Mitral Valve Repair / Replacement

CPT 33430
Approach Open
Add-on / Variant CPTs
  • 33425 — Valvuloplasty, mitral valve, with cardiopulmonary bypass
  • 33426 — Valvuloplasty, mitral valve, with cardiopulmonary bypass, with prosthetic ring
Preoperative Diagnosis:

Severe [primary / secondary] mitral regurgitation [/ mitral stenosis] secondary to [posterior leaflet prolapse / chordal rupture / rheumatic disease / ischemic MR / Barlow's disease]

Postoperative Diagnosis:

Same

Procedure Performed:

[Mitral valve repair (posterior leaflet resection + annuloplasty ring) / mitral valve replacement with [31-mm] bioprosthesis]

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 primary mitral regurgitation secondary to [posterior leaflet prolapse (P2 segment) / chordal rupture] with [LVEF X%, LVESD X mm, pulmonary hypertension X mmHg]. Surgical intervention was indicated per [guideline criteria / symptoms of dyspnea NYHA class III / LV dilation]. Valve repair was planned; replacement as contingency. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The mitral valve was exposed via [left atrial / right atrial transseptal] approach. The leaflets were [thin and pliable / myxomatous / rheumatic, with fusion]. The [P2 / posterior] leaflet had a [flail segment / chordal rupture / prolapse]. The anterior leaflet was [normal]. The annulus was [dilated (X mm) / calcified]. Repair was feasible.

Description of Procedure:

The patient was positioned supine. Median sternotomy was performed. Cardiopulmonary bypass was established. [Cold blood] cardioplegia was delivered antegrade. The left atrium was entered through the [intra-atrial groove (Waterston) / right atrial transseptal] approach with a left atrial retractor.

The mitral valve was inspected. The pathology was confirmed: [P2 flail segment with ruptured chordae]. The repair was performed as follows:

[REPAIR:]
The P2 segment was resected as a [triangular / quadrangular] resection. The posterior annulus was [plicated with [2-0 Ethibond] sutures]. A [30-mm / 32-mm] [complete / partial] [rigid / semirigid] annuloplasty ring was implanted with [interrupted pledgeted] sutures and tied. The repair was tested with [cold saline injection / valve tester]. [No regurgitation / trace regurgitation.] The left atrium was closed.

[REPLACEMENT:]
[When repair was not feasible:] The mitral valve was excised, preserving the [subvalvular apparatus]. The annulus was sized at [X mm]. A [27-mm / 29-mm / 31-mm] [bioprosthetic / mechanical] valve was seated with [interrupted pledgeted 2-0 Ethibond] sutures [mattress / non-everting configuration].

The heart was de-aired. Clamps were released. Post-bypass TEE confirmed [no / trace] MR, [competent valve, gradient X mmHg, EF X%]. Weaned from CPB. Protamine administered. Hemostasis. Chest tubes. Sternum closed.

Complications:

None

Specimens:

[Resected P2 segment / mitral valve leaflets] to pathology

Estimated Blood Loss:

[X] mL

Drains:

[2] mediastinal chest tubes

Disposition:

The patient was transferred to the cardiac ICU intubated. [Anticoagulation: warfarin for mechanical MVR (target INR 2.5–3.5). Aspirin for bioprosthetic MVR × 3–6 months.]

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Severe MR, *** (P2 prolapse/chordal rupture/rheumatic)
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Mitral valve repair/replacement, ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, ETT, TEE, art line

INDICATIONS: .PTAGE-year-old .PTSEX with severe MR, *** pathology. LVEF ***%, LVESD *** mm, PASP *** mmHg. Symptoms: ***. Consent obtained.

FINDINGS: Valve *** (myxomatous/rheumatic). P2/*** flail/prolapse. Annulus dilated *** mm. Repair feasible.

PROCEDURE:
Supine. Sternotomy. CPB. Cardioplegia antegrade. LA entered ***. Valve inspected: P2 flail, ruptured chordae. [Repair: P2 resection ***, annular plication, *** mm ring with interrupted sutures. Saline test: no/trace MR.] [Replacement: leaflets excised, subvalvular preserved. *** mm *** valve, interrupted pledgeted sutures.] LA closed. De-aired. Clamps released. Post-CPB TEE: no/trace MR, EF ***%, gradient *** mmHg. Protamine. Closed.

EBL: *** mL
SPECIMENS: Resected P2/valve to pathology
COMPLICATIONS: None
DISPOSITION: Cardiac ICU. Anticoagulation: ***.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Chordal Transfer / Neo-Chordae (GORE-TEX)

For an anterior leaflet prolapse not amenable to direct resection, [chordal transfer from the posterior to the anterior leaflet / neo-chordoplasty with expanded PTFE (CV-5 GORE-TEX)] was performed. [Neo-chordae: the appropriate length was determined by measuring the height of a normal P2 segment as reference. GORE-TEX sutures were passed through the papillary muscle tip and through the free edge of the anterior leaflet and tied to set the correct length.] Annuloplasty ring was implanted as described. Saline testing confirmed competent repair.

Charting Tips
  • Document post-bypass TEE findings explicitly. Post-repair MR grade determines whether the patient returns to bypass for re-repair. Document 'post-bypass TEE: no residual MR / trace MR hemodynamically insignificant / [1+] MR accepted given repair complexity.' Any ≥2+ MR should prompt return to bypass.
  • Document annuloplasty ring type and size. Rigid vs. semirigid rings have different durability and remodeling profiles. The ring size must be documented as it affects durability assessment and future re-operative planning. Incomplete annuloplasty (partial ring without full posterior annular support) has higher recurrence.
  • Document the saline test result before closing the left atrium. The intraoperative saline test (injecting cold saline under pressure through the valve to assess leaflet coaptation) is the first quality check. Document 'saline injection revealed competent mitral valve without regurgitation.' This precedes post-bypass TEE assessment.
Billing Tips
  • Bill 33425 for mitral valve repair (48.71 wRVU, 90-day global). This is the highest-wRVU non-transplant cardiac procedure in the CMS fee schedule. Use for any open surgical mitral repair technique.
  • Bill 33430 for mitral valve replacement (49.66 wRVU, 90-day global) when repair is not feasible. Document the reason repair was not attempted or was abandoned, as surgeons are expected to attempt repair before replacement for degenerative disease.
  • Concomitant tricuspid repair (33463-33465) is separately billable with modifier -51 when performed at the same setting. Document each valve procedure as a distinct component.
  • Ring annuloplasty, chordal reconstruction, and leaflet resection are not separately billed. They are all captured within 33425. Document the specific technique used (Carpentier-Edwards ring size, chordal transfer technique) for operative completeness.
  • 90-day global period: echo surveillance, anticoagulation management, and routine cardiac follow-up are bundled for the surgical fee. Cardiology follows independently and bills their own E/Ms.