Left heart catheterization by direct ventricular puncture: Withstanding the test of time

Abstract

If retrograde arterial catheterization of the left ventricle fails because of a stenosed native or tissue valve or is contraindicated because of the presence of a mechanical aortic prosthesis, then alternative routes of access to the left ventricle are either transseptal or direct (transapical) left ventricular puncture. The transseptal approach is contraindicated in the presence of a mechanical mitral valve prosthesis. Under these circumstances we have used direct transapical left ventricular puncture in the treatment of 112 patients and have found this technique to be successful with little associated risk. A major complication occurred in 3% of the patients, but the study provided the required data in 95%, and these figures compare favorably with the reported results of transseptal catheterization.

Transapical Coronary Artery Intervention

“…Since the 1950s, transapical procedures using left ventricular apical puncture have mainly been performed to provide hemodynamic data in the presence of mechanical prosthetic valves, ventricular angiography, and more recently, for paravalvular leak closures. [1][2][3] It has been shown that left ventricular apical puncture is associated with a significant number of major complications including hemothorax and pericardial tamponade. 4 In patients scheduled for transapical aortic valve implantation, however, a sheath needs to be placed anyways and in selected cases, the risks associated with transapical coronary intervention may be lower than those of a transfemoral or transradial access.…”

“…A transapical left ventricular access is sometimes used for diagnostic purposes and has been described for structural cardiac interventions, but not for coronary artery interventions. [1][2][3][4] A significant number of patients who undergo catheter-based aortic valve implantation also require coronary intervention. In selected cases, it may be desirable to perform coronary revascularization via the transapical access, for example if aortic disease makes a transfemoral or transradial approach impossible or may lead to complications.…”

Hemodynamic rounds series II: Left ventricular puncture for hemodynamic evaluation of double prosthetic valve stenosis

“…Other investigators [3][4][5] have provided the cardiology community with clinical examples in larger series involving over 300 patients, and have demonstrated the major complication rates, estimated to be at 3-4%.…”

“…The use of a long 18-gauge pericardiocentesis needle to place a guidewire followed by the 4F catheter has been described [4,5,9] and is associated with minimal complications. The reported complications of direct left ventricular puncture have included transient hypotension, vasovagal symptoms, pneumothorax, ventricular arrhythmias, coronary laceration, and postpericardiotomy syndrome.…”

“…Although infrequent, critical hemodynamic assessment for the severity of valvular compromise in patients with double-valve prostheses is especially important before interventions. Although the technique and methodology have been well-described [3][4][5], their infrequent application makes periodic review worthwhile.…”