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Transhepatic venous cardiac
catheterization
David Shim, MD
Division of Pediatric Cardiology
The Heart Center
Children's Hospital Medical Center
Cincinnati, Ohio
Indications for right heart
catheterization
Hemodynamics
 right heart pressures
 pulmonary vascular resistance
 thermodilution cardiac output
Angiography
 right ventricular function
 pulmonary valve and artery
anatomy
Indications for right heart
catheterization
Electrophysiology
 radiofrequency ablation
Interventions





ASD occlusion
balloon atrial septostomy
endomyocardial biopsy
prograde PDA coil embolization
pulmonary artery balloon
dilation/stent
Indications for right heart
catheterization
Interventions (continued)
 pulmonary valve balloon dilation
 RV-PA conduit balloon
dilation/stent
 SVC balloon dilation/stent
 transseptal puncture
Reasons for no access
 previous central lines or
catheterization
 interrupted inferior vena cava
 obstructed superior vena cava
 bidirectional Glenn/Hemifontan
 infection at site of access
 devices (eg, Greenfield filter)
Background
Percutaneous Transhepatic
Cholangiography (PTC)
 has been performed for 2 decades
with low morbidity
other transhepatic procedures
 portal venous system
hemodynamics
 localize occult neuroendocrine
tumors
 embolization of varices
Contraindications
 Abnormal clotting/prothrombin time
 Active liver disease or peritonitis
 Abnormally draining hepatic veins
Transhepatic technique
1. 22 gauge Chiba needle inserted to
midlliver under fluoroscopic guidance
2. needle withdrawn with small injections
of contrast until hepatic vein identified
3. 0.018” Cope wire advanced to RA
4. 4F coaxial dilator placed and wire
exchanged for a 0.035-0.038”
guidewire
Transhepatic technique
(continued)
5. dilator removed and curved sheath
placed
6. cardiac catheterization performed
7. Gianturco coil placed in liver
parenchyma upon removal of
sheath
8. puncture site dressed with opsite
dressing and post-catheterization
care as routine
Transhepatic technique
(continued)
Transhepatic technique
(continued)
Transhepatic technique
(continued)
Transhepatic technique
(continued)
Transhepatic technique
(continued)
Transhepatic technique
(continued)
Transhepatic technique
(continued)
Evaluation of Efficacy
and Safety
 Patient population (N=42)
Range
Median
Age
1 day - 41 yrs
25 months
Weight
2.4 - 74 kg
11 kg
RA mean pressure 0 - 24 mm Hg
9 mm Hg
Shim D, et al. Circulation 1995;92:1526-1530
Diagnoses
univentricular heart (25)
critical pulmonary stenosis (5)
tetralogy of Fallot (3)
AV canal (2)
One each:
atrial septal defect, mitral stenosis,
peripheral pulmonary stenosis,
Shone’s complex, status post transplant,
transposition of the great arteries,
and truncus arteriosus
Limitations to access
bilateral femoral venous occlusion (30)
bidirectional Glenn/Hemifontan (9)
interrupted inferior vena cava (7)
obstructed superior vena cava (4)
preferred route for intervention (3)
Greenfield filter (1)
Efficacy
Range
number of
1-7
hepatic punctures
time to enter
1 - 21 min
right atrium
fluoroscopy time
0.1 - 9.2 min
Median
3 attempts
4 min
2.3 min
Safety
Parameter
Pre-Cath
ALT (IU/L)
47.2  41.5 52.3  22.3 NS
AST (IU/L)
51.1  44.0 69.1  30.8 NS
HGB (gm/dL) 14.4  2.6
Post-Cath
13.4  2.4
p value
NS
Safety (continued)
Chest radiographs
 no effusions
 no pneumoperitoneum/pneumothorax
Liver ultrasound (n=34)
 small amount of peritoneal fluid (n=4)
 no subcapsular hematoma
Clinical hemorrhage (n=2; 5%)
29/30 (97%) successful interventions
 angioplasty ± stent
 pulmonary (10)
 Fontan baffle (3)
 superior vena cava (2)
 valvuloplasty
 pulmonary valve (2)
 transseptal mitral valve (1)
 radiofrequency ablation
 ± transseptal puncture (4)
Shim D,et al. Cathet Cardiovasc Interv 1999;47:41-5
Transhepatic interventions
 Others
 atrial septal defect device occlusion (2)
 Fontan fenestration device occlusion (2)
 coil embolization of pulmonary artery
pseudoaneurysm(2)
 device retrieval (1)
 endomyocardial biopsy (1)
 Sheath sizes: 4-14 French
Pulmonary valvuloplasty
Pulmonary valvuloplasty
(continued)
Pulmonary valvuloplasty
(continued)
Pulmonary valvuloplasty
(continued)
Pulmonary valvuloplasty
(continued)
Fontan stent placement
Fontan stent placement
(continued)
Fontan stent placement
(continued)
Fontan stent placement
(continued)
Fontan stent placement
(continued)
Conclusions
The transhepatic approach is
effective as a route for right sided
cardiac catheterization and can be
performed with relative safety
The transhepatic approach will allow
therapeutic procedures to be
performed in a subset of children
where this has been previously not
possible
Speculations
Transhepatic access will allow larger
sheaths to be used in smaller patients
The transhepatic approach may allow
better sheath stability in the right
ventricular outflow tract for pulmonary
valvuloplasty and angioplasty
The transhepatic approach may also
allow a more perpendicular approach to
the atrial septum