CPT® Code 0451T

Official Description

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes)

Common Language Description

The procedure described by CPT® Code 0451T involves the insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system using an endovascular approach. This advanced medical intervention is designed to support patients with severe cardiac conditions, particularly those experiencing acute cardiogenic shock or end-stage chronic heart failure. The aortic counterpulsation system consists of several critical components, including a pneumatic pump that operates by utilizing pressurized air, a console that drives the pump, and electrodes that synchronize the device's operation with the patient's heartbeat. During the procedure, the pump fills with blood during ventricular systole, which reduces the workload of the left ventricle by decreasing afterload. Conversely, during ventricular diastole, the pump ejects blood, thereby enhancing cardiac output and improving both coronary and systemic blood flow. The insertion process begins with a surgical incision made in the right chest, specifically along the infraclavicular line, where the pump is placed into a subcutaneous pocket above the pectoralis muscle. A pneumatic drive line is then tunneled through the skin to the right upper quadrant of the abdomen, where it connects to the console. An interposition vascular graft is anastomosed to the subclavian artery, and the main graft is linked to the pump. After ensuring that air is removed from the system, the device is activated. Subcutaneous electrocardiogram electrodes are positioned on the chest wall and connected to the console, while mechano-electrical skin interface electrodes are placed on various locations such as the wrist, finger, or ankle to capture the heartbeat and synchronize the pump's function. The surgical team checks the graft site for any bleeding, and if necessary, implantable hemostatic sealing agents are applied before closing the incisions. In cases where a replacement of the device is required, the procedure involves making an incision to expose the existing pump, subclavian artery, and vascular graft. The device is clamped at the subclavian artery, excised, and replaced following the same steps as the initial insertion. CPT® Code 0451T encompasses the complete system, which includes the counterpulsation device, vascular graft, any vascular seal used, and the necessary electrocardiogram electrodes, along with the programming of sensing and therapeutic parameters.

1. Indications

The procedure described by CPT® Code 0451T is indicated for patients experiencing severe cardiac conditions that necessitate mechanical support. The specific indications include:

Acute Cardiogenic Shock - A critical condition where the heart suddenly cannot pump enough blood to meet the body's needs, often requiring immediate intervention.
End-Stage Chronic Heart Failure - A progressive condition where the heart's ability to pump blood is severely compromised, leading to significant symptoms and reduced quality of life.

2. Procedure

The procedure for the insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system involves several detailed steps:

Step 1: Surgical Incision - An incision is made in the right chest along the infraclavicular line to access the area where the pump will be placed. This incision allows the surgeon to create a subcutaneous pocket above the pectoralis muscle for the pump.
Step 2: Placement of the Pump - The pneumatic pump is inserted into the subcutaneous pocket. This pump is a critical component of the counterpulsation system, designed to assist the heart's function.
Step 3: Tunneling the Drive Line - A pneumatic drive line is tunneled through the skin to the right upper quadrant of the abdomen. This drive line connects the pump to the console, which controls the pump's operation.
Step 4: Anastomosis of the Vascular Graft - An interposition vascular graft is anastomosed to the subclavian artery. This connection is essential for the proper functioning of the pump and the overall system.
Step 5: Connection of the Main Graft - The main graft is then connected to the pump, ensuring that blood flow is properly directed through the system.
Step 6: System Activation - After confirming that air has been removed from the system, the device is cycled on to begin its operation.
Step 7: Placement of Electrodes - Subcutaneous electrocardiogram electrodes are positioned on the chest wall and connected to the console. Additionally, mechano-electrical skin interface electrodes are placed over the wrist, finger, or ankle to capture the heartbeat and synchronize the pump's function.
Step 8: Graft Site Inspection - The surgical team checks the graft site for any signs of bleeding. If necessary, implantable hemostatic sealing agents may be applied to control any bleeding.
Step 9: Closure of Incisions - Finally, the incisions made during the procedure are closed, completing the insertion or replacement of the device.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any complications related to the surgical site and the functioning of the aortic counterpulsation system. Patients may require close observation in a critical care setting to ensure that the device is operating correctly and that there are no signs of infection or bleeding at the incision sites. Follow-up appointments will be necessary to assess the device's performance and make any adjustments to the programming of sensing and therapeutic parameters as needed. Additionally, patients may need education on managing their condition and recognizing any potential complications that may arise from the device.

Short Descr	INSJ/RPLCMT AORTIC VENTR SYS
Medium Descr	INSJ/RPLCMT IMPLTBL AORTIC VENTR COMPLETE SYSTEM
Long Descr	Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes)
Status Code	Carriers Price the Code
Global Days	YYY - Carrier Determines Whether Global Concept Applies
PC/TC Indicator (26, TC)	9 - Not Applicable
Multiple Procedures (51)	9 - Concept does not apply.
Bilateral Surgery (50)	9 - Concept does not apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	9 - Concept does not apply.
Co-Surgeons (62)	9 - Concept does not apply.
Team Surgery (66)	9 - Concept does not apply.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Inpatient Procedures, not paid under OPPS
Berenson-Eggers TOS (BETOS)	P5E - Ambulatory procedures - other
MUE	Not applicable/unspecified.