CPT® Code 33927

1. Indications

The implantation of a total replacement heart system (CPT® code 33927) is indicated for patients experiencing severe heart failure who are not candidates for traditional heart surgery or for those awaiting a heart transplant. The following conditions may warrant the use of a total artificial heart:

• Severe Heart Failure Patients with advanced heart failure that is unresponsive to medical therapy.
• Bridge to Transplant Individuals who require temporary support while awaiting a suitable donor heart for transplantation.
• Cardiac Dysfunction Patients with significant cardiac dysfunction that compromises their quality of life and daily functioning.

2. Procedure

The procedure for the implantation of a total replacement heart system involves several critical steps, each designed to ensure the successful placement and function of the device:

• Step 1: Median Sternotomy The surgical procedure begins with a median sternotomy, which involves making an incision along the midline of the chest to gain access to the thoracic cavity.
• Step 2: Creation of Peritoneal Pocket The left diaphragm is divided medially, and dissection is performed beneath the left posterior fascia to create a peritoneal pocket in the left upper abdomen for the external pumping drive.
• Step 3: Incisions for Drive Lines Two small incisions, approximately 5 cm apart, are made through the skin and rectus fascia below the left costal margin to create intramuscular tunnels for the pneumatic drive lines.
• Step 4: Maintenance of Patency Penrose drains are passed through the tunnels into the chest to maintain patency during the procedure.
• Step 5: Cannulation for Bypass The aorta is cannulated, followed by the superior and inferior vena cava, to facilitate heart-lung bypass during the surgery.
• Step 6: Cross-Clamping and Division The aorta is cross-clamped and divided at the aortic root, and the main pulmonary artery is cut just above the valve commissures.
• Step 7: Excising the Right Ventricle The right ventricle is excised distal and parallel to the atrioventricular groove, continuing anteriorly into the right ventricular outflow tract.
• Step 8: Opening the Left Ventricle The left ventricle is opened by incising the intraventricular septum and extending the incision laterally into the left ventricular outflow tract.
• Step 9: Removal of Ventricular Septum The remaining ventricular septum is divided and removed, and if a patent foramen ovale is present, the defect is sutured closed.
• Step 10: Inspection of Coronary Sinus The overflow orifice of the coronary sinus is inspected and oversewn to prevent complications.
• Step 11: Excision of Valves The tricuspid valve leaflets are excised while preserving a cuff of the annulus, followed by a similar excision of the mitral valve leaflets.
• Step 12: Trimming of Ventricular Cuffs Both ventricular cuffs are trimmed, leaving a 1 cm rim of tissue, and oversewn for hemostasis and size reduction to match the device connectors.
• Step 13: Connector Sizing and Trimming The connectors are sized and trimmed, then sutured to the left and right ventricular cuffs.
• Step 14: Graft Connection The aortic and pulmonary grafts are trimmed and fitted to the connectors, with the pulmonary graft sewn to the pulmonary artery and the aortic graft connector sewn to the aorta.
• Step 15: Gore-Tex Lining The pericardium is lined with Gore-Tex to decrease blood loss and facilitate reentry and explant of the device when a transplant heart becomes available.
• Step 16: Protection During Reentry A strip of Gore-Tex is placed in the transverse sinus to protect the right pulmonary artery during reentry, explant, and transplant.
• Step 17: Opening Tunnels Dilators are passed through the Penrose drains to open the tunnels and guide the drive lines through the abdominal wall.
• Step 18: Device Preparation The device is prepared, and the chest cavity is irrigated and suctioned free of embolic debris.
• Step 19: Connecting Drive Lines The drive lines are attached to the leaflet connectors and secured, with metal connectors replaced with plastic for safety.
• Step 20: Activation of Pump The internal and external drive lines are connected and secured, the pump is turned on, and cross-clamps are removed to restore circulation.
• Step 21: Closure of Chest Incision Lung ventilation is resumed, and the chest incision is closed to complete the procedure.

3. Post-Procedure

After the implantation of a total replacement heart system, patients will require careful monitoring and management in a postoperative setting. Expected recovery includes close observation for any complications related to the surgery, such as bleeding or infection. Patients may need to stay in the hospital for an extended period to ensure the proper functioning of the device and to manage any potential side effects. Follow-up care will involve regular assessments of the device's performance and the patient's overall health status, as well as preparation for potential heart transplantation if a donor heart becomes available.