After reading the operative report below, provide a complete response and codes to the questions that follow.
Preoperative Dianoses: Ventricular septal defect, aortic regurgitation, subaortic membrane, patent foramen
ovale
Postoperative Diagnoses: Ventricular septal defect, aortic regurgitation, subaortic membrane, patent foramen
ovale
This patient is a 2-year-old boy who had a diagnosis of a subpulmonic ventricular septal defect. He
has been clinically stable; however, in the recent past he has had progressive worsening of aortic regurgitation.
Description of Procedure: The patient was laid supine on the table and was given general endotracheal
anesthesia. The routine monitoring lines were placed. An intraoperative transesophageal echocardiogram
study was performed and revealed the previously known ventricular septal defect. The amount of valve
regurgitation was more than we had anticipated and it was a moderate and somewhat eccentric. There was
also a patent foramen ovale and a subaortic membrane that was not clearly visualized on the initial portion of
the echocardiogram. The study was repeated at the end and showed adequate closure of the ventricular septal
defect. The amount of aortic regurgitation was trace, almost none. There was no shunting across the
ventricular septum or the atrial septum.
The chest, abdomen, and legs were prepped and draped in the usual manner. The chest was entered through
a median sternotomy. The pericardium was opened to the left of the midline and portion of it saved for patch
material. The patient was heparinized. The ascending aorta was cannulated with a straight cannula and the
venous return through two right-angle cannulas inserted directly in the superior vena cava and at the right
atrium-inferior vena cava junction. The patient was placed on cardiopulmonary bypass. The aorta was cross
clamped and cold blood cardioplegia given into the aortic root. This was repeated at 20-minute intervals. A left
atrial vent was inserted at the junction of the right superior pulmonary vein and the left atrium. The superior and
inferior vena cavi were ensnared. The exposure for the ventricular septal defect was made through the
pulmonary artery. A longitudinal incision was made. This provided adequate exposure. The defect was oval in
shape with a maximum diameter a little less than 1 cm. The leaflet of the aortic valve was almost protruding
through the VSD. We closed the defect with two pledgeted stitches going from the inferior rim of the defect and
passing through the upper portion of the defect into the hinge of the right-sided posterior pulmonary valve. Two
stitches were necessary. On the top portion, a small strip of pericardium was utilized. This effectively closed the
defect. Because we were not certain that this will provide adequate repair of the aortic valve, we made an
aortotomy in the usual location. This allowed us to visualize the valve adequately. There was a redundant
portion of a leaflet at the bottom, which corresponded to the location of the ventricular septal defect closure.
The valve itself was also somewhat redundant and a plication valvuloplasty was performed by folding the top
portion of the right coronary leaflet at the location of the commissure next to the noncoronary leaflet. This
folding valvuloplasty was reinforced with a figure-of-eight in the same region to provide further support. From
what we could tell by direct visualization, this would provide adequate support. It should be noted that the
leading edge of this leaflet was normal with some thickening and fibrosis corresponding to a chronic
regurgitation situation. The two other leaflets at their edges were completely normal in anatomy. The repair
subsequently proven by repeat echocardiography was adequate. The arthrotomy was closed with a double
running #5-0 Prolene. It should be noted that at the time of the closure of the ventricular septal defect, we could
visualize a subaortic membrane but we wanted to get a better look at it from the aortic side. Once the aorta
was closed, we evacuated the air from the left-sided chambers and removed the cross clamp. Preliminary
closure of patent foramen ovale was 5 mm in diameter was performed with a mattress suture of #5-0 Prolene.
The heart started spontaneous rhythm. The atrium was closed with a double running #5-0 Prolene. Once we
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were warmed, connections were made to perform modified ultrafiltration and once this was completed, the
cannulae were removed in a routine manner and the heparin reversed with protamine. Hemostasis was
adequate. Two chest tubes were placed, one in the right pleural cavity and one anteriorly. The chest was
closed with wires for the sternum and Vicryl for the superficial layers. The patient the procedure well and was
transferred to ICU in satisfactory condition.
Cardiopulmonary Bypass Data: Bypass time 85 minutes, cross clamp time 52 minutes, maximum flow rate 1.4
L/minute, lowest esophageal temperature 31 degrees Celsius
Questions
• The ventricular septal defect was repaired using a patch graft. What root operation is used for this part of the
operation?
• A portion of pericardial tissue is used to patch the ventricular septal defect. Is a code for the harvest of this
tissue added?
• What approach will be used for these procedures?
• Based on the documentation, three procedures were performed. What codes would be assigned for each
procedure?
• What code is added for the cardiopulmonary bypass?
In a fusion procedure, when autologous bone graft material is used, this means that the bone graft was taken
from
.a donor.
an animal.
the patient.
an identical twin
Sample Solution