CPT® Code 33778

1. Indications

The procedure described by CPT® Code 33778 is indicated for patients diagnosed with transposition of the great arteries, a congenital heart defect that requires surgical intervention to correct the abnormal positioning of the aorta and pulmonary arteries. The following conditions may warrant this procedure:

• Transposition of the Great Arteries A congenital anomaly where the aorta arises from the right ventricle and the pulmonary arteries arise from the left ventricle, leading to improper circulation of oxygenated and deoxygenated blood.
• Ventricular Septal Defect (VSD) An abnormal opening in the ventricular septum that allows for the mixing of oxygen-rich and oxygen-poor blood, often associated with transposition of the great arteries.
• Subpulmonary Stenosis A narrowing of the main pulmonary artery just below the pulmonary valve, which can complicate the condition and necessitate surgical repair.

2. Procedure

The surgical procedure for CPT® Code 33778 involves several critical steps to effectively repair transposition of the great arteries through aortic and pulmonary artery reconstruction:

• Accessing the Heart The procedure begins with the patient being placed under general anesthesia. A median sternotomy or thoracotomy is performed to gain access to the heart. During this step, the thymus gland may be resected to facilitate better access to the cardiac structures.
• Incising the Pericardium The pericardium, which is the fibrous sac surrounding the heart, is incised. A section of the pericardium is harvested for later use as a patch graft, which will be utilized in the reconstruction process.
• Dissection of Cardiac Structures The ascending aorta, main pulmonary artery, and their branches are carefully dissected free from surrounding tissues to prepare for the reconstruction. This step is crucial for ensuring that the structures can be manipulated without damage.
• Establishing Cardiopulmonary Bypass The aorta and the superior and inferior vena cava are cannulated to establish cardiopulmonary bypass. This allows for the heart to be temporarily stopped while maintaining blood circulation throughout the body.
• Cross-Clamping the Aorta Once bypass is established, the aorta is cross-clamped to prevent blood flow during the surgical repair. This step is essential for creating a bloodless field for the subsequent surgical maneuvers.
• Transecting the Aorta and Pulmonary Artery The ascending aorta and the main pulmonary artery are transected to facilitate the reconstruction of the great arteries. This involves cutting through the vessels to create new connections.
• Visualizing and Excising Coronary Artery Ostia The ostia (openings) of the left and right coronary arteries at the anomalous aortic root in the right ventricle are visualized and excised along with the adjacent aortic wall. This step is critical for repositioning the coronary arteries correctly.
• Transferring Coronary Artery Ostia The excised coronary artery ostia are transferred as buttons to the newly created main pulmonary artery root sinuses in the left ventricle. This ensures that the coronary arteries are properly reconnected to the new aortic outflow tract.
• Repositioning the Main Pulmonary Artery The distal main pulmonary artery and its branches are brought forward to connect with the right ventricle, while the aorta is moved posteriorly to align with the left ventricle.
• Anastomosing the Distal Aorta The distal aorta is anastomosed to the newly created aortic root in the left ventricle, establishing a new pathway for oxygenated blood to flow to the body.
• Anastomosing the Coronary Arteries The coronary arteries are also anastomosed to the newly created aortic outflow tract, ensuring that the heart muscle receives adequate blood supply.

3. Post-Procedure

After the completion of the surgical repair, the sternum may be closed or left open, with plans for closure in a subsequent procedure if necessary. Chest tubes are placed as needed to facilitate drainage and prevent fluid accumulation in the thoracic cavity. Post-operative care includes monitoring for complications, managing pain, and ensuring proper recovery. The patient will typically be observed in a critical care setting for a period following the surgery to ensure stability and address any immediate post-operative concerns.