CPT® Code 93527

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1. Indications

The combined right heart catheterization and transseptal left heart catheterization procedure is indicated for various clinical scenarios, including but not limited to the following:

• Assessment of Heart Function: This procedure is performed to evaluate the hemodynamics of the heart, including pressure measurements in the right and left heart chambers.
• Diagnosis of Cardiac Conditions: It is utilized in the diagnosis of conditions such as heart failure, valvular heart disease, and congenital heart defects.
• Evaluation of Pulmonary Hypertension: The procedure helps in assessing pulmonary artery pressures, which is crucial for diagnosing pulmonary hypertension.
• Preoperative Assessment: It may be indicated as part of the preoperative evaluation for patients undergoing cardiac surgery.
• Investigation of Chest Pain: The procedure can assist in determining the cause of unexplained chest pain or other cardiac symptoms.

2. Procedure

The procedure involves several critical steps to ensure accurate assessment and intervention:

• Step 1: Access Site Preparation The procedure typically begins with the preparation of the right femoral vein in the groin area. A small stab incision is made to facilitate access to the vein, followed by the insertion of a needle.
• Step 2: Insertion of Sheath and Guidewire After the needle is placed, a sheath is introduced into the vein. A guidewire is then threaded through the femoral vein, progressing through the external iliac vein, inferior vena cava, and into the right atrium.
• Step 3: Catheter Placement Once the guidewire is in place, a catheter is inserted and advanced over the guidewire into the right atrium, right ventricle, and pulmonary arteries. The guidewire is subsequently withdrawn.
• Step 4: Hemodynamic Measurements As the catheter is positioned, the right heart chambers are inspected, and pressure and oxygen levels are measured. The tricuspid and pulmonary valves are evaluated, and pressure gradients are obtained.
• Step 5: Angiography If indicated, a separately reportable angiogram of the right heart and/or pulmonary arteries may be performed to visualize these structures.
• Step 6: Transseptal Puncture The intra-atrial septum is punctured, allowing the catheter to advance into the left atrium. Here, the left atrium and mitral valve are inspected, and pressures are measured.
• Step 7: Further Catheter Advancement If the catheter is advanced into the left ventricle, the left ventricle and aortic valve are also inspected, with additional pressure measurements taken.
• Step 8: Coronary Artery Inspection The right and left coronary arteries may be inspected as part of the evaluation process.
• Step 9: Additional Angiograms Separately reportable angiograms of the aorta, left heart chambers, coronary arteries, arterial conduits, and/or aortocoronary venous bypass grafts may be obtained as necessary.
• Step 10: Retrograde Left Heart Catheterization (if applicable) If retrograde left heart catheterization is performed, a second catheter is placed through the brachial, axillary, or femoral artery. The artery is punctured, and a sheath is placed, followed by the insertion of a guidewire that is threaded retrograde into the aorta and left heart.
• Step 11: Final Inspection and Pressure Measurements The left heart structures are inspected, and additional pressures may be obtained as needed.
• Step 12: Completion of Procedure Upon completion of the procedure, the catheter(s) are withdrawn, and a compression dressing is applied to the access site to ensure hemostasis.

3. Post-Procedure

After the completion of the combined right heart catheterization and transseptal left heart catheterization, patients are typically monitored for any complications or adverse effects. The access site is assessed for bleeding, and a compression dressing is applied to promote healing and minimize the risk of hematoma formation. Patients may be advised to rest and limit physical activity for a specified period. Follow-up care may include additional imaging or assessments based on the findings from the procedure. It is essential to monitor vital signs and ensure that the patient is stable before discharge.