Hi,

Require CPT codes and Clinical Trail for mentioned below procedure.

I thought the appropriate CPT code 0484T

PROCEDURE PERFORMED:
1. Transapical transcatheter valve in mitral ring via left thoracotomy.
2. Temporary transvenous pacemaker insertion.
3. Transesophageal echocardiography.

OPERATIVE REASON FOR PROCEDURE: Intermediate risk for surgical mitral valve replacement,
4% to 8% risk of 30-day mortality.

IMPLANTATION: 29 mm Edwards Sapien 3 transcatheter valve in mitral ring via left
thoracotomy transapical approach.

CLINICAL INDICATIONS:

The patient is an 85-year-old male, who recently presented with
progressive symptoms of shortness of breath and fatigue, and was found to have severe
mitral stenosis. He does have a prior history of mitral valve repair with placement of a
mitral annuloplasty ring in 1998. He also has multiple other comorbidities including
nonischemic cardiomyopathy, ejection fraction of 30% to 40%, status post prior AICD
implantation, chronic atrial fibrillation, on long-term oral anticoagulation with
Coumadin, history of atrial fibrillation ablation twice. Due to his severe symptoms of
shortness of breath and fatigue, and underlying mitral valve stenosis, he was evaluated
initially by Cardiovascular Surgery, Dr. Accola, for an open heart surgery. However,
considering his advanced age, multiple comorbidities, diminished left ventricular ejection
fraction, he was felt to be at high risk for postoperative complications. Thus, the
decision was made to proceed with placement of a transcatheter mitral valve in his mitral
ring through a transapical approach. The rationale of the procedure, other options, all
the risks and benefits were extensively discussed with the patient and his family, and
consent was signed to proceed as planned. His case was also discussed extensively in our
structural heart meeting

DETAILS OF PROCEDURE:

Intraoperative transesophageal echocardiography was performed and
showed significant pannus within the prior mitral ring with presence of severe mitral
valve stenosis. There was no significant mitral regurgitation present. The patient was
brought to the hybrid operating room and placed in the supine position. He was prepped
and draped in the usual fashion. The patient was placed under general anesthesia.
Transesophageal echocardiography probe was placed and used throughout the procedure to
evaluate the mitral valve and position of our catheters. A 5-French bipolar pacing
catheter was placed in the apex of the right ventricle through right femoral venous
access. We also obtained access in the right femoral artery and placed a 5-French sheath,
just in case we needed to place an intra-aortic balloon pump for hemodynamic support
during the case. Subsequently, the left chest was opened via anterior thoracotomy, and we
found the anterior apical portion which would be appropriate for placement of the valve.
Two pledgetted sutures were placed around the LV apex. The left apex was cannulated with
a needle, and a soft wire was placed into the left atrium. Using a JR4 catheter, we
placed the wire into the right superior pulmonary vein. Then, we exchanged out the wire
for a stiff Amplatz wire. At that point, the patient had already been anticoagulated with
heparin to keep an ACT greater than 250 seconds. At that point, we placed an Ascendra
transcatheter valve introducer into the left ventricular apex, and subsequently we
prepared a 29 mm Edwards Sapien 3 transcatheter valve. Since this was a 31 mm ring, we
decided to go with a 29 mm regular prep of Sapien valve. We also had measured the ring
area on echocardiography. The transcatheter valve was deployed with rapid ventricular
pacing, and the valve was very carefully deployed under fluoroscopy guidance. The valve
deployed in excellent position. The delivery device was subsequently removed. We did
postdilate the valve by adding 1 mL of contrast due to presence of mild paravalvular leak.
After the postdilatation, there was only trivial paravalvular leak noted. There was no
central mitral regurgitation. The mitral valve seemed to be well seated inside the prior
mitral ring. This concluded the operation. The patient tolerated the surgery well, and
there were no complications. The postprocedure mitral valve area was 2.66 sq cm, the mean
gradient across the valve was 3 mmHg. There was presence of trivial paravalvular mitral
insufficiency after valve deployment. The patient was transferred to the cardiovascular
recovery area in a stable condition.