Outcomes of Percutaneous Trans–Right Atrial Access to the Left Ventricle for Catheter Ablation of Ventricular Tachycardia in Patients With Mechanical Aortic and Mitral Valves

Abstract

IMPORTANCEIn patients with mechanical valves in the aortic and mitral positions, percutaneous access to the left ventricle (LV) via a transfemoral approach for catheter ablation of ventricular tachycardia (VT) has been considered infeasible.OBJECTIVE To describe the outcomes of a novel percutaneous trans-right atrial (RA) access to the LV via a femoral venous approach for catheter ablation of VT in patients with mechanical aortic and mitral valves. DESIGN, SETTING, AND PARTICIPANTSThis observational study included consecutive patients with mechanical valves in the aortic and mitral positions and recurrent monomorphic drug-refractory VT associated with an LV substrate. Percutaneous LV access was performed from a transfemoral venous route with the aid of a deflectable sheath and a radiofrequency wire by creating an iatrogenic Gerbode defect with direct puncture of the inferior and medial aspect of the RA, adjacent to the inferior-septal process of the LV (ISP-LV), under intracardiac echography guidance. Once the wire crossed to the LV, balloon dilatation of the ventriculotomy site (with a noncompliant balloon; diameter, 8 to 10 mm) was performed to facilitate passage of the sheath within the LV.EXPOSURES Percutaneous trans-RA access to the LV via puncture of the ISP-LV to perform catheter ablation of VT in patients with mechanical aortic and mitral valves. MAIN OUTCOMES AND MEASURESFeasibility and safety of a trans-RA access to the LV for catheter ablation of VT. RESULTS A total of 4 patients (mean [SD] age, 60 [7] years; mean [SD] LV ejection fraction, 31% [9%]) with recurrent VT associated with an LV substrate (ischemic cardiomyopathy, 3 patients; nonischemic cardiomyopathy, 1 patient) and mechanical valves in the aortic and mitral position underwent trans-RA access through the ISP-LV for catheter ablation of VT. The time to obtain LV access ranged from 60 minutes (first case) to 22 minutes (last case) (mean [SD], 36 [15] minutes). No complications associated with the access occurred. In particular, in the 3 patients with preserved atrioventricular conduction at baseline, no new conduction abnormalities were observed after the access. Complete VT noninducibility at programmed ventricular stimulation was achieved in 3 cases, and no patient had VT recurrence at a median follow-up of 14 months (range, 6-21 months). CONCLUSIONS AND RELEVANCEA percutaneous trans-RA access to the LV via a femoral venous approach for catheter ablation of VT in patients with mechanical aortic and mitral valves is feasible and appears safe. This novel technique may allow for catheter ablation of VT in a population of patients in whom conventional LV access via retrograde aortic or atrial transseptal routes is not possible.

Novel use of preprocedure imaging for planning and guidance of right atrium–to–left ventricle access for catheter ablation of ventricular tachycardia

“…Finally, while in the original published series of RA-to-LV access 2 of the 4 patients developed sustained ventricular arrhythmias requiring cardioversion during use of the RF wire, 1 in our case only short runs of nonsustained VT were induced with RF, which we believe was because we chose to use shorter 1-second bursts rather than 4- to 5-second bursts as previously described. Furthermore, after balloon dilation, the sheath was successfully advanced using a technique known as balloon-assisted tracking.…”

“…Similarly, stereotactic radioablation 5 was considered; however, without prior electroanatomic mapping or contrast imaging to guide dose planning, it was felt to have a lower chance of success. Thus, a direct RA-to-LV approach 1 was felt to be the optimal approach. Furthermore, in case of difficulty with sheath contact or stability in this region, we discussed attempting puncture from just inside the ostium of the coronary sinus, as has been anecdotally reported; however, this was ultimately not required.…”

“…Traditional approaches to access the left ventricle (LV) for endocardial catheter ablation of ventricular tachycardia (VT) are not feasible in patients with simultaneous mitral and aortic mechanical valve replacements. Recent data 1 have shown that access directly from the right atrium through the inferior septal process of the left ventricle, site of a so-called Gerbode defect, can be safely performed. In this report, pre-procedure imaging was used to plan the optimal site of access and registered to the mapping system to help guide the procedure in real-time.…”

Characteristics and Outcomes of Ventricular Tachycardia and Premature Ventricular Contractions Ablation in Patients with Prior Mitral Valve Surgery

“…In such cases, options would include epicardial approach, 29 transventricular septal puncture, 30 transcoronary venous approach, 31 transapical approach, 32 or trans-right atrial to the LV approach. 33 Percutaneous epicardial access can be challenging in patients with prior cardiac surgery. A previous study reported that prior cardiac surgery precludes LV access in most patients with only 20% success rate.…”

Use of Stereotactic Radioablation Therapy as a Bailout Therapy for Refractory Ventricular Tachycardia in a Patient with a No-entry Left Ventricle

“…Several operators have reported on the application of non-conventional techniques for VT ablation, including transventricular septal puncture, transmechanical valve, transcoronary venous, and transapical approaches. 1 – 5 Promising alternatives to radiofrequency ablation include percutaneous or surgical sympathetic neuromodulation, alcohol ablation from the coronary arterial or venous system, direct current or pulsed-field electroporation, and noninvasive stereotactic radioablation therapy (SBRT) in critically ill patients. 6 – 9 We herein describe the effect of SBRT as a bailout therapy on the management of a challenging VT case with two mechanical valve prostheses in aortic and mitral positions.…”