CPT® Code 33500

1. Indications

The procedure described by CPT® Code 33500 is indicated for the repair of coronary arteriovenous or arteriocardiac chamber fistulas. These conditions may present with various symptoms or complications, including:

• Abnormal Blood Flow: The presence of a fistula can lead to altered hemodynamics, resulting in symptoms such as heart failure or reduced cardiac output.
• Cardiac Murmurs: The abnormal communication between the coronary artery and the vein or heart chamber may produce audible heart murmurs during auscultation.
• Chest Pain: Patients may experience angina or other forms of chest discomfort due to compromised coronary circulation.
• Fatigue: Reduced efficiency of the heart can lead to increased fatigue and decreased exercise tolerance.
• Signs of Heart Failure: Symptoms such as shortness of breath, edema, and palpitations may occur as a result of the fistula's impact on cardiac function.

2. Procedure

The surgical procedure for repairing a coronary arteriovenous or arteriocardiac chamber fistula involves several critical steps, which are outlined as follows:

• Step 1: The procedure begins with a median sternotomy, which is the surgical opening of the chest to access the heart. This approach allows the surgeon to visualize the heart and surrounding structures effectively.
• Step 2: Once access is obtained, the surgeon identifies the feeding coronary artery, which is the artery supplying blood to the fistula. The specific site of the fistula's insertion into the feeding artery is also located to ensure accurate repair.
• Step 3: The course of the fistula is traced, and the drainage site, whether it is into a vein or a cardiac chamber, is identified. This step is crucial for determining the appropriate method of closure.
• Step 4: If cardiopulmonary bypass is indicated, it is initiated at this stage to maintain blood circulation and oxygenation during the repair process.
• Step 5: If the fistula drains into a vein, the surgeon will close the venous end of the fistula using sutures to prevent further abnormal blood flow.
• Step 6: In cases where the fistula drains into a cardiac chamber, the chamber is opened to allow access to the drainage site. The surgeon then closes this site with sutures or may place a patch if necessary to ensure a secure closure.
• Step 7: If the feeding vessel is large, the surgeon may need to incise the coronary artery to close the opening to the fistula. After the closure of the fistula, the incision in the coronary artery is also sutured closed to restore the integrity of the vessel.

3. Post-Procedure

After the completion of the procedure, patients are typically monitored in a recovery area to assess their vital signs and overall stability. Post-operative care may include managing pain, monitoring for any signs of complications such as bleeding or infection, and ensuring proper cardiac function. Patients may require follow-up imaging studies to confirm the successful closure of the fistula and to evaluate the heart's performance. The expected recovery period can vary based on individual patient factors and the complexity of the procedure, but patients are generally advised to follow specific activity restrictions and attend follow-up appointments for ongoing assessment of their cardiac health.