Aortic Valve Replacement (AVR)
[Severe aortic stenosis / severe aortic regurgitation / combined aortic valve disease], symptomatic [/ meeting guideline criteria for intervention]
Same
Aortic valve replacement with [21-mm / 23-mm / 25-mm] [bioprosthetic (Carpentier-Edwards Perimount / INSPIRIS) / mechanical (St. Jude Medical / On-X)] valve
[***, MD/DO]
[Resident/PA name]
General endotracheal with TEE and arterial line
The patient is a [age]-year-old [male / female] with severe [aortic stenosis (AVA [X] cm², mean gradient [X] mmHg, peak gradient [X] mmHg) / aortic regurgitation (LVEDD [X] mm, LVEF [X]%)], presenting with [exertional dyspnea / syncope / angina / asymptomatic, meeting guideline criteria]. Surgical AVR was recommended by Heart Team. The risks, benefits, and alternatives including TAVR were discussed and informed consent was obtained.
The aortic valve was [tricuspid / bicuspid / rheumatic] with [heavily calcified / fused] leaflets. The aortic annulus measured [X] mm on TEE. The leaflets were [excised and the annulus debrided of calcium]. The native valve measured [X] mm. The prosthetic valve was seated without obstruction. TEE post-bypass confirmed [no paravalvular leak / trace paravalvular leak (hemodynamically insignificant)], EF [X]%, and mean gradient [X] mmHg.
The patient was positioned supine. A median sternotomy was performed. The pericardium was opened and the ascending aorta, right atrium, and aortic root were exposed. Cardiopulmonary bypass was instituted via aortic and venous cannulation. [Cold blood / del Nido] cardioplegia was given antegrade.
A transverse aortotomy was made [2 cm above the right coronary ostium]. The aortic valve was inspected. It was [tricuspid / bicuspid, with heavy calcification]. The valve leaflets were excised and the annulus was debrided of calcium to a smooth, non-obstructing rim. [Care was taken to avoid injury to the anterior leaflet of the mitral valve and the membranous septum.]
The annulus measured [X mm]. A [21 / 23 / 25]-mm [bioprosthetic (Carpentier-Edwards Perimount / INSPIRIS) / mechanical (On-X)] valve was selected. The valve was seated with [X] pledgeted interrupted [2-0 Ethibond] sutures in [everting mattress / non-everting] configuration. The valve was lowered into position and the sutures were tied. The valve moved [freely] with no obstruction.
The aortotomy was closed with [3-0 Prolene] running suture in two layers. Air was de-aired from the aortic root. Clamps were released. The heart [resumed sinus rhythm spontaneously / was defibrillated]. The patient was weaned from CPB. Post-bypass TEE confirmed [no paravalvular leak, EF X%, mean gradient X mmHg].
Protamine was administered. Hemostasis was achieved. Mediastinal chest tubes were placed. The sternum was closed with sternal wires. The wound was closed in layers.
None
Aortic valve leaflets to pathology
[X] mL
[2] mediastinal chest tubes, [pericardial drain]
The patient was transferred to the cardiac ICU intubated. [Anticoagulation with heparin was initiated and transitioned to warfarin (target INR [2.0-2.5 / 2.5-3.5]) for mechanical valve.] [Aspirin only for bioprosthetic valve.]
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Severe aortic stenosis/regurgitation, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: AVR, *** mm *** (bio/mechanical)
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, ETT, TEE, art line
INDICATIONS: .PTAGE-year-old .PTSEX with severe AS/AR: AVA *** cm², gradient ***, LVEF ***%. Symptoms: ***. Heart Team: AVR. Consent obtained.
FINDINGS: Aortic valve *** (tricuspid/bicuspid), heavily calcified. Annulus *** mm. Valve excised, calcium debrided. Post-bypass TEE: no PVL, EF ***%, gradient *** mmHg.
PROCEDURE:
Supine. Sternotomy. Pericardium opened. CPB: aortic + venous. Cold blood/del Nido cardioplegia antegrade. Transverse aortotomy *** cm above RCA ostium. Valve *** with heavy calcium. Leaflets excised, annulus debrided. Sized *** mm. *** mm *** valve seated with *** interrupted 2-0 Ethibond, everting/non-everting. Valve moves freely. Aortotomy closed 3-0 Prolene × 2 layers. De-aired. Clamps released. Sinus rhythm / defibrillated. Weaned CPB. Post-CPB TEE: no PVL, EF ***%. Protamine. Chest tubes. Sternum wires. Closed.
EBL: *** mL
SPECIMENS: Aortic valve to pathology
COMPLICATIONS: None
DISPOSITION: Cardiac ICU. Anticoagulation: *** (warfarin INR ***-*** / aspirin).
Signed: .ME, .MYDEGREE
.TODAYVariants
Minimally Invasive AVR (Mini-Sternotomy / Right Anterior Thoracotomy)
AVR was performed via [upper hemisternotomy (J-incision) / right anterior minithoracotomy] for minimally invasive access. The sternum was divided to the [3rd / 4th] intercostal space. A [modified] cannulation strategy was used: [standard aortic / femoral artery + femoral vein]. The aortotomy and valve replacement proceeded as described. Advantages include reduced blood loss, shorter length of stay, and superior cosmesis; disadvantages include limited surgical access and longer CPB time for complex anatomy.
Charting Tips
- Document paravalvular leak assessment by post-bypass TEE. Trace paravalvular regurgitation at a bioprosthetic valve is generally acceptable. For mechanical valves, any more-than-trace paravalvular jet warrants consideration of return to bypass; trace jets may be observed briefly post-protamine and re-evaluated before closure. Document the TEE finding, severity (trace/mild/moderate), and the management decision.
- Document final valve position and gradient on post-bypass TEE. A mean gradient >15 mmHg for a new bioprosthetic AVR is elevated and warrants evaluation; >20 mmHg suggests obstruction or patient-prosthesis mismatch and should prompt consideration of return to bypass for revision or upsizing. Patient-prosthesis mismatch is defined as projected indexed EOA 0.85 cm2/m2 or less (moderate) or 0.65 cm2/m2 or less (severe). Document the measured mean gradient and indexed EOA.
- Document the anticoagulation plan for a mechanical valve. Mechanical valves require lifelong vitamin K antagonist therapy. For an On-X mechanical aortic valve without additional thromboembolic risk factors, an INR target of 1.5-2.0 with aspirin 75-100 mg daily may be considered beginning 3 months after surgery. Use valve- and risk-specific targets for other mechanical valves or patients with additional risk factors. Document the immediate postoperative anticoagulation and warfarin transition plan.
- Document cross-clamp time and total CPB time. These are required STS quality metrics. Cross-clamp time and CPB time >120 minutes are associated with increased operative morbidity. Both should appear in the operative note.
- Document placement of temporary epicardial pacing wires. Atrial and ventricular epicardial wires are standard after AVR and must be documented in the operative note. Complete heart block can develop post-AVR due to proximity of the AV node and bundle of His to the noncoronary cusp annulus.
Documentation & Reimbursement Considerations
- Primary service: Report Aortic Valve Replacement (AVR) as the primary service when it is the definitive operation performed.
- Use for traditional sternotomy AVR with cardiopulmonary bypass.
- Note TAVR codes have a 0-day global period vs. 90-day for SAVR.
- Concomitant procedures at the time of SAVR are separately billable using procedure-specific combinations. Multiple-procedure reporting is generally not applied to cardiac surgery combinations; procedure-specific pairing rules apply. Document each component in its own operative section.
- Cardiopulmonary bypass is bundled into the primary valve replacement code (the primary and related services/the related service) and is not separately billable as a surgeon reporting options. There is no surgeon-billable reporting options for CPB.
- 90-day global period for SAVR: anticoagulation management, valve clinic follow-up, and routine echo surveillance are bundled for the surgical fee. Cardiology follows independently and bills their own E/Ms.