CPT® Code 33963

1. Indications

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) are indicated for patients experiencing severe cardiac and respiratory failure. The specific indications for the repositioning of central cannula(e) include:

• Severe Heart Failure: Patients with significant left heart failure may require repositioning to ensure adequate decompression of the left atrium.
• Right Atrial Appendage Cannulation: When the right atrial appendage has been cannulated, repositioning may be necessary to optimize blood flow and support.
• Aortic Arch/Ascending Aorta Cannulation: In cases where cannulation of the aortic arch or ascending aorta has occurred, repositioning is performed to maintain effective circulation.

2. Procedure

The procedure for repositioning central cannula(e) involves several critical steps, which are detailed as follows:

• Step 1: Preparation and Anesthesia The patient is prepared for the procedure, which includes administering appropriate anesthesia to ensure comfort and safety during the intervention.
• Step 2: Incision A standard vertical sternotomy incision is made through the sternum or a thoracotomy incision is performed through the ribs, allowing access to the thoracic cavity. This step is crucial for visualizing the heart and major blood vessels.
• Step 3: Identification of Cannula(e) Once the chest is opened, the physician identifies the existing central cannula(e) and the associated blood vessels. This identification is essential for the subsequent repositioning process.
• Step 4: Fluoroscopic Guidance Fluoroscopic imaging may be utilized to guide the repositioning of the cannula(e). This imaging technique provides real-time visualization, ensuring accurate placement within the vessel(s).
• Step 5: Repositioning of Cannula(e) The cannula(e) are repositioned using gentle manual pressure or a snare technique until optimal placement is confirmed. This step is critical to ensure that the cannula(e) are correctly positioned for effective blood flow.
• Step 6: Securing the Cannula(e) Once the cannula(e) are in the desired position, they are secured in place using sutures to prevent any movement that could compromise the procedure's effectiveness.
• Step 7: Closure of Incision After securing the cannula(e), the incision is closed carefully, ensuring that the chest is properly sealed to promote healing.
• Step 8: Reconnection of ECMO/ECLS Circuit The ECMO/ECLS circuit is reconnected, and the tubing is secured to the skin using sutures and/or dressings to maintain stability and prevent dislodgment.

3. Post-Procedure

Post-procedure care involves monitoring the patient closely for any complications related to the repositioning of the cannula(e). This includes assessing the function of the ECMO/ECLS system, ensuring that blood flow is adequate, and observing for any signs of infection or bleeding at the incision site. The patient will typically remain in a critical care setting for ongoing evaluation and support as they recover from the procedure. Additionally, healthcare providers will continue to monitor the patient's hemodynamic status and respiratory function to ensure optimal outcomes.