Assign the CPT and ICD-10-CM codes: 28.

Assign the CPT and ICD-10-CM codes: 28. PREOPERATIVE DIAGNOSES: Hypoplastic left heart syndrome, status post Norwood Procedure, status post balloon dilation of the restricted atrial septal defect. POSTOPERATIVE DIAGNOSES: Same. PROCEDURE: Bidirectional Glenn shunt and atrial septectomy. ANESTHESIA: General. INDICATIONS: The patient is a 6-month-old male with the diagnoses as outlined above. A bidirectional Glenn shunt is indicated for release of single ventricle volume overload and cyanosis. He had initially undergone a cath and bidirectional Glenn shunt was planned several weeks ago however he was noted to have an elevated end-diastolic pressure. This was treated with continuous IV milrinone and his end-diastolic pressure is decreased and he is now a suitable candidate. Our plan is to proceed with bidirectional Glenn shunt. At that time, I will also enlarge his atrial septal defect. The procedure, indications, and risks have been discussed with the parents. Their questions have been and they are in agreement to proceed with surgery. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed supine upon the operating table and general anesthesia was induced by the anesthesiologist. An adequate level of general endotracheal anesthesia was achieved. Adequate peripheral IV access was obtained. A central venous line was placed as well as an arterial line. The Foley catheter inserted. Additional monitoring placed. The patient’s chest, abdomen, and groins were prepped and draped in the usual sterile manner. Resternotomy was accomplished without difficulty. The right pleural space was entered. The pericardial adhesions were taken down. Eventually, I freed up the diaphragmatic surface, the inferior vena cava, the right atrial free wall, the superior vena cava, the anterior portion of the Blalock-Taussig shunt, and the neoascending aorta. The left and right pulmonary arteries were mobilized. The ascending aorta was dissected out as well. Heparin was administered and pursestrings were placed for cannulation. Aorta-bicaval cannulation was achieved. The patient was connected to the heart-lung machine. Bypass was instituted and we cooled to 32 degrees. With initiation of bypass, the shunt was ligated in continuity with medium large Hemoclips and divided. The azygos vein was ligated in continuity and divided. An antegrade cardioplegic cannula was placed in the ascending aorta. Aorta was cross-clamped and cold antegrade blood cardioplegia was injected in the aortic groove. The caval snares were lowered. The superior vena cava was divided just above its insertion into the right atrium. Working through the resultant right atriotomy, I enlarged the atrial septal defect. When this was completed, the superior vena caval stump was closed using a 5-0 Prolene suture. At this point, the patient was placed in Trendelenburg position. The aortic root was placed on gentle suction and the cross-clamp was released. The left pulmonary artery was controlled with a curved DeBakey clamp. The right pulmonary artery was controlled with a Cooley carotid clamp. All of the shunt and patch material used on the central pulmonary artery confluence was excised. I then performed the bidirectional Glenn shunt, anastomosing the posterior half of the circumference of the superior vena cava to the posterior edge of the arteriotomy in the main pulmonary artery. Anteriorly, this connection was patched with a patch of pulmonary homograft. All this was accomplished using 7-0 Prolene suture. As this was being completed, we rewarmed. Deairing was accomplished. Transesophageal echo was carried out to make sure that deairing had been completed. There was some anterior residual air. This was directly aspirated with needle and syringe, and when I was completely satisfied that there is no residual air we removed the superior vena cava cannula and weaned from bypass. We weaned from bypass easily on the first attempt. Transesophageal echo showed satisfactory function, a nonrestrictive ASD, and trivial tricuspid valve insufficiency. Hemodynamics were satisfactory. Arterial saturations were satisfactory. Modified ultrafiltration was carried out. When this was completed, the inferior vena cava cannula was removed. A common atrial line was placed through the right atrial appendage cannulation site. Protamine was administered. When protamine administration was complete, the arterial cannula was removed. When hemostasis was complete, preparations were made for closure. Two atrial and 2 ventricular pacing wires were placed. Chest tubes were placed to drain the mediastinum and right pleural space. The chest tubes, intracardiac lines, and pacing wires were all secured to the skin using nylon suture. Sternum reapproximated with Maxon suture. Remainder of the incision was closed in layers and a dry sterile dressing was applied. The patient tolerated all this well and transferred back to the intensive care unit in serious, but stable condition 29. PREOPERATIVE DIAGNOSIS: Bicuspid aortic valve status post aortic valve replacement with recurrent aortic insufficiency. (The aortic valve repair was performed several years ago.) POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Modified Ross procedure. Pulmonary autograft replacement of the aortic valve. Placement of pulmonary autograft within a 29-mm sinus of valsalva graft. Replacement of pulmonary root with 26-mm pulmonary homograft. ANESTHESIA: General. BRIEF PREOPERATIVE HISTORY: Derrick Sullivan is a 43-year-old man with a diagnosis as outlined above. Presently, he has severe aortic insufficiency with LV dilatation and decreased LV function, non-rheumatic. The aortic valve replacement is indicated. I met with the patient and discussed valve replacement options. He has selected the Ross procedure and this procedure has been explained along with the others in detail. He is well educated on the procedure, indications, risks, and long-term implications. He agreed to proceed. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed supine upon the operating room table, and general anesthesia was induced by the anesthesiologist. An adequate level of general endotracheal anesthesia had been achieved. Adequate peripheral IV access was obtained. An arterial line was placed. A central venous line was placed. Foley catheter inserted. Additional monitoring lines were placed, and the patient’s chest, abdomen, and groins were prepped and draped in the usual sterile manner. The previous median sternotomy scar was excised and re-sternotomy was undertaken with the oscillating saw. During re-sternotomy, more than the acceptable amount of dark bleeding was encountered after division of the junction of the lower one-third and upper two-thirds of the sternum. This was controlled with digital pressure. The patient remained hemodynamically stable. The groins had been prepped off. The right groin was incised and the femoral vessels were dissected out. Heparin was administered and bypass was initiated via the femoral vessels using an 18-French arterial cannula and a 24-French thin-flex venous cannula. With this, we were able to achieve adequate flow. We stayed warm. The pump sucker was placed through what now became clear was the right atrial appendage, which was adhesed to the undersurface of the sternum. The sternotomy completed without any additional problems. The bleeding site was controlled using 4-0 Prolene suture. We were 32 degrees and rewarmed completely. Mechanical ventilation was resumed and we weaned from bypass. The remainder of the pericardial adhesions were then taken down and freed off the diaphragmatic surface, the inferior vena cava, the right atrial free wall, the right-sided pulmonary veins, the superior vena cava, the aorta, and the main pulmonary artery. The aorta was separated from the pulmonary artery. I dissected out the proximal ascending aorta down to the previous suture line. At this point, additional pursestrings were placed in the distal ascending aorta, the superior vena cava, the inferior vena cava, right atrial junction and at the vent site at the right superior pulmonary vein and left atrium. The arterial and venous cannulae were removed from the femoral vessels and these were then each repaired. The repairs were accomplished in identical way using interrupted 7-0 Prolene suture to re-approximate the transverse arteriotomy and venotomy. The groin was then packed with an antibiotic sponge. Then a new 18 arterial cannula was used to cannulate the distal ascending aorta. We used bicaval cannulation. The patient was connected to heart-lung machine and bypass was instituted and we cooled to 28 degrees. The heart was allowed to fill and a 16-French event was placed in the junction right superior pulmonary vein, left atrium, and directed into the left ventricle. We continued to cool. A retroplegic cannula was placed. The aorta was cross-clamped and cold retrograde cardioplegia was used to arrest the heart. Additional doses were given every 15 to 20 minutes throughout the cross-clamp. The previous transverse aortotomy incision was reopened. There was a bicuspid valve made up of a combination of a left versus a combined non-right cusp. It appeared that there was significant prolapse especially anteriorly. I did not feel the valve was amenable to repair and given the patient has decreased LV function, I did not think he would tolerate anything but complete release of his aortic insufficiency. I then made a transverse arteriotomy in the distal main pulmonary artery and inspected the pulmonary valve. It appeared normal. At this point, I excised the coronary ostial buttons and excised the cusps of the aortic valve. I then harvested the autograft. The autograft would accommodate a 20 dilator easily and I selected a 24-mm sinus of Valsalva graft. I brought this up and trimmed it so that there was one ring above below the sinus of Valsalva portion. I placed the autograft within the Dacron tube graft and I sutured this so that the black lines corresponded to the commissures of the pulmonary valve. At the distal end, the autograft was stitched at 3 points corresponding to the tops of the commissures and proximally the autograft was secured to the tube graft using running 5-0 Prolene suture. I then sutured this in place into junction of the left ventricular outflow tracts in the aorta positioning this so that the nadir of the sinus of Valsalva or one of the cusps of the valve correspond to the left coronary ostial button position. The proximal anastomosis was accomplished using a running 5-0 Prolene suture. I then implanted the left coronary ostial button. I made a defect in the sinus of Valsalva graft and in the sinus of Valsalva of the sinus facing the left coronary ostial button and implanted the left coronary ostial button into this using running 5-0 Prolene suture. I then anastomosed the distal end of the autograft Dacron tube graft combination of the distal ascending using running 5-0 Prolene suture. I then gave a dose of antegrade cardioplegia to pressurize the root, and with this, I was able to identify the implantation site for the right coronary ostial button. The right coronary ostial button was positioned such that it would go into near normal position of the right sinus of Valsalva, but slightly rightward of a dead center. When the cardioplegia had been delivered, I excised a portion of the sinus of Valsalva graft and the corresponding portion of the sinus of Valsalva of the right sinus and then implanted the right coronary ostial button into this, also using running 5-0 Prolene suture. I made a small defect about 3 mm in diameter in the noncoronary sinus to prevent accumulation of blood between the Dacron tube graft and the sinus of Valsalva of the autograft in the noncoronary sinus position. At this point, I brought up a 26-mm homograft. This was a pulmonary homograft. I cut it to the appropriate length and I performed the distal anastomosis using running 5-0 Prolene suture. I then performed the proximal anastomosis securing the posterior one-half of the homograft. The patient was then placed in Trendelenburg position, the aortic root was placed on gentle suction and the cross-clamp was released. Re-warming had been underway for a while. I then completed the anterior connection of the homograft to the LV outflow tract. As we rewarmed, cardiac action returned reasonably soon. Sinus rhythm returned and he had an episode of fibrillation. The heart was defibrillated. Following this, we had stable rhythm and we continued to see improved cardiac function. As we rewarmed, I placed chest tubes in the right pleural space and mediastinum, 2 atrial and 2 ventricular pacing wires were placed. After we completely rewarmed, transesophageal echo was carried out and showed no residual air in the heart. The left ventricular vent was removed and a left atrial line was placed in the vent site. Mechanical ventilation which had been briefly halted for vent removal was resumed. We remained in Trendelenburg position with the root on gentle suction and we weaned from bypass. We weaned from bypass in the first attempt. Initially, function was decreased, but we had satisfactory hemodynamics. Inotropic support, which at this point consisted of 0.05 mcg/kg per minute of epinephrine and 0.5 mcg/kg per minute of Milrinone were increased to 0.1 of epinephrine. With this and with modified ultrafiltration, left ventricular function improved significantly. At the end of the ultrafiltration we had essentially normal LV function. When modified ultrafiltration was completed, the venous cannula were removed and protamine was administered. When protamine administration was completed, the arterial cannula was removed. When hemostasis was complete, preparations were made for closure. Chest tubes, intracardiac lines, and pacing wires were all secured to the skin using nylon suture. Gore-Tex pericardium used to replace the pericardium anteriorly to facilitate re-sternotomy in the future. The groin incision was closed in layers of absorbable suture. Dry sterile dressings were applied. The patient tolerated all this well and transferred back to the intensive care unit in serious but stable condition. SCIENCE HEALTH SCIENCE NURSING ALH 216-01

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