Cardiothoracic Surgery

John F. Seccombe, MD

AAPC 20th National Conference

All rights reserved

Objective #1

Accept that

– anatomy is the FOUNDATION of medical

understanding

Objectives

2

Objective #2

Understand How Things Work

– Physiology

Objectives

3

Objective #3

Know What is Broken

– Pathology

Objectives

4

Objective #4

Understand the Goal of the Surgeon

– Surgical Procedures

Objectives

5

Objective #5

Learn to Decipher the Surgeon’s Intent

– Diagnosis vs. Treatment

Objectives

6

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Confusing CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

7

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Confusing CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

8

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Confusing CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

9

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Complex CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

10

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Confusing CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

11

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Confusing CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

12

Chest Wall Musculature

Regional Differences in Anatomy

Chest Wall Musculature

Regional Differences in Anatomy

Wisconsin

Chest Wall Musculature

Regional Differences in Anatomy

Chest Wall Musculature

Regional Differences in Anatomy

Las Vegas

Chest Wall Musculature

17

Chest - Skeleton

Anatomy – Lungs

Anatomy – Lobes

Right Upper Lobe

Right Lower Lobe

Right Middle Lobe

Anatomy – Lobes

Right Lung

Anatomy – Lobes

Left Upper Lobe

Left Lower Lobe

Right Lung Left Lung

Anatomy – Lung Segments

Apical

Segment

Anterior

Segment

Posterior

Segment

Right Upper Lobe

Thymus

Anatomy – Great Veins

Anatomy – Pericardial Sac

The Pericardial Sac

27

The Heart

28

The Coronary Arteries

29

The Aorta

Ascending Aorta

Aortic Root

Aortic Arch

Descending Aorta

Abdominal Aorta

Esophagus

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Confusing CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

32

The Heart in Action

Inside the Heart

34

Inside the Heart

35

Inside the Working Heart

Normal Valve Function

Normal Heart Valves

Normal Valve Function

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Confusing CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

40

Coronary Artery Disease

41

Coronary Artery Atherosclerosis

Coronary Artery Stenting

43

Coronary Artery Stenting

44

Heart Surgery History

History of Heart Surgery

"Any surgeon who would attempt an

operation of the heart should lose the

respect of his colleagues."

Theodor Billroth

Theodore Billroth

Dr. Daniel Hale Williams

47

July 9, 1883

48

William Cornish

Dr. Daniel Hale Williams

49

Dr. Charles Mayo

50

51

Coronary Artery Bypass Grafting

Greater Saphenous Vein

53

Endoscopic Vein Harvest

54

Coronary Artery Bypass Grafting

Proximal Anastomosis

Distal Anastomosis

CABG: End to Side Anastomosis

Sequential Vein Graft

57

Side to Side Anastomosis

58

CABG: End to Side Anastomosis

Sequential Graft

60

CABG Options

• On Pump – Motionless Heart

• Off Pump – Beating Heart

• On Pump – Beating Heart

CABG: On Pump

CABG: Off Pump

CABG: Off Pump

CABG: On Pump – Beating Heart Options

Endarterectomy

66

http://www.youtube.com/watch?v=M0kW-

VcNAsU

Heart Valves

67

Normal Valve Function

Valve Stenosis

Leaky Heart Valves

Leaky Heart Valves

Heart Valve Surgery

72

• Replacement

• Repair

• Valvuloplasty

• Artificial chordae

• Annuloplasty

• Trans-Catheter Techniques

Median Sternotomy

73

Connecting to the Heart Lung Machine

74

Removing the Old Valve

75

Prosthetic Aortic Valve

76

Prosthetic Aortic Valve

77

Implanting the New Valve

78

Aortic Valve Repair

79

Mitral Valve - Normal

80

Mitral Valve - Leaflet Segment Prolapse

81

Mitral Valve Repair – Leaflet Segment Prolapse

82

Mitral Valve Repair– Resection of Leaflet Segment

83

Mitral Valve Repair – Resection of Leaflet Segment

84

Mitral Valve Repair - Valvuloplasty

85

Mitral Valve Repair - Annuloplasty

86

Artificial Chordae

87

Artificial Chordae

88

Artificial Chordae

89

TAVR

90

Trans – Apical AVR

91

Trans – Catheter Repair for Mitral Regurgitation

92

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Complex CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

93

94

Importance of Beer in the History of Heart Surgery

95

C. Walton Lillehei

96

97

Child

Parent

Lyman and Gregory Glidden

98

99

Importance of Beer in the History of Heart Surgery

100

101

102

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Complex CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

103

104

Aortic Aneurysm

105

Thoracic Aortic Aneurysms

106

Aortic Root Aneurysms

107

Removing the Old Valve

108

Composite Graft – Valved Conduit

109

Modified Bentall Procedure

110

ç

Modified Bentall Procedure

111

Replacement of Aortic Valve, Aortic Root and Ascending Aorta

112

Replacement of Ascending Aorta

113

Valve Sparing Replacement of Aortic Root Replacement

114

Valve Sparing Replacement of Aortic Root Replacement

115

Valve Sparing Replacement of Aortic Root Replacement

116

Valve Sparing Replacement of Aortic Root Replacement

117

Ascending Aortic Aneurysms

118

Replacement of Aortic Root and Ascending Aorta

119

Interposition Graft

120

Aortic Arch Aneurysm

121

Replacement of Aortic Arch

122

Ascending, + Arch + Descending Aortic Aneurysms

123

Elephant Trunk

124

Descending Thoracic Aortic Aneurysm

125

Descending Thoracic Aortic Aneurysm

126

TEVAR

127

Aortic Dissection

128

Aortic Dissection

129

Case Scenario

130

Interposition Graft

131

Replacement of Aortic Root and Ascending Aorta

132

133

Aortic Transection

134

Aortic Transection

135

Aortic Transection

136

• Anatomy of the Chest

• Normal Heart Function

• Common Problems and Procedures

• Complex CT Surgical Procedures

• CT Surgery Coding – The Importance of Intent

Outline

137

Objective #5

Learn to Decipher the Surgeon’s Intent

– Surgical Procedures

Objectives

138

Deciphering the Surgeon’s Intent

139

► However, a diagnostic biopsy of a lung nodule using a wedge

technique requires only that a tissue sample be obtained without

particular attention to resections margins. A therapeutic wedge

resection requires attention to margins and complete resection

even when the wedge resection is ultimately followed by a more

extensive resection. In the case of a wedge resection where

intraoperative pathology consultation determines that a more

extensive resection is required in the same anatomic location, it

becomes classified as a diagnostic wedge resection (32507,

32668). When no more extensive resection is required, the same

procedure is a therapeutic wedge resection (32505, 32666).◄

• Is the Intent of the Surgeon to Diagnose or to Treat?

– Case Scenarios

32507 and 32668 OR 32505 and 32666

140

Questions

141

142

143

144

145

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