Clinical Experience With Percutaneous Left Ventricular Transapical Access for Interventions in Structural Heart Defects (original) (raw)

Direct Percutaneous Left Ventricular Access and Port Closure: Pre-Clinical Feasibility

2011

Objectives-This study sought to evaluate feasibility of nonsurgical transthoracic catheter-based left ventricular (LV) access and closure. Background-Implanting large devices, such as mitral or aortic valve prostheses, into the heart requires surgical exposure and repair. Reliable percutaneous direct transthoracic LV access and closure would allow new nonsurgical therapeutic procedures. Methods-Percutaneous direct LV access was performed in 19 swine using real-time magnetic resonance imaging (MRI) and an "active" MRI needle antenna to deliver an 18-F introducer sheath. The LV access ports were closed percutaneously using a commercial ventricular septal defect occluder and an "active" MRI delivery cable for enhanced visibility. We used "permissive pericardial tamponade" (temporary fluid instillation to separate the 2 pericardial layers) to avoid pericardial entrapment by the epicardial disk. Techniques were developed in 8 animals, and 11 more were followed up to 3 months by MRI and histopathology. Results-Imaging guidance allowed 18-F sheath access and closure with appropriate positioning of the occluder inside the transmyocardial tunnel. Of the survival cohort, immediate hemostasis was achieved in 8 of 11 patients. Failure modes included pericardial entrapment by the epicardial occluder disk (n = 2) and a true-apex entry site that prevented hemostatic apposition of the endocardial disk (n = 1). Reactive pericardial effusion (192 ± 118 ml) accumulated 5 ± 1 days after the procedure, requiring 1-time drainage. At 3 months, LV function was preserved, and the device was endothelialized. Conclusions-Direct percutaneous LV access and closure is feasible using real-time MRI. A commercial occluder achieved hemostasis without evident deleterious effects on the LV. Having established the concept, further clinical development of this approach appears realistic.

Percutaneous transthoracic ventricular puncture for diagnostic and interventional catheterization

Catheterization and Cardiovascular Interventions, 2008

Objective: To describe our experience in a case series of patients requiring percutaneous direct ventricular puncture and sheath placement for diagnosis or intervention. Background: Access to the right or left ventricle for percutaneous interventions is limited in patients with mechanical prostheses in either the tricuspid, or mitral and aortic positions. Methods: After coronary angiography, direct ventricular puncture under ultrasound and fluoroscopic guidance was performed. At end of case, protamine was given to reverse the heparin, and sheaths were pulled with purse-string suture closure of the skin entrance. Results: For right ventricular access, 8-to 9-F sheaths were placed from subxiphoid approach in 2 patients to allow conduit and pulmonary artery interventions. For left ventricular access in patients with mitral and aortic prostheses, 4-to 8-F sheaths were placed from apical approach to allow diagnostic evaluation in 1 and interventions in 5 to occlude perivalvular mitral leaks and postoperative ventricular septal defect. Complication in one consisted of intercostal vein injury resulting in hemothorax requiring chest tube drainage. Conclusion: In this small cases series, direct ventricular puncture allowed the intervention to proceed with up to 9-F sheath size. Attention to puncture site relative to intercostal vascular anatomy is warranted.

Transcatheter closure of perimembranous ventricular septal defects using umbrella devices

Catheterization and Cardiovascular Interventions, 2006

To report the immediate and midterm results of transcatheter closure of perimembranous ventricular septal defect (PmVSD) using the Amplatzer membranous VSD occluder (AMVSD). Between April 2002 and August 2004, 100 patients underwent an attempt of percutaneous device closure of PmVSD using the AMVSD in 24 international centers. The median age was 9.0 years (0.7-58 years) and the median weight was 27.5 kg (7-121 kg). A device was successfully deployed in 93/100 (93%) patients. Reasons for procedural failure were an increased gradient across the left ventricle outflow tract in one patient, aortic regurgitation in 2 patients, and inability to securely position the device in 4 patients. The median VSD size by TEE was 7.0 mm (1.5-13 mm), median device size 10 mm (4-16 mm) and median fluoroscopy time 22.1 min (8.9-96.0 min). Weight below 10 kg (P = 0.0392), inlet extension of the VSD (P = 0.0139) and aortic cusp prolapse into the VSD (P = 0.0084) were significantly associated with a lower procedural success. Patients have been followed up for a median of 182 days (1-763 days). There were no procedure-related deaths. Complications were encountered in 29/100 (29%) patients, including rhythm or conduction anomalies in 13 patients (two with complete heart block requiring permanent pacemaker implantation), new or increased aortic (9 patients) or tricuspid (9 patients) regurgitation, most of which were classified as trivial or mild. Patients with a weight below 10 kg had a significantly higher incidence of adverse events than patients with a weight above 10 kg (58.3% versus 25.0%, P = 0.0285). Immediately after device release complete closure of the defect was present in 54/93 (58.1%) patients, increasing to 46/55 (83.6%) patients at 6-months follow-up (P = 0.0012). Left ventricle end-diastolic diameter decreased from a median of 44 mm prior to device closure to a median of 39 mm at 6-months postprocedure (P = 0.0015). Closure of PmVSDs using the AMVSD occluder is safe and effective. However, longer follow-up period is warranted prior to the wide spread use of this device.

Transcatheter approaches to non-valvar structural heart disease

The International Journal of Cardiovascular Imaging, 2011

With advancement in transcatheter technology, numerous non-congenital structural heart lesions previously untreated, or treated with surgery are now amenable to transcatheter therapy. These therapies have centered on transcatheter valve replacement, however, other lesions are increasingly treated via the percutaneous approach. These procedures include patent foramen ovale closure, left atrial appendage occlusion, closure of post-infarct ventricular septal defects, occlusion of ruptured sinus of Valsalva aneurysm and treatment of paravalvar leaks. This review will outline indications for and approach to each of these procedures in the context of the current literature base with emphasis on pre-and intra-procedural imaging modalities.

Percutaneous transcatheter obliteration of mitral prosthetic paravalvular leaks

International Journal of Cardiology, 2016

Paravalvular leak (PVL) is a common complication after surgical valve replacement. Several studies have shown that the long-term incidence of this complication is about 10% [1]. Although most of these PVL are asymptomatic, about 2-3% can cause serious complications: congestive heart failure (CHF), hemolysis, or both. When these symptoms are severe, surgical remains the gold standard [2]. However, there is a very high surgical risk in this population. Since the first procedure [3], percutaneous closure (PC) of PVL appears to be an alternative therapy. The aim of this study was to assess the feasibility and efficacy of PC of PVL. Between September 2009 and December 2013, 14 patients were referred to our center for PC procedure of symptomatic PVL. Patients were considered for percutaneous repair if all the following criteria were present: CHF or hemolytic anemia, symptoms related to PVL, high surgical risk, absence of active endocarditis, and informed consent. CHF was defined as symptoms consistent with a New York Heart Association (NYHA) functional class III or IV. Symptomatic hemolysis was defined as hemolytic anemia (hemoglobin b9 g/dl, lactate dehydrogenase N500 IU/l, haptoglobin b 5 mg/dl) requiring more than 2 red blood cell (RBC) transfusions, without any other origin of anemia. Surgical risk was evaluated by the logistic Euroscore, the number of previous cardiac surgery interventions, and a careful check of other comorbidities. Heart team validated the risk, feasibility, and indication of this procedure. Patients were informed of the risk of the procedure and the possibility of surgical conversion. The study was approved by

The transradial approach during transcatheter structural heart disease interventions: a review

European Journal of Clinical Investigation, 2015

Aims To review the safety and feasibility of a transradial (TR) approach during transcatheter structural or congenital heart disease interventions when utilized as either as a primary or secondary arterial access site. Methods and Results Studies and case reports published between 2002 and 2014 utilizing the TR access during transcatheter structural and congenital heart disease interventions during alcohol septal ablation (ASA), ventricular septal defect (VSD), renal denervation (RD), paravalvular leak (PVL) closure, transcatheter aortic valve implantation (TAVI, secondary access) and endovascular repair of aortic coarctation (ERAC, secondary access) were evaluated. Access-site (femoral vs. TR) vascular and bleeding complications were assessed. Femoral access complications ranged from 0Á16% to 40%, with an overall incidence of 2Á2% (56/2521). There were 18 reports or studies specifically evaluating the utility of TR access in the context of transcatheter structural heart disease interventions (ASA: 3; VSD: 1; RD: 3; PVL closure: 1; TAVI: 7, ERAC: 3). The use of TR access either as primary or secondary access site was feasible and allowed the completion of the procedure in all cases. The overall incidence of access-site complications following a TR approach was 0Á5% (2/406 patients), with no major vascular or bleeding complications. Conclusions A TR approach during transcatheter structural heart disease interventions appears to be a safe, effective means of delivering high procedural success accompanied by lower bleeding complications compared with the transfemoral approach.