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Scenario Week of January 18, 2012:
View Current Scenario

OPERATIVE REPORT:
Ascending aortic replacement with sinotubular junction normalization and aortic valve resuspension with #28 Vascutek gelweave graft. Proximal arch replacement with island anastomosis and heavy beveling of lesser curvature on deep hypothermic circulatory arrest with retrograde cerebral protection using #28 Vascutek gelweave graft. Transesophageal echocardiogram.

DIAGNOSIS:
Ascending aortic aneurysm, greater than 6 cm
Aortic valve insufficiency

OPERATIVE PROCEDURE:
The patient was laid in supine position and prepped and draped in a normal fashion using chlorhexidine and DuraPrep. A median sternotomy was performed in the usual fashion. The pericardium was opened in the midline and tacked to the skin using multiple skin sutures. Systemic heparinization was performed. Aortic cannulation was performed in the distal ascending aorta. Venous cannulation was performed in both the SVC and the right atrium. A retrograde cardioplegia cannula was placed in the coronary sinus via the right atrium.

The patient was placed on cardiopulmonary bypass and cooled to circulatory arrest. An LV vent was placed via the right superior pulmonary vein. A cross-clamp was then placed across the aorta and retrograde cardioplegia solution was instilled. The ascending aorta was entered sharply, and hand-held antegrade cardioplegia solution was given down both coronary ostia for cardiac standstill. The ascending aorta was then dissected and carried down to the sinotubular junction. The sinotubular junction otherwise appeared normal at this point. Sinus segment appeared normal. Valve sizers were used, and a #28 Vascutek graft was selected.

A running 4-0 Prolene suture was then used to perform an end-to-end anastomosis. Plegia solution was then instilled through the new root, and the valve appeared competent. At this point in time, cooling was for approximately 45 minutes and the patient had achieved a core body temperature of less than 20 degrees Celsius. The patient was placed in steep Trendelenburg, and ice was applied to the head. Circulatory arrest was instituted. Retrograde cerebral protection was provided by the SVC cannula and monitored by anesthesia. Cross-clamp was removed, and the aortic cannula was removed. Dissection was carried up to the innominate artery, and heavy beveling across the lesser curvature was performed. The tissue appeared good and strong. #28 Vascutek graft was heavy beveled as well and an end-to-end anastomosis was performed using a running 4-0 Prolene suture. The graft was then recannulated using an aortic cannula. The patient was then de-aired, cross-clamp reapplied, and cardiopulmonary bypass reinstituted.

After 5 minutes of re-perfusion, the patient was rewarmed. At this point, the 2 graft segments were cut for a normal aortic curvature. A graft-to-graft anastomosis was performed using a running 4-0 Prolene suture. A needle was placed for de-airing. The heart was filled and re-aired through the needle. Cross-clamp was removed. Ventricular pacing wires were placed on the right ventricular surface, and atrial pacing wires were placed on the right atrial surface. A posterior pericardial chest tube was placed. The patient was then re-warmed back to normothermia. The LV vent was removed. The patient was weaned from cardiopulmonary bypass without difficulty. Transesophageal echocardiogram showed no aortic valve insufficiency. Protamine was administered. The patient was decannulated. After surgical hemostasis was achieved, an anterior pericardial chest tube was placed, and the sternum was reapproximated using the sternal cable system. The skin, subcutaneous, and subcuticular tissue were then closed over the sternum using running Vicryl and Monocryl sutures.

Overall, the patient tolerated the procedure well and was transported to the ICU on no drips, in normal sinus rhythm.

Assign ICD-9-CM diagnosis and procedure codes.


ICD-9-CM Codes
Diagnoses:
441.2 Thoracic aneurysm without mention of rupture
424.1 Aortic valve disorders (insufficiency)

Procedures:
38.45 Resection of (thoracic vessel) with replacement
35.11 Open heart valvuloplasty of aortic valve without replacement
88.72 Transesophageal echocardiogram
39.61 Extracorporeal circulation auxiliary to open heart surgery

Rationale:
The reason for surgery was to repair the 6 cm ascending aortic aneurysm with the associated aortic valve insufficiency. The aorta was replaced by graft at two sites, and then these grafts were joined by a graft-to-graft anastomosis. The aortic valve was resuspended by 4-0 Prolene sutures, lifting the valve into correct anatomical position, which is described in AHA Coding Clinic 2Q 2008. Intraoperative transesophageal echocardiogram was performed, demonstrating a competent aortic valve. The chest tube insertion is inherent in the procedure and is not coded separately unless it is performed for a specified diagnosis.

 
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