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

Operation: Patch repair of ventricular septal defect, aortic valve repair, closure of patent foramen ovale on cardiopulmonary bypass

Indications: 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 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?

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