33405

Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve

CPT code 33405 describes the open surgical replacement of the aortic valve utilizing cardiopulmonary bypass, specifically employing a prosthetic valve that is neither a homograft nor a stentless valve. This procedure is a cornerstone of cardiothoracic surgery, primarily indicated for patients suffering from severe aortic stenosis, severe aortic regurgitation, infective endocarditis, or symptomatic bicuspid aortic valve disease. The surgery demands a highly orchestrated approach beginning with general anesthesia and a median sternotomy to provide full access to the mediastinum and pericardial cavity. Once the heart is exposed, the patient is systemically heparinized. The surgeon then establishes cardiopulmonary bypass by cannulating the ascending aorta for arterial return and the right atrium or venae cavae for venous drainage. An aortic cross-clamp is applied to isolate the heart from the systemic circulation, and cardioplegia solution is administered into the aortic root or coronary ostia to achieve electromechanical arrest and myocardial protection. With the heart arrested, a transverse aortotomy is performed just above the sinotubular junction to expose the diseased aortic valve. The surgeon carefully excises the calcified or degenerated native leaflets and extensively debrides the aortic annulus of any calcium deposits to ensure a secure and well-sealed seating for the new valve. The annulus is sized, and an appropriate mechanical or stented bioprosthetic valve is selected. The surgeon places multiple interrupted, pledgeted sutures through the patient annulus and then through the sewing ring of the prosthetic valve. The valve is parachuted into position, seated firmly, and the sutures are tied down. The aortotomy is then securely closed using continuous non-absorbable suture. Before releasing the cross-clamp, meticulous de-airing of the heart and aorta is performed to prevent systemic air embolism. The cross-clamp is removed, allowing blood to reperfuse the coronary arteries, and the heart typically resumes beating spontaneously or requires internal defibrillation. The patient is slowly weaned from cardiopulmonary bypass. Following decannulation, heparin is reversed with protamine, and hemostasis is meticulously achieved. Epicardial pacing wires and mediastinal and pleural chest tubes are placed. Finally, the sternum is approximated and closed securely with stainless steel wires, followed by layered closure of the fascia, subcutaneous tissue, and skin. This code exclusively applies to traditional stented bioprostheses or mechanical valves and strictly requires the utilization of a cardiopulmonary bypass machine.

Clinical Indications

  • Severe aortic stenosis with symptoms such as angina, syncope, or heart failure
  • Severe aortic regurgitation causing left ventricular dilation or dysfunction
  • Symptomatic bicuspid aortic valve disease
  • Infective endocarditis affecting the aortic valve native leaflets
  • Structural valve deterioration of a previously placed aortic bioprosthesis requiring open redo replacement
  • Aortic valve disease with concurrent surgical coronary artery disease requiring combined CABG and AVR

Procedure Steps

  1. Administration of general anesthesia followed by endotracheal intubation.
  2. Performance of a median sternotomy to expose the pericardial cavity and great vessels.
  3. Systemic heparinization and cannulation of the ascending aorta and right atrium to establish cardiopulmonary bypass.
  4. Initiation of cardiopulmonary bypass and application of an aortic cross-clamp.
  5. Delivery of cardioplegia solution to arrest the heart and protect the myocardium.
  6. Creation of a transverse aortotomy to expose the native aortic valve.
  7. Excision of diseased aortic valve leaflets and thorough debridement of annular calcifications.
  8. Sizing of the aortic annulus to select the appropriately sized mechanical or stented bioprosthetic valve.
  9. Placement of interrupted pledgeted sutures through the annulus and the sewing ring of the prosthesis.
  10. Parachuting the prosthetic valve into the annulus, seating it firmly, and tying the sutures.
  11. Closure of the aortotomy with continuous suture.
  12. De-airing of the heart and aorta, followed by removal of the aortic cross-clamp.
  13. Weaning the patient from cardiopulmonary bypass and decannulation.
  14. Reversal of heparin with protamine and achievement of meticulous hemostasis.
  15. Placement of temporary epicardial pacing wires and mediastinal chest tubes.
  16. Sternal closure utilizing stainless steel wires and layered closure of the overlying soft tissues and skin.

Coding Guidelines

  • Do not report 33405 in conjunction with homograft (33406) or stentless valve (33411) procedures.
  • Cardiopulmonary bypass is an integral component of this procedure and must not be reported separately.
  • If a concurrent coronary artery bypass grafting (CABG) is performed, report the appropriate CABG codes separately in addition to 33405.
  • Do not report temporary epicardial pacemaker wire placement or chest tube insertion separately as they are bundled into the global surgical package.
  • For transcatheter aortic valve replacement (TAVR), use codes 33361-33369 instead of 33405.
  • Modifier 22 may be appended if the procedure involves significant, unusually complex scar tissue from a previous sternotomy (redo surgery), requiring substantially more work than typical.

Associated ICD-10 Codes