CPT® Code 33611

1. Indications

The procedure is indicated for patients diagnosed with a double outlet right ventricle (DORV), particularly when accompanied by a ventricular septal defect (VSD). The following conditions may warrant this surgical intervention:

• Double Outlet Right Ventricle (DORV) A congenital heart defect where both the aorta and pulmonary artery arise from the right ventricle, leading to inadequate oxygenation of blood.
• Ventricular Septal Defect (VSD) The presence of a defect in the ventricular septum that allows blood to flow from the left ventricle to the right ventricle, which can cause volume overload and heart failure.
• Right Ventricular Outflow Tract Obstruction Conditions that may lead to obstruction of blood flow from the right ventricle to the pulmonary artery, necessitating surgical correction.

2. Procedure

The surgical procedure for CPT® Code 33611 involves several critical steps to repair the DORV through the creation of an intraventricular tunnel:

• Establishment of Cardiopulmonary Bypass The procedure begins with the establishment of cardiopulmonary bypass using bicaval cannulation, which allows for the diversion of blood away from the heart, ensuring that the patient remains hemodynamically stable during the surgery.
• Cardioplegic Arrest Once bypass is established, cardioplegic arrest is initiated to temporarily stop the heart, allowing the surgeon to operate on a still and bloodless field.
• Incision of the Right Atrium The surgeon incises the right atrium to gain access to the heart's internal structures, allowing for direct visualization of the anatomy, including the VSD.
• Visualization of the VSD The VSD is visualized through the tricuspid valve, and the relationship between the VSD and the aorta is assessed to determine the best approach for repair.
• Approach to the VSD The VSD may be approached either through the tricuspid valve or by incising the right ventricle, depending on the specific anatomical considerations.
• Enlargement of the VSD If the circumference of the VSD is smaller than the planned tunnel, the surgeon enlarges the VSD by incising the ventricular septum superiorly and anteriorly, taking care to avoid damaging the conduction tissue located inferiorly.
• Creation of the Intraventricular Tunnel A tunnel is constructed using pericardium, polytetrafluoroethylene (PTFE), or other synthetic materials, matching the circumference of the aorta. This tunnel is positioned to connect the anterior portion of the aorta to the VSD.
• Suturing the Tunnel Sutures are placed through the base of the tricuspid valve leaflet and the midportion of the tunnel. Additional sutures are placed on the atrial side of the septal leaflet of the tricuspid valve and along the inferior and posterior rim of the VSD, securing the tunnel in place.
• Closure of the VSD If the VSD is larger than the tunnel, the remaining opening is closed to ensure proper heart function.
• Closure of Incisions Finally, the incisions made in the right atrium and right ventricle are closed, completing the surgical repair.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any complications that may arise following the surgery. Patients are typically placed in an intensive care unit (ICU) for close observation. Recovery may include management of pain, monitoring of vital signs, and assessment of cardiac function. The surgical team will also evaluate the effectiveness of the repair and ensure that the patient is stable before transitioning to a regular recovery unit. Follow-up appointments will be necessary to monitor the patient's progress and address any ongoing concerns related to the congenital heart defect.