CPT® Code 33928

1. Indications

The total replacement heart system (TAH) is indicated for patients with 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 TAH:

• Severe Heart Failure Patients experiencing advanced heart failure symptoms that significantly impair their quality of life and daily functioning.
• Bridge to Transplant Individuals who require temporary mechanical support while waiting for a suitable donor heart for transplantation.
• Cardiac Dysfunction Patients with deteriorating cardiac function due to various underlying conditions that have not responded to medical management.

2. Procedure

The procedure for the removal and replacement of a total replacement heart system involves several critical steps, each requiring careful execution to ensure patient safety and device functionality.

• Step 1: Median Sternotomy The surgical process begins with a median sternotomy, where an incision is made through the breastbone to access the heart. This approach provides the necessary visibility and access for the subsequent steps.
• Step 2: Diaphragm Division The left diaphragm is divided medially, and dissection is performed beneath the left posterior fascia to create a peritoneal pocket in the upper left abdomen. This pocket will house components of the TAH.
• Step 3: Incision for Drive Lines Two small incisions, approximately 5 cm apart, are made through the skin and rectus fascia below the left costal margin. These incisions facilitate the creation of intramuscular tunnels for the pneumatic drive lines that connect the TAH to the external pump.
• Step 4: Maintaining Patency Penrose drains are passed through the tunnels into the chest to maintain patency, ensuring that the pathways for the drive lines remain open throughout the procedure.
• Step 5: Cannulation The aorta is cannulated, followed by the superior and inferior vena cava, to facilitate heart-lung bypass. This step is crucial for maintaining blood circulation and oxygenation 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 to allow for the removal of the failing heart structures.
• Step 7: Ventricular Excision The right ventricle is excised distal and parallel to the atrioventricular groove, continuing anteriorly into the right ventricular outflow tract. The left ventricle is opened by incising the intraventricular septum and extending the incision laterally into the left ventricular outflow tract.
• Step 8: Septum Division The remaining ventricular septum is divided and removed. If a patent foramen ovale is present, the defect is sutured closed to prevent complications.
• Step 9: Valve Excision The tricuspid valve leaflets are excised while preserving a cuff of the annulus, followed by a similar excision of the mitral valve leaflets to prepare for the new device.
• Step 10: Cuff Trimming and Oversewing Both ventricular cuffs are trimmed, leaving a 1 cm rim of tissue. The cuffs are then oversewn for hemostasis and size reduction to ensure that the orifice matches the device connectors.
• Step 11: Connector Sizing The connectors are sized and trimmed, then sutured to the left and right ventricular cuffs to secure the new TAH in place.
• Step 12: Graft Connection The aortic and pulmonary grafts are trimmed and fitted to the connectors. The pulmonary graft connection is sewn to the pulmonary artery, and the aortic graft connector is sewn to the aorta.
• Step 13: Pericardium 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 14: Tunnel Preparation A sheet of Gore-Tex is tacked to the lateral pericardium prior to connecting the pump device, and a strip of Gore-Tex is placed in the transverse sinus to protect the right pulmonary artery during reentry, explant, and transplant.
• Step 15: Drive Line Guidance Dilators are passed through the Penrose drains to open the tunnels and guide the drive lines through the abdominal wall, ensuring proper placement of the device.
• Step 16: Device Preparation The device is prepared, and the chest cavity is irrigated and suctioned free of embolic debris to ensure a clean environment for the new heart system.
• Step 17: Drive Line Connection The drive lines are attached to the leaflet connectors and secured. The metal connectors of the external drive lines are replaced with plastic, and the internal and external drive lines are connected and secured.
• Step 18: Activation The pump is turned on, and the cross-clamps are removed to restore blood flow. Lung ventilation is resumed, and the chest incision is closed to complete the procedure.

3. Post-Procedure

After the procedure, patients will require close monitoring in a critical care setting to assess the function of the total artificial heart and manage any potential complications. Post-operative care includes monitoring vital signs, ensuring proper blood flow, and managing any discomfort or pain. Patients may also need to undergo rehabilitation to adjust to the new device and improve their overall health. Regular follow-up appointments will be necessary to evaluate the performance of the TAH and to prepare for potential heart transplantation when a donor heart becomes available. The surgical team will provide specific instructions regarding activity restrictions, medication management, and signs of complications that should prompt immediate medical attention.