Percutaneous interventricular septal access in a patient with aortic and mitral mechanical valves: A novel technique for catheter ablation of ventricular tachycardia

Abstract

IntroductionCatheter ablation of ventricular tachycardia (VT) is typically performed using either the atrial transseptal approach or a retrograde aortic approach in order to gain access to the left ventricle (LV). However, neither approach is feasible in the setting of mechanical aortic and mitral valve replacements, given the risk of catheter entrapment and death. 1, 2 Therefore, approaches that avoid traversing these valves, such as a percutaneous trans-apical approach, have been developed. [3][4][5][6] However, the trans-apical approach is associated with a significant rate of access related complications, particularly bleeding at the puncture site, and necessitates the placement of closure devices in the LV. 7,8 We describe a novel percutaneous inter-ventricular transseptal puncture technique and placement of a sheath across the inter-ventricular septum for catheter ablation of VT. This method allowed for stable LV access and spontaneous closure of the septal access site. Case Report Clinical HistoryA 35-year-old male was referred to our center for catheter ablation of recurrent VT requiring multiple implantable cardiac defibrillator (ICD) therapies. He had undergone mechanical aortic and mitral valve replacements after developing endocarditis due to a dental abscess. Five years later, he suffered from sudden cardiac arrest and a single-lead ICD was placed. His ejection fraction was estimated at 35% and Q waves were noted on the ECG in the inferior leads. He subsequently suffered from VT storm with increasing number of ICD shocks and anti-tachycardia pace terminated (ATP) episodes despite therapy with sotalol and © 2013 The Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.Address for correspondence: Kalyanam Shivkumar, M.D., Ph.D., FHRS, UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, 100 UCLA Medical Plaza, Suite # 660, Los Angeles, CA 90095, 310-206-2235 (phone), 310-825 4251 (Fax), kshivkumar@mednet.ucla.edu. Disclosure: The Regents of the University of California, Los Angeles has intellectual property developed by the author (KS) that relate to data reported in this paper.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. amiodarone, and also developed trans-aminitis secondary to amiodarone. In the past year, he had suffered from 110 episodes of VT requiring either ATP or ICD shocks and was highly symptomatic, even during the ATP episodes. Given the presence of mechanical prostheses in the mitral and aortic valve positions, a novel method of LV access across the interventricular septum was discussed wi...

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

“…Another group have recently described ventricular septal puncture using a Brockenberg needle and a Mullins transseptal sheath, to access the LV for endocardial ablation. 19 It is not known how challenging it would be to extract a chronic ventricular transseptal lead if required, or whether this could be done percutaneously or necessitate surgical intervention. There may been concerns over whether patients with an endocardial LV lead could safely be treated with a LV assist device.…”

“…The structure of the septal muscle seems to facilitate rapid tissue contraction around a defect, and other groups have shown closure of large iatrogenic defects. 18,19 The ventricular septal approach avoids lead interaction with the mitral valve, potentially preventing worsening of mitral regurgitation and reducing the risk of mitral valve endocarditis.Providing oral anticoagulation is continued lifelong, there seems to be a relatively low risk of systemic thromboembolism with LV endocardial pacing. 12,[20][21][22] Embolic events in atrial transseptal lead patients have been ascribed to subtherapeutic anticoagulation.…”

“…The structure of the septal muscle seems to facilitate rapid tissue contraction around a defect, and other groups have shown closure of large iatrogenic defects. 18,19 The ventricular septal approach avoids lead interaction with the mitral valve, potentially preventing worsening of mitral regurgitation and reducing the risk of mitral valve endocarditis.…”

Ventricular arrhythmias in nonischemic cardiomyopathy

“…The transseptal approach is effective in reaching most of the LV endocardium, whereas the retrograde aortic approach is more effective in accessing the basal septum, basal inferior, and basal lateral segments, and the aortic outflow tract 56. For conditions where entry into the LV is difficult, a percutaneous interventricular septal access, an epicardial approach, or a percutaneous transapical procedure will serve as a rescue procedure for those with mechanical aortic or mitral valves 57, 58, 59, 60. Steerable long sheaths can also provide additional support for difficult endocardial mapping and epicardial procedures 61.…”

Percutaneous Transapical Access With Closure for Ventricular Tachycardia Ablation

“…Because of the circuitous path required to reach subaortic and other LV regions via the trans-septal route, ablation catheter contact force may not be sufficient 1 for successful energy delivery. Therefore, additional techniques for a more direct access to the LV may be advantageous, including ventricular trans-septal access, 2 and transapical access via surgical mini-thoracotomy. 3 Percutaneous transapical access to the LV combines the advantages of a direct LV access (abundance of catheter maneuverability and contact force needed for ablation energy delivery) with the convenience of a nonsurgical technique (performable in the electrophysiological laboratory).…”