled fashion maintaining inclusion of the left subclavian
ostium but completely resecting the secondary tear site. Dissection extended
down the entire descending thoracic aorta beyond the tear site, and just
beyond the tear site, we tacked the walls with a neo medial piece of Teflon
felt similar to the root reconstruction placed in dissected plane. Layers
were once again tacked to one another with pledgeted 4-0 Prolene sutures. We
then took a 26 mm Vascutek graft and anastomosed it end-to-end to the distal
arch/descending thoracic aorta using running 4-0 Prolene suture taking care
to intussuscept graft into the native true lumen for hemostatic suture line
and to facilitate exclusion of the false lumen. Following completion of this
distal anastomosis, we then cannulated the graft distally and began
reperfusing the lower body and once again after appropriately de-airing the
descending aorta and graft in a retrograde fashion. Once we reconstituted
the total cardiopulmonary bypass flow, the patient was systemically rewarmed.
During rewarming, we then made an elliptical graftotomy on the arch graft on
its proximal greater curve. Then we cut the 14 mm graft in a beveled fashion
and anastomosed it end-to-side to the arch graft using running 2-0 Prolene
suture. We maintained antegrade cerebral perfusion during this anastomosis
and removed the catheter from that graft upon completion of the anastomosis,
taking great care to ensure de-airing of the entire circuit prior to
reconstituting antegrade flow through the arch cannulation site. Next the
proximal aspect of the arch graft and the distal aspect of the root graft
were each trimmed to an appropriate length and cut in a beveled fashion and
then the two anastomosed to one another using running 2-0 Prolene suture
completing the ascending aortic reconstruction. This again was completed
using running 2-0 Prolene suture. All the while we were systemically
rewarming and upon achieving normothermia, the patient was subsequently
weaned from cardiopulmonary bypass with preserved right and left ventricular
function. The aortic valve was well seated, and there was trace to mild
aortic insufficiency. The patient was subsequently decannulated. The
heparin reversed with IV protamine. Meticulous hemostasis was confirmed.
Temporary atrial and ventricular pacing leads were placed, although the
patient was in normal sinus rhythm and required no pacing.
Blake drains were placed in the mediastinum. The overlying thymic fat and
pericardium were reapproximated from the level of innominate vein to the base
of the heart protecting all graft material from scarring to the sternum. The
sternum was reapproximated with interrupted heavy gauge wire. The pectoralis
fascia, subcutaneous tissues, and skin were all approximated with running
absorbable sutures. The patient tolerated procedure well and was sent to
CT
-------------------------------------------------------------------------------------------------------
PREOPERATIVE DIAGNOSES: Acute type A aortic dissection, mild-to-moderate
aortic insufficiency.
POSTOPERATIVE DIAGNOSES: Acute type A aortic dissection, mild-to-moderate
aortic insufficiency.
PROCEDURES PERFORMED: Repair of type A aortic dissection, aortic valve
resuspension and aortic root repair, ascending aortic replacement (28 mm
Vascutek graft), total aortic arch replacement (26 mm Vascutek graft, 14 mm
graft for a bovine trunk replacement).
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. A Swan-Ganz
catheter and radial arterial line were placed by the anesthesia team for
intraoperative monitoring. A transesophageal echocardiogram was performed,
and this demonstrated an acute type A aortic dissection. There was mild to
moderate aortic insufficiency, and right and left ventricular function was
preserved.
The patient was prepped and draped in the usual sterile fashion from chin to
toes. A midline sternotomy was made, and then a pericardial cradle created
to expose the heart and great vessels. The patient was heparinized and then
cannulated for cardiopulmonary bypass essentially using a Seldinger
technique. A needle was introduced into the true lumen and a guidewire
advanced under TEE guidance in the true lumen. The guidewire was then
serially dilated up, and a 20-French femoral type Edwards catheter was placed
in the true lumen of the aortic arch to serve as primary inflow. The right
atrial appendage was cannulated with a dual stage and the superior vena cava
cannulated with a 26-French soft angled cannula to facilitate retrograde
cerebral perfusion. A coronary sinus catheter was placed for retrograde
cardioplegia, and then, the patient placed on cardiopulmonary bypass and was
systemically cooled to deep hypothermia. We were monitoring the patient with
continuous EEG and SSEPs throughout the procedure to help direct a safe
period of deep hypothermic circulatory arrest. During systemic cooling, an
aortic crossclamp was applied, and initial induction cold blood high
potassium cardioplegia was delivered retrograde while the ascending aorta was
transected. We identified the primary tear site in the proximal ascending
aorta at the sinotubular junction. Upon transecting the aorta, we then
delivered direct ostial antegrade cold blood high potassium cardioplegia to
the left and right coronary arteries to complete myocardial protection. From
that point forward, we maintained myocardial protection using a combination
of intermittent retrograde and intermittent antegrade cardioplegia. Next we
carefully inspected the aortic valve. The cusps themselves were of normal
quality and were deemed acceptable for preservation. Dissection itself
extended into the noncoronary sinus and portions of the right coronary sinus
but only halfway down the sinus segment. Consequently, we resuspended the
aortic valve and repaired the sinus segments using a neo medial
reconstruction technique with tailored pieces of Teflon felt placed within
the dissected plane. We then sandwiched the native intima adventitia in neo
planes around the Teflon felt for a neo medial reconstruction. There was no
felt internally or externally, only within the aortic wall. It was tacked
into place using 4-0 Prolene sutures as well as a few pledgeted 4-0 Prolene
sutures for additional support. This resuspended the valve well. We then
took a 28 mm Vascutek graft and anastomosed it end-to-end to the aortic root
for creation of a neo-sinotubular junction. This anastomosis was completed
with running 4-0 Prolene suture taking care to intussuscept graft into the
native root for hemostatic suture line. We then connected that graft to the
cardioplegia circuit and confirmed competency of the valve and gave
additional antegrade cardioplegia. All the while we were systemically
rewarming. Upon achieving electrocerebral silence for greater than 4
minutes, we brief period of deep hypothermic circulatory arrest was
initiated. The aortic arch was transected obliquely from the takeoff of the
innominate artery to the distal lesser curve and then we inspected the
dissected aorta. We then identified a very large distal re-entry tear in the
distal arch just opposite the level of left subclavian arterial takeoff and
extending into the descending thoracic aorta. This was quite concerning as
there was a large secondary tear and in order to exclude it, this mandated a
total arch replacement. Of note, the patient had a bovine arch anatomy and
the bovine trunk itself was dissected homing in its very proximal most
aspect. We replaced the bovine trunk with a 14 mm Vascutek graft. This was
done first. 14 mm graft was then trimmed to an appropriate length and then
anastomosed end-to-end to the bovine trunk using running 4-0 Prolene suture
taking care to intussuscept graft into the bovine trunk. We then connected
that 14 mm graft to the cardiopulmonary bypass circuit via separate side arm
and then began antegrade cerebral perfusion to both carotids via this bovine
trunk, and we completed the rest of the arch reconstruction with continuous
antegrade cerebral perfusion through this graft. Next we cut the distal arch
in somewhat of a beveled fashion maintaining inclusion of the left subclavian
ostium but completely resecting the secondary tear site. Dissection extended
down the entire descending thoracic aorta beyond the tear site, and just
beyond the tear site, we tacked the walls with a neo medial piece of Teflon
felt similar to the root reconstruction placed in dissected plane. Layers
were once again tacked to one another with pledgeted 4-0 Prolene sutures. We
then took a 26 mm Vascutek graft and anastomosed it end-to-end to the distal
arch/descending thoracic aorta using running 4-0 Prolene suture taking care
to intussuscept graft into the native true lumen for hemostatic suture line
and to facilitate exclusion of the false lumen. Following completion of this
distal anastomosis, we then cannulated the graft distally and began
reperfusing the lower body and once again after appropriately de-airing the
descending aorta and graft in a retrograde fashion. Once we reconstituted
the total cardiopulmonary bypass flow, the patient was systemically rewarmed.
During rewarming, we then made an elliptical graftotomy on the arch graft on
its proximal greater curve. Then we cut the 14 mm graft in a beveled fashion
and anastomosed it end-to-side to the arch graft using running 2-0 Prolene
suture. We maintained antegrade cerebral perfusion during this anastomosis
and removed the catheter from that graft upon completion of the anastomosis,
taking great care to ensure de-airing of the entire circuit prior to
reconstituting antegrade flow through the arch cannulation site. Next the
proximal aspect of the arch graft and the distal aspect of the root graft
were each trimmed to an appropriate length and cut in a beveled fashion and
then the two anastomosed to one another using running 2-0 Prolene suture
completing the ascending aortic reconstruction. This again was completed
using running 2-0 Prolene suture. All the while we were systemically
rewarming and upon achieving normothermia, the patient was subsequently
weaned from cardiopulmonary bypass with preserved right and left ventricular
function. The aortic valve was well seated, and there was trace to mild
aortic insufficiency. The patient was subsequently decannulated. The
heparin reversed with IV protamine. Meticulous hemostasis was confirmed.
Temporary atrial and ventricular pacing leads were placed, although the
patient was in normal sinus rhythm and required no pacing.
Blake drains were placed in the mediastinum. The overlying thymic fat and
pericardium were reapproximated from the level of innominate vein to the base
of the heart protecting all graft material from scarring to the sternum. The
sternum was reapproximated with interrupted heavy gauge wire. The pectoralis
fascia, subcutaneous tissues, and skin were all approximated with running
absorbable sutures. The patient tolerated procedure well and was sent to
CT