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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?