procedure. It’s a rare birth defect, so the procedure isn’t one that performed frequently.
From the op report:
PROCEDURE:
1. Left superior vena cava baffling towards the right atrium.
2. ASD closure with a fresh pericardial patch.
Description of Procedure:
… the TEE was done that confirmed the diagnosis of a very large ASD with absent
of the IVC drain and also confirmed the diagnosis of left superior vena cava arising
to the dome of the left atrium without bridging innominate vein. After opening
the chest, the thymus was fully dissected. Then a large piece of pericardium was
harvested and the rest of the pericardium was marsupialized. The pursestring was
done in the ascending aorta and right superior vena cava, left superior vena cava
and inferior vena cava. A pursestring was done in the right upper pulmonary veins.
Then the patient was heparinized and was cannulated in the usual fashion and
cardiopulmonary bypass was initiated at 32 degrees Celsius. A plegia needle was
placed in the ascending aorta and LA vent was placed in the right superior pulmonary vein.
Right and left SVC snuggers were placed and tied down. Next, the aorta was
crossclamped and needle cardioplegia was antegrade infused and the patient had
good cardiac arrest. The IVC snuggers was tied down and the right atrium was
opened and stay sutures were placed on the edges of the atrium for better
visualization. Inside the heart, a large ostium secundum ASD was visualized
with a complete absence of the IVC rim Then the left superior vena cava was
visualized that was arising to the dome of the left atrium. In order to repair
this kind of congenital malformation, a large piece of autologous pericardium
was harvested and it was used to baffle the left superior vena cava with a 5-0
C1 Prolene running suture line. The first stitch was placed in the tissue
between the left superior vena cava and the left atrial appendage and that
suture line was carried out toward the anterior close to the mitral annulus on
the left side and then anterior, close to the right superior vena cava on the
right side. Then this pericardial patch was turned and baffled inferior,
posterior toward the direction of the IVC. In that way, both arterial rims
were taken with this pericardial patch. Once finalized, the LSVC was baffling
with a single pericardial patch toward the right atrium and with the same
single pericardial patch the ASD was closed. After closing the ASD and
baffling the LSVC. The LA vent was stopped and the heart was de-aired and the
aortic crossclamp was removed, recovering the patient with normal sinus rhythm.
I was able to find a more straight-forward description of this procedure in an old
issue of The Annals of Thoracic Surgery (circa 1986!!):
Repair of Left Superior Vena Cava Entering the Left Atrium
ABSTRACT Connection of an anomalous left superior
vena cava to the left atrium is an uncommon lesion that is
usually associated with other complex intracardiac malformations.
A technique for diverting the anomalous caval
return along the left atrial roof and into the right atrium is
presented. This simple tunnel method avoids potential obstruction
to systemic and pulmonary venous return and
leaves viable atrial tissue comprising the majority of the
new pathway… We present an alternative method of
repair that consists of constructing a tunnel along the roof
of the left atrium, thereby diverting the anomalous caval
return into the right atrium. This simple method leaves
viable atrial wall comprising the majority of the new
pathway.
SO… my provider is suggesting we use 33774 (Repair of transposition of the great arteries,
atrial baffle procedure (eg, Mustard or Senning type) stating that it was a modified
Mustard procedure. I want to agree, but the only similarities between the CPT code and his op rpt
is the baffle/tunnel that was created. Other options I have suggested include 33999 (unlisted cardiac)
or 34502 (repair of vena cava, any method). The ASD repair will be billed in addition to this code.
Am I missing a more obvious choice for this procedure? (it feels like I am…)
If you’ve made it to this point, bless you… 
Andrea T Williams, CPC