Aortic Valve Replacement (AVR)

CPT 33405
Approach Open
Add-on / Variant CPTs
  • 33410 — Replacement of aortic valve with prosthesis
  • 33406 — Replacement of aortic valve, with cardiopulmonary bypass; with aortic annulus enlargement
Preoperative Diagnosis:

[Severe aortic stenosis / severe aortic regurgitation / combined aortic valve disease], symptomatic [/ meeting guideline criteria for intervention]

Postoperative Diagnosis:

Same

Procedure Performed:

Aortic valve replacement with [21-mm / 23-mm / 25-mm] [bioprosthetic (Carpentier-Edwards Perimount / INSPIRIS) / mechanical (St. Jude Medical / On-X)] valve

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal with TEE and arterial line

Indications:

The patient is a [age]-year-old [male/female] with severe [aortic stenosis (AVA [X] cm², mean gradient [X] mmHg, peak gradient [X] mmHg) / aortic regurgitation (LVEDD [X] mm, LVEF [X]%)], presenting with [exertional dyspnea / syncope / angina / asymptomatic, meeting guideline criteria]. Surgical AVR was recommended by Heart Team. The risks, benefits, and alternatives including TAVR were discussed and informed consent was obtained.

Findings:

The aortic valve was [tricuspid / bicuspid / rheumatic] with [heavily calcified / fused] leaflets. The aortic annulus measured [X] mm on TEE. The leaflets were [excised and the annulus debrided of calcium]. The native valve measured [X] mm. The prosthetic valve was seated without obstruction. TEE post-bypass confirmed [no paravalvular leak / trace paravalvular leak (hemodynamically insignificant)], EF [X]%, and mean gradient [X] mmHg.

Description of Procedure:

The patient was positioned supine. A median sternotomy was performed. The pericardium was opened and the ascending aorta, right atrium, and aortic root were exposed. Cardiopulmonary bypass was instituted via aortic and venous cannulation. [Cold blood / del Nido] cardioplegia was given antegrade.

A transverse aortotomy was made [2 cm above the right coronary ostium]. The aortic valve was inspected. It was [tricuspid / bicuspid, with heavy calcification]. The valve leaflets were excised and the annulus was debrided of calcium to a smooth, non-obstructing rim. [Care was taken to avoid injury to the anterior leaflet of the mitral valve and the membranous septum.]

The annulus measured [X mm]. A [21 / 23 / 25]-mm [bioprosthetic (Carpentier-Edwards Perimount / INSPIRIS) / mechanical (On-X)] valve was selected. The valve was seated with [X] interrupted [2-0 Ethibond] sutures in [everting mattress / non-everting] configuration. The valve was lowered into position and the sutures were tied. The valve moved [freely] with no obstruction.

The aortotomy was closed with [3-0 Prolene] running suture in two layers. Air was de-aired from the aortic root. Clamps were released. The heart [resumed sinus rhythm spontaneously / was defibrillated]. The patient was weaned from CPB. Post-bypass TEE confirmed [no paravalvular leak, EF X%, mean gradient X mmHg].

Protamine was administered. Hemostasis was achieved. Mediastinal chest tubes were placed. The sternum was closed with sternal wires. The wound was closed in layers.

Complications:

None

Specimens:

Aortic valve leaflets to pathology

Estimated Blood Loss:

[X] mL

Drains:

[2] mediastinal chest tubes; [pericardial drain]

Disposition:

The patient was transferred to the cardiac ICU intubated. [Anticoagulation with heparin was initiated and transitioned to warfarin (target INR [2.0–2.5 / 2.5–3.5]) for mechanical valve.] [Aspirin only for bioprosthetic valve.]

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Severe aortic stenosis/regurgitation, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: AVR, *** mm *** (bio/mechanical)
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, ETT, TEE, art line

INDICATIONS: .PTAGE-year-old .PTSEX with severe AS/AR: AVA *** cm², gradient ***, LVEF ***%. Symptoms: ***. Heart Team: AVR. Consent obtained.

FINDINGS: Aortic valve *** (tricuspid/bicuspid), heavily calcified. Annulus *** mm. Valve excised, calcium debrided. Post-bypass TEE: no PVL, EF ***%, gradient *** mmHg.

PROCEDURE:
Supine. Sternotomy. Pericardium opened. CPB: aortic + venous. Cold blood/del Nido cardioplegia antegrade. Transverse aortotomy *** cm above RCA ostium. Valve *** with heavy calcium. Leaflets excised, annulus debrided. Sized *** mm. *** mm *** valve seated with *** interrupted 2-0 Ethibond, everting/non-everting. Valve moves freely. Aortotomy closed 3-0 Prolene × 2 layers. De-aired. Clamps released. Sinus rhythm / defibrillated. Weaned CPB. Post-CPB TEE: no PVL, EF ***%. Protamine. Chest tubes. Sternum wires. Closed.

EBL: *** mL
SPECIMENS: Aortic valve to pathology
COMPLICATIONS: None
DISPOSITION: Cardiac ICU. Anticoagulation: *** (warfarin INR ***–*** / aspirin).

Signed: .ME, .MYDEGREE
.TODAY
Variants

Minimally Invasive AVR (Mini-Sternotomy / Right Anterior Thoracotomy)

AVR was performed via [upper hemisternotomy (J-incision) / right anterior minithoracotomy] for minimally invasive access. The sternum was divided to the [3rd / 4th] intercostal space. A [modified] cannulation strategy was used: [standard aortic / femoral artery + femoral vein]. The aortotomy and valve replacement proceeded as described. Advantages include reduced blood loss, shorter length of stay, and superior cosmesis; disadvantages include limited surgical access and longer CPB time for complex anatomy.

Charting Tips
  • Document paravalvular leak assessment by post-bypass TEE. Mild paravalvular leak is acceptable for bioprosthetic valves, but any paravalvular leak with a mechanical valve requires return to bypass for repair. Document 'TEE showed no paravalvular regurgitation' or characterize the leak (trace/mild/moderate) and the management decision.
  • Document final valve position and gradient on post-bypass TEE. A mean gradient >20 mmHg for a bioprosthetic valve or patient-prosthesis mismatch (EOA <0.85 cm²/m²) should be documented and may require annular enlargement or upsizing. Document the final gradient and indexed EOA.
  • Document anticoagulation plan for mechanical valve. Mechanical valves require lifelong warfarin. Document the target INR range (2.0–3.0 for AVR, 2.5–3.5 for higher-risk patients), when heparin bridging was started, and when warfarin was initiated. This prevents anticoagulation gaps in the post-operative transition.
Billing Tips
  • Bill 33405 for open surgical aortic valve replacement (SAVR, 40.29 wRVU, 90-day global). Use for traditional sternotomy AVR with cardiopulmonary bypass.
  • TAVR uses entirely separate codes: 33361 for percutaneous/transfemoral (21.91 wRVU, 0-day global) or 33362 for open transcatheter approach (23.93 wRVU). Note TAVR codes have a 0-day global period vs. 90-day for SAVR.
  • Concomitant procedures at the time of SAVR (CABG, mitral repair, atrial maze) are separately billable with modifier -51. Document each component of a combined cardiac procedure in its own operative section.
  • Cardiopulmonary bypass (33508) is an add-on code separately billable by the perfusionist, not the surgeon. The surgeon bills the valve replacement code only.
  • 90-day global period for SAVR: anticoagulation management, valve clinic follow-up, and routine echo surveillance are bundled for the surgical fee. Cardiology follows independently and bills their own E/Ms.