CPT® Code 33676

1. Indications

The procedure associated with CPT® Code 33676 is indicated for patients presenting with multiple ventricular septal defects (VSDs) in conjunction with obstruction of the right ventricular outflow tract. This condition may be seen in cases of mild (acyanotic) tetralogy of Fallot, where the presence of VSDs can lead to significant hemodynamic changes and potential complications if left untreated.

• Multiple Ventricular Septal Defects The presence of one or more abnormal openings in the ventricular septum that require surgical intervention.
• Obstruction of Right Ventricular Outflow Tract Conditions that cause narrowing or blockage in the pathway from the right ventricle to the pulmonary artery, necessitating surgical correction.
• Acyanotic Tetralogy of Fallot A specific congenital heart defect characterized by a combination of VSD and right ventricular outflow tract obstruction, which may require this surgical approach.

2. Procedure

The surgical procedure for CPT® Code 33676 involves several critical steps to ensure the effective closure of multiple VSDs and the correction of any associated outflow tract obstruction. Initially, an incision is made in the chest to access the heart, followed by an incision in the pericardium to expose the heart structures. Cardiopulmonary bypass is then initiated to maintain circulation and oxygenation during the surgery. The surgeon will access the right ventricle or pulmonary artery through an incision, where they will identify and excise any obstructive fibrous or muscular bands that are contributing to the outflow tract obstruction. If necessary, tissue may be removed from the thickened muscular infundibulum to enlarge the outflow tract, facilitating improved blood flow. The pulmonary valve is carefully inspected, and if the commissures are found to be fused, they are opened using sharp dissection to restore normal function. Following these steps, the multiple VSDs are repaired using sutures or patches, which may include synthetic materials or previously harvested pericardial patches. Once the repairs are completed, the access incision is closed, and cardiopulmonary bypass is discontinued. Chest tubes are placed to allow for proper drainage, and the chest incision is subsequently closed to complete the procedure.

• Step 1: Incision and Access An incision is made in the chest to access the heart, followed by an incision in the pericardium.
• Step 2: Initiation of Cardiopulmonary Bypass Cardiopulmonary bypass is initiated to maintain circulation and oxygenation during the procedure.
• Step 3: Accessing the Right Ventricle or Pulmonary Artery The surgeon makes an incision to access the right ventricle or pulmonary artery, identifying any obstructive bands.
• Step 4: Excision of Obstructive Tissue Obstructive fibrous or muscular bands are excised, and tissue may be removed from the muscular infundibulum to enlarge the outflow tract.
• Step 5: Inspection and Repair of the Pulmonary Valve The pulmonary valve is inspected, and fused commissures are opened using sharp dissection.
• Step 6: Closure of Ventricular Septal Defects The multiple VSDs are repaired using sutures or patches as necessary.
• Step 7: Closure of Incisions The access incision is closed, cardiopulmonary bypass is discontinued, chest tubes are placed, and the chest incision is closed.

3. Post-Procedure

Post-procedure care following the closure of multiple VSDs with pulmonary valvotomy or infundibular resection involves careful monitoring of the patient’s recovery. Patients are typically observed in a critical care setting to ensure stable hemodynamics and to manage any potential complications. Chest tubes are monitored for drainage, and the patient’s respiratory status is assessed regularly. Pain management is provided as needed, and the surgical site is monitored for signs of infection or other complications. Follow-up echocardiograms may be performed to evaluate the success of the VSD closure and the function of the pulmonary valve. The overall recovery period may vary depending on the individual patient's condition and the complexity of the surgery, but patients are generally expected to gradually resume normal activities as they heal.