CPT® Code 33606

1. Indications

The Damus-Kaye-Stansel procedure, represented by CPT® Code 33606, is indicated for the following conditions:

• Double inlet left ventricle A congenital heart defect where both atria connect to a single ventricle, leading to inadequate blood flow and oxygenation.
• Tricuspid atresia with transposition of great vessels A condition where the tricuspid valve is absent, and the great vessels are positioned incorrectly, resulting in poor circulation.
• Transposition of the great vessels with hypoplastic right ventricle A serious congenital defect where the aorta and pulmonary artery are switched, and the right ventricle is underdeveloped, causing significant challenges in blood flow and oxygenation.

2. Procedure

The Damus-Kaye-Stansel procedure involves several critical steps to ensure successful anastomosis of the pulmonary artery to the aorta:

• Step 1: Median sternotomy The procedure begins with a median sternotomy, which is an incision made along the sternum to provide access to the heart. This approach allows the surgeon to visualize and operate on the heart structures effectively.
• Step 2: Establishing cardiopulmonary bypass Once access is obtained, cardiopulmonary bypass is established to take over the function of the heart and lungs during the surgery. This is crucial for maintaining blood circulation and oxygenation while the heart is being operated on.
• Step 3: Initiating cardioplegia Cardioplegia is then initiated to protect the heart muscle from damage during the procedure. This involves infusing a solution that temporarily stops the heart's activity, allowing for a still and bloodless surgical field.
• Step 4: Dissection of the aorta and pulmonary artery The surgeon carefully dissects the aorta away from the pulmonary artery, ensuring both vessels are completely mobilized for the anastomosis. This step is critical for creating a proper connection between the two vessels.
• Step 5: Mobilization of the pulmonary artery The pulmonary artery is also mobilized to facilitate the anastomosis. This may involve preparing a patch graft from a cadaver donor if the pulmonary artery is too short for direct connection.
• Step 6: Incision of the right atrium The right atrium is incised, and the atrial septum is resected to allow for proper alignment and connection of the vessels.
• Step 7: Opening the underside of the aorta The underside of the aorta is opened to prepare for the anastomosis with the proximal pulmonary artery.
• Step 8: Anastomosis of the aorta to the pulmonary artery The aorta is then anastomosed to the proximal pulmonary artery in an end-to-side fashion, creating a new pathway for blood flow. If the pulmonary artery is too short, a cadaver donor pulmonary artery graft is utilized to achieve the necessary length.
• Step 9: Patching the distal end of the pulmonary artery The distal end of the divided pulmonary artery is patched using either a cadaver donor patch or a synthetic patch to ensure proper closure and function.
• Step 10: Closure of the heart After the anastomosis is complete, the heart is closed, and cardiopulmonary bypass is discontinued. This step involves carefully suturing the heart structures back together.
• Step 11: Placement of chest tubes Finally, chest tubes are placed to allow for drainage of any fluid or air that may accumulate in the chest cavity post-surgery, and the chest is closed to complete the procedure.

3. Post-Procedure

Post-procedure care following the Damus-Kaye-Stansel procedure involves monitoring the patient closely for any complications and ensuring proper recovery. Patients typically require intensive care following surgery, where vital signs, heart function, and fluid balance are closely observed. The placement of chest tubes aids in the management of any potential fluid accumulation in the thoracic cavity. Pain management is also an essential aspect of post-operative care, as patients may experience discomfort from the surgical incision and manipulation of heart structures. Rehabilitation and follow-up appointments are crucial to assess the success of the procedure and the patient's overall cardiac function. Long-term monitoring may be necessary to evaluate the effectiveness of the anastomosis and to manage any arising complications related to the congenital heart defect.