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Catheterization and Cardiovascular Interventions 74:137–142 (2009)
Case Reports
Transapical Left Ventricular Access for Difficult
to Reach Interventional Targets in the Left Heart
S.C. Brown,1,2 MD, D.E. Boshoff,2 MD, F. Rega,3 MD, B. Eyskens,2 MD, W. Budts,2
H. Heidbüchel,2 MD, B. Meyns,3 MD, and M. Gewillig,2* MD
MD,
Objective: Interventional targets may be virtually ‘‘excluded’’ due to vascular access
problems or complex previous surgical procedures. This study reviews our experience
using transapical ventricular puncture to gain direct access to the systemic ventricle.
Patients: Patient 1 (74 years, 2 previous sternotomies), patient 2 (66 years, 5 previous
sternotomies), and patient 5 (69 years, 3 previous sternotomies) with prosthetic valves
had paravalvular mitral valve leaks. Patient 3 (6.3 years, 2 previous sternotomies) with an
extracardiac Fontan conduit, had a significant residual leak after two previous surgical
attempts of patch closure of a severely regurgitant right atrioventricular valve. Patient 4
(10 months) had failure of standard ablation of the posteroseptal region of the mitral
valve with persistent life-threatening episodes of ventricular tachycardia. Methods: Procedures were performed under general anesthesia. Entry site was percutaneous in three
patients and in two (and one conversion) a mini-thoracotomy was used. Sheaths were
placed (6 F) using standard Seldinger technique, followed by the procedure as required.
Direct surgical closure of the puncture site was done in 4 patients and in patient 3, a percutaneous vascular occlusion device was used. Results: Easy and immediate access
was obtained in all patients. The paravalvular leaks were crossed within seconds and
completely closed with Amplatzer occluders. In patient 3 the valve was crossed using a
Brokenbrough needle and a 12-mm Amplatzer device was placed in the patch leak.
Patient 4 was successfully ablated using a 7-F irrigated catheter endo- and epicardially.
Complications were in the percutaneous puncture group: in one patient a coronary artery
was punctured and in one a hemothorax developed. Conclusion: Direct left ventricular
puncture offers a very useful alternative access site in selected patients to reach ‘ inaccessible’’ targets for certain percutaneous interventions in patients where standard
approaches may be impossible or difficult. ' 2009 Wiley-Liss, Inc.
Key words: percutaneous intervention; paravalvular leak; excluded target; heart
access; direct puncture; vascular occlusion device
INTRODUCTION
Percutaneous interventions are becoming increasingly complex, but in some instances the target lesion
may be difficult to reach using conventional transvenous or transarterial access and in some, interventional
targets may be virtually ‘‘excluded’’ due to vascular
access problems or surgical procedures such as prosthetic valves or Fontan circuits. Some procedures also
require large diameter or multiple sheaths as well as
stable guidewire positions, which may be difficult to
secure where sharp or many angles are involved.
Transapical left ventricular puncture gives direct
access to the systemic ventricle and although frequently used in the past for diagnostic reasons [1], has
largely been abandoned in favor of transvenous-transatrial or retrograde access due to lower morbidity and
' 2009 Wiley-Liss, Inc.
1
Department of Paediatric Cardiology, University of the Free
State, South Africa
2
Department of Pediatric and Congenital Cardiology, University
Hospital Gasthuisberg, Leuven, Belgium
3
Department of Cardiac Surgery, University Hospital Gasthuisberg, Leuven, Belgium
Grant sponsor: Rotary Tienen, Belgium.
Conflict of interest: Nothing to report.
*Correspondence to: Marc Gewillig, MD, PhD, University Hospital
Gasthuisberg, Herestraat 49, B 3000 Leuven, Belgium.
E-mail: [email protected]
Received 15 October 2008; Revision accepted 17 November 2008
DOI 10.1002/ccd.21939
Published online 29 April 2009 in Wiley InterScience (www.
interscience.wiley.com).
138
Brown et al.
TABLE I. General Patient Characteristics
Age
No. (years) Sex
1
2
3
4
5
74
66
6.3
0.10
69
f
m
f
m
f
Lesion
Motivation
Previous
sternotomies (n)
Initial
puncture
Maximal sheath
size (F)
Closure
method
Mitral and aortic valve prosthesis
Mitral valve prosthesis
DILV, Fontan
Cardiomyopathy, tachycardia induced
Mitral valve prosthesis
Paravalvular leak
Paravalvular leak
Valve-patch leak
Ventricular tachycardia
Paravalvular leak hemolysis
2
5
2
0
3
Percutaneous
Percutaneous
Percutaneous
Thoracotomy
Thoracotomy
6
9
8
7
336
Surgical
Surgical
Device
Surgical
Surgical
F, French; m, male; f, female; DILV, double inlet left ventricle.
mortality. Experience with hybrid procedures [2] and
percutaneous aortic valve implantation [3] has refocused attention on the benefits of direct ventricular
access. In addition, direct transthoracic ventricular
access is also being used in fetal dilation of critical
aortic or pulmonary valve stenosis [4].
The objective of this study is to review our experience using direct left ventricular puncture to perform
percutaneous interventions in patients with complex
congenital cardiac lesions and paravalvular leaks.
METHODS
This is a retrospective analysis of all patients in
whom direct left ventricular puncture was performed at
our institution from 2004 to 2008. Details of the
patients are summarized in Table I.
Patients
Three patients (no. 1, 2, 5) who had mechanical
valve prostheses presented with significant paravalvular
mitral valve leaks (for details see Table I). All three
patients had multiple previous sternotomies (Table I).
The leak in patient 1 was considered difficult to access
using traditional transvenous or transarterial routes;
patient 2 was referred after a failed attempt to close
the paravalvular leak transatrially; patient 5 had a long
and angulated crescent-shaped leak and the need for
multiple devices was anticipated. Patient 3 was a child
with a failing Fontan circuit (extracardiac conduit)
who was referred because of a significant residual leak
after two previous surgical attempts of patch closure of
a right-sided atrioventricular valve. A previous attempt
to cross the defect via anterograde and retrograde techniques failed. Patient 4 was a 10-month old who had a
tachycardia-induced cardiomyopathy and presented
several times with life-threatening episodes of ventricular tachycardia (VT) due to an ectopic focus/microreentrant circuit in a left posteroseptal location. The
infant did not respond to medical therapy despite using
a combination of three antiarrythmic drugs. Initially,
transseptal and retrograde ablation was performed,
ablating the VT in the posteroseptal region of the mi-
tral valve annulus. Eight days later the child presented
with recurrence leading to shock. As this area of the
left ventricle proved difficult to reach using conventional approaches, and because larger diameter and/or
cooled ablation catheters would be required to deliver
adequate energy for a clinical result, transapical access
was attempted.
All patients were intubated and procedures performed under general anesthesia. In general, we followed the previously described technique [5–8]. In
patients 1, 2, and 3, direct percutaneous left ventricular
apical puncture was performed after delineation of the
cardiac apex using echocardiography. In patients 2
(second puncture), 4, and 5, the cardiac apex was
exposed using a mini thoracotomy, allowing direct visualization for puncture and placement of a purse string
suture with pledgets. The left ventricle was then punctured during induced expiratory apnea to avoid accidental puncturing of the lung. Using a 19-Gauge needle, a guidewire was placed in the left ventricular cavity. Once in the left ventricular cavity, a 6 F sheath
was inserted using standard Seldinger technique.
Depending on the device required, these were then
exchanged for appropriately sized sheaths (6–9
French). Patient 5 had 3 sheaths inserted to allow
delivery and release of 3 devices at the same time. We
only used conventional (15–20 cm) femoral introducer
sheaths for the procedures and avoided cut-off or long
sheaths. Heparin (100 U/kg) was administered intravenously immediately following ventricular puncture and
ACT monitored throughout the procedure. Angiographies during the procedure were done by direct hand
injection through the apical sheath.
Transesophageal echocardiography was used to assist
crossing defects. Direct closure of the puncture site
was done in four patients, except for patient 3, where
a percutaneous vascular device (Prostar XLTM, Perclose Europe, Berkshire, UK) [9] was used. Umbillication of the skin was noticed immediately after placement of the device; after 10 days the sutures were
removed. Following all procedures, chest radiography
and repeated echocardiography were performed on all
patients to screen for the presence of any complica-
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Transapical Access For Difficult Targets
139
Fig. 1. A–C: A: Fluoroscopic frame in RAO of patient 1 with
aortic and mitral valve prosthesis, and an endocavitary right
ventricular pacing lead. A 0.03500 wire has been placed through
a 6 F apical sheath, through the paravalvular leak into the left
pulmonary vein. A 12 mm balloon is used to size the leak; the
leak was subsequently closed with a 4-mm muscular Amplatzer VSD device. B: Patient 5, where 3 muscular Amplatzer
devices have been deployed (and still attached) through three
different apical sheats; (C) same patient after release of the
three devices (6 - 8 - 6 mm).
tions, especially the presence of pericardial or pleural
effusions.
All procedures were successful. Fluoroscopy times
ranged from 23 to 60 min. In the patients with valve
prostheses (no. 1, 2, and 5), paravalvular leaks were
completely closed using respectively a 4 mm, 8 mm,
and three (6, 8, and 6 mm) muscular VSD Amplatzer
devices (AGA Medical Corporation, Plymouth, MN)
(Fig. 1A–C). The valve-patch leak was completely
closed using a 12-mm muscular VSD Amplatzer device (Fig. 2C). The focus of the ventricular tachycardia
in the 10-month old infant could be accessed by a significantly larger catheter than was possible via standard
vascular access allowing delivery of adequate energy
to successfully ablate.
RESULTS
Easy and immediate access of the left ventricle was
obtained in four patients; in patient 2 the first ‘‘blind’’
puncture damaged a coronary artery, and the procedure
was then converted to a mini thoracotomy. Guidewire
crossing of the defects and sheath exchanges were
remarkably fast and easy. Rapid crossing (within seconds) of the paravalvular leak was achieved in patients
1, 2, and 5 (Fig. 1A). In patient 3 it was difficult to
retrogradely cross the patch-closed tricuspid valve: the
leaflets remained in a near-closed position throughout
the cardiac cycle. We used a long stiff Brockenbrough
needle to open and cross the valve leaflets under echographic guidance. Only then could the patch-leak be
wire-probed (Fig, 2A–C). The leak was balloon sized
and an Amplatzer device was deployed. We monitored
with transesophageal echography for complete closure
of the leak; if a paravalvular leak persisted, an additional device was deployed. If a shunt persisted
through the device, additional coils would have been
deployed within the device though a microcatheter system.
During the procedure in patient 4, high energy cold
ablation of the posteroseptal area produced only transient block and mapping indicated an epicardial focus
as well. As the pericardium was already open, the intrapericardial space was used to locate the specific epicardial region posterior to the mitral valve and the
focus was directly and permanently ablated (Fig. 3).
Complications
Major complications occurred in two of the three
patients with a ‘‘blind percutaneous puncture’’. After
removal of the apical sheath, patient 1 developed a left
hemothorax which required drainage. In patient 2 the
procedure started with a percutaneous puncture, but the
left anterior descending coronary artery was punctured
and dissected, requiring a coronary stent. A mini thoracotomy was then performed with puncture under direct
vision of the left ventricle through a purse string
suture, and the procedure was completed. No coronary
angiography had been performed prior to puncture.
DISCUSSION
Transapical puncture allows direct access to the systemic ventricle. Transventricular access used to be the
standard route for diagnostic work involving the left
heart from the thirties to the early sixties [10–12].
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Brown et al.
Fig. 2. A–C. A: Diagrammatic representation of Fontan circuit
of patient 3: The right atrio-ventricular valve is incompletely
closed with a patch. B: Fluoroscopic antero-posterior view
showing two atrial and three ventricular epicardial leads. A 25mm sizing balloon is inflated across the patch leak. C:
Through an 8 F apical sheath a 12-mm muscular Amplatzer is
deployed in the patch leak (still attached on the delivery
cable). F, extracardiac Fontan conduit; LA, left atrium; Le PA,
left pulmonary artery; LV, Left Ventricle; ICV, inferior caval vein;
Ri PA, right pulmonary artery; SCV, superior caval vein; TR, tricuspid regurgitation.
Fig. 3. A, B: Fluoroscopic frames (A: antero-posterior; B: lateral) of patient 4. (1) 5 F transvenous His bundle RV lead; (2) 7 F transapical ablation catheter; (3) 7 F epicardial cooled irrigation catheter.
However, because of the complications and the advent
of modern catheters and techniques, this approach has
largely been abandoned. The left ventricle may also be
accessed by a subxyphoidal approach [13], but the less
favorable angle of approach and passage through the
interventricular septum precludes its use for interventions. Direct apical access during cardio-pulmonary
bypass has been used for years as a standard surgical
technique [14] in certain conditions where the left ventricle needs adequate venting.
Our study emphasizes the fact that this technique is
especially advantageous for paravalvular mitral valve
leaks, lesions in Fontan patients and for targets with
difficult access requiring larger catheters than is possible via vascular routes. The access permits multiple
sheaths to be introduced, allowing multiple devices to
be delivered simultaneously. This is a major advantage
in patients with large paravalvular leaks, because sequential deployment and release of the occluder devices may result in embolisation of the previously
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Transapical Access For Difficult Targets
released device(s) while manipulating and deploying
the next occluder.
From our limited experience, the following technical
aspects must be emphasized. Firstly, one needs to get
into the left ventricle by puncturing either ‘‘blind percutaneously’’ or ‘‘under direct vision’’ after a mini thoracotomy.
Percutaneous puncture is appealing for an interventional cardiologist, but can be complicated with lung
puncture resulting in pneumothorax, or hemothorax
due to damage of the internal mammary and subcostal
arteries, or persistant leak after sheath withdrawal.
Damage to the coronary artery can be avoided by
doing selective coronary angiography before puncture.
However, most of these complications can be avoided
by puncturing ‘‘under direct vision’’ after a mini thoracotomy.
We preferred using 20-cm introducer sheaths for
access and deployment of all devices to limit the danger of thrombus formation and air embolism. Attention
should also be paid to removal of sheaths from the
ventricle. Most of our punctures were surgically closed
under direct vision. It was our clinical impression that
if the patient had previous sternotomies, the adhesions
will protect against cardiac tamponade. However, as
one of our patients proved, hemothorax remains a
potential complication. In one patient (no. 3), we successfully used a cutoff vascular occlusion device
(Prostar XLTM Perclose Europe, Berkshire, UK) to
close the left ventricular puncture wound; the sutures
were probably attached only to the thickened pericardium (two previous sternotomies) and overlying skin
(umbillication), but with good clinical result. We have
subsequently shown in an animal model (unpublished
data) that the untouched endomyopericardium is too
soft to give satisfactory anchorage for the sutures to
safely close the ventriculotomy with a percutaneous
vascular occlusion device.
Our current approach when transapical access is
considered, is to use a mini thoracotomy with direct
puncture of the ventricle through a purse string. Only
when significant pericardial adhesions after (multiple)
pericardiotomies are present, ‘‘blind’’ percutaneous
puncture and use of a vascular occlusion device might
also be considered; however in our small series this
technique was associated with more complications.
The advantages of this route are obvious. It is clear
from our and other studies [15] that it offers an elegant
alternative access to get to difficult to reach and/or surgically excluded targets in the left heart (ventricle,
atrium, or pulmonary veins). Also, it allows straight,
stable, and multiple guidewire positions. The short,
direct route also enables one to use stiffer catheters/
guidewires allowing the use of more ‘‘force’’ if neces-
141
sary compared to the usual antegrade or retrograde
approaches. This may allow entering of a previously
placed device and fill it with coils to occlude a residual shunt, or enter long, narrow paravalvular leaks to
deliver additional or multiple occlusion devices simultaneously. An additional major advantage is that large
diameter sheaths may be used, as demonstrated in the
percutaneous aortic valve studies [16,17] where sheath
sizes up to 33 F have been used by way of mini-thoracotomy. Our study also highlights the advantages of
the interventionalist and cardiac surgeon performing together as a team and opens up the possibility that this
‘‘hybrid’’ approach can also be applied to smaller
infants as demonstrated in patients 3 and 4, as well as
recent reports [18–20].
CONCLUSION
Direct left ventricular puncture offers a very useful
alternative access site in selected patients to reach
‘‘inaccessible’’ or multiple targets for certain percutaneous interventions in patients where standard
approaches may be impossible or difficult. Complications occur, but are usually minor and can be minimized by careful attention to technique.
ACKNOWLEDGMENTS
This work was performed in part during sabbatical
of Dr. S Brown allowed by the University of the Free
State and Free State Department of Health, Bloemfontein, South Africa.
REFERENCES
1. Levy MJ, Lillehei CW. Percutaneous direct cardiac catheterization. New Eng J Med 1964;271:273–280.
2. Gibbs JL, Wren C, Watterson KG, Hunter S, Hamilton JR.
Stenting of the arterial duct combined with banding of the pulmonary arteries and atrial septectomy or septostomy: A new
approach to palliation for the hypoplastic left heart syndrome.
Br Heart J 1993;69:551–555.
3. Lichtenstein SV, Cheung A, Ye J, Thompson CR, Carere RG,
Pasupati S, Webb JG. Transapical transcatheter aortic valve implantation in humans. Circulation 2006;114:591–596.
4. Maxwell D, Allan L, Tynan MJ. Balloon dilatation of the aortic
valve in the fetus: A report of two cases. Br Heart J 1991;
65:256–258.
5. Havranek EP, Sherry PD. Left heart catheterization by direct
puncture with two dimensional echocardiographic guidance: A
case report. Cathet Cardiovasc Diagn 1995;35:358–361.
6. Turgut T, Deeb M, Moscucci M. Left ventricular apical puncture: A procedure surviving well into the new millennium.
Cathet Cardiovasc Interv 2000;49:68–73.
7. Cata CF, Grassman ED, Johnson SA. Technique of apical left
ventricular puncture revisited: A case report of double-valve
prosthesis evaluation. J Invasive Cardiol 1994;6:251–255.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
142
Brown et al.
8. Vignola PA, Swaye PS, Gosselin AJ. Safe transthoracic left ventricular puncture performed with echocardiographic guidance.
Cathet Cardiovasc Diagn 1980;6:317–324.
9. Carere RG, Webb JG, Ahmed T, Dodek AA. Initial experience
using prostar: A new device for percutaneous suture-mediated
closure of arterial puncture sites. Cathet Cardiovasc Diagn
1996;37:367–372.
10. Wong PHC, Chow JSF, Chen WWC, Miller GAH. Aortic catheterization via percutaneous left ventricular puncture. Cathet CardiovascDiagn 1983;9:421–427.
11. Greene DG, Sharp JT, Griffith GT, Bunnell IL, Macmanus JE.
Surgical application of anterior percutaneous left heart puncture.
Surgery 1958;43:1–6.
12. Fleming P, Gibson R. Percutaneous left ventricular puncture in
the assessment of aortic stenosis. Thorax 1957;12:37–49.
13. Zuguchi M, Shindoh C, Chida K, Saito H, Takai Y, Yamada S,
Iguchi A, Endo M, Akimoto H, Tabayashi K. Safety and clinical
benefits of transsubxiphoidal left ventricular puncture. Cathet
Cardiovasc Interv 2002;55:58–65.
14. Watanabe H, Eguchi S, Miyamura H, Hayashi J, Ohzeki H,
Sugawara M, Hiratsuka M. Transapical cannulation in pedaitric
patients. Ann Thorac Surg 1997;63:1149–1150.
15. Lim DS, Ragosta M, Dent JM. Percutaneous transthoracic ventricular puncture for diagnostic and interventional catheterization. Cathet Cardiovasc Interv 2008;71:915–918.
16. Walther T, Falk V, Kempfert J, Borger MA, Fassl J, Chu
MWA, Schuler G, Mohr FW. Transapically minimally invasive
aortic valve implantation; the initial 50 patients. Eur J Cardiothorac Surg 2008;33:983–988.
17. Walther T, Falk V, Borger MA, Dewey T, Wimmer-Greinecker
G, Schuler G, Mack M, Mohr FW. Minimally invasive transapical beating heart aortic valve implantation-proof of concept. Eur
J Cardiothorac Surg 2007;31:9–15.
18. Holzer RJ, Sisk M, Phillips A. Hybrid balloon pulmonary valvuloplasty in a 700g infant: thinking outside the box. Cathet Cardiovasc Interv 2008;72:93–96.
19. Davenport JJ, Lam L, Whalen-Glass R, Nykanen DG, Burke RP,
Hannan R, Zahn EM. The successful use of alternative routes of
vascular access for performing pediatric interventional cardiac
catheterization. Catheter Cardiovasc Interv 2008;72:392–398.
20. Schmitz C, Esmailzadeh B, Herberg U, Lang N, Sodian R,
Kozlik-Feldmann R, Welz A, Breuer J. Hybrid procedures can
reduce the risk of congenital cardiovascular surgery. Eur J
Cardiothorac Surg 2008;34:718–725.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).