Transapical left ventricular access for difficult to reach interventional targets in the left heart

Brown, Stephen C.; Boshoff, Derize; Rega, Filip; Eyskens, Bénédicte; Budts, Werner; Heidbüchel, Hein; Meyns, Bart; Gewillig, Marc

doi:10.1002/ccd.21939

Cited by 53 publications

(45 citation statements)

References 49 publications

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“…9,[15][16][17][18][19][20][21][22][23][24][25][26][27][28] Most transapical procedures are performed transcutaneously, with direct puncture of the left ventricle. This technique is less invasive compared with open access, but is associated with a risk of coronary artery dissection that may be reduced with preprocedural computed tomography.…”

Section: Transapical Accessmentioning

confidence: 99%

“…This technique is less invasive compared with open access, but is associated with a risk of coronary artery dissection that may be reduced with preprocedural computed tomography. 15,29 The advantage of open versus transcutaneous transapical access is that it provides a direct visualization of the cardiac apex and enables the use of multiple sheaths for simultaneous occluder device implantation.…”

Section: Transapical Accessmentioning

confidence: 99%

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Open Transapical Approach to Transcatheter Paravalvular Leakage Closure

Nijenhuis

Swaans

Post

et al. 2014

Circ: Cardiovascular Interventions

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Background-Significant prosthetic paravalvular leakage (PVL) could have serious clinical consequences and impairs survival. Reoperation is associated with a high mortality rate, and transcatheter closure is a new treatment modality for high-risk patients. The goal of this study was to determine safety and midterm clinical efficacy of transcatheter PVL closure using an open transapical approach. Methods and Results-All consecutive patients who underwent transcatheter PVL closure in our center were prospectively enrolled. Pre-and postprocedural quality of life and 6-minute walk test were ascertained. All outcomes were defined according to the Valve Academic Research Consortium-2 consensus document. In total, 37 consecutive patients (mean age 67±12 years, 65% male, logistic European System for Cardiac Operative Risk Evaluation 27±17%, Society of Thoracic Surgeons score 7±4%) with severe symptomatic PVL in mitral (81%) or aortic (19%) position underwent transcatheter PVL closure. Procedure success was 86%. Early safety at 30 days (ie, event-free survival) was 84%. The 1-year survival rate was 66%. New York Heart Association functional class and quality of life significantly improved. Clinical efficacy (ie, survival free of stroke, rehospitalization, New York Heart Association 3/4, and device-related dysfunction) was 49% at 3 months and 31% at 1 year. Moderate to severe residual PVL was associated with all-cause mortality (hazard ratio, 3.9; 95% confidence interval, 1.2-12.1; P=0.03). Conclusions-The open transapical approach to PVL closure in high-risk patients has a high procedural success rate with an acceptable risk of adverse outcomes. This is the first study to prove an increased functional capacity and quality of life after transapical PVL closure. Residual PVL is associated with 1-year mortality. (Circ Cardiovasc Interv. 2014;7:611-620.)Key Words: heart failure ◼ heart valve diseases ◼ heart valve prosthesis ◼ mitral valve insufficiency ◼ quality of life ◼ septal occluder device ◼ surgical procedures, minimally invasive

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Section: Transapical Accessmentioning

confidence: 99%

Section: Transapical Accessmentioning

confidence: 99%

Open Transapical Approach to Transcatheter Paravalvular Leakage Closure

Nijenhuis

Swaans

Post

et al. 2014

Circ: Cardiovascular Interventions

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“…Brown et al 22 report, "Transapical left ventricular access for difficult to reach interventional targets in the left heart." In this report, one of the patients had an extracardiac Fontan and required ablation.…”

Section: Advantage 4: Atrial Access For Electrophysiology Study May Smentioning

confidence: 99%

“…The authors concluded that "blind" percutaneous left ventricular puncture was effective and could be considered, but that puncture under direct visualization following minithoracotomy was preferable because of fewer complications. 22 More importantly, Pass et al 23 report "A transbaffle approach to ablation in a child with an extracardiac Fontan." Successful ablation was performed in an 11-year-old child with a double-inlet left ventricle, who underwent extracardiac Fontan at age 3.…”

Section: Advantage 4: Atrial Access For Electrophysiology Study May Smentioning

confidence: 99%

Is the Extracardiac Conduit the Preferred Fontan Approach for Patients With Univentricular Hearts?

Kogon

2012

Circulation

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W ith improvements in technology, operative technique, and critical care medicine, more and more children with congenital heart disease are surviving into adulthood. As they age, these patients are providing physicians with new challenges, and we are realizing the long-term consequences of our previous interventions. This oftentimes has changed the mode of treatment for subsequent children. Response by Khairy and Poirier on p 2515Fontan palliation for single-ventricle patients was first described in 1971. 1 The original approach was in the form of a classic atriopulmonary Fontan connection, bypassing the nonfunctional right ventricle. After recognizing the long-term complication of an atriopulmonary connection (right atrial dilation, arrhythmias, and thrombus formation), modifications have been made. The atriopulmonary connection has been abandoned in favor of modified Fontan anatomy and physiology.The modified Fontan can be performed by the use of an extracardiac conduit approach or a lateral tunnel approach. The extracardiac Fontan uses an external conduit to anastomose the inferior vena cava into the pulmonary arteries, whereas a lateral tunnel Fontan uses a baffle within the right atrium (Figure 1). Because the systemic venous pathway is completely separated from the right atrium with the extracardiac Fontan, it is more challenging for the electrophysiologist to access the heart for ablation. My aim is to demonstrate why "the extracardiac conduit is the preferred Fontan approach for patients with univentricular hearts."The extracardiac Fontan has several advantages over the lateral tunnel Fontan. Advantage 1: Reduced Cardiopulmonary Bypass and Ischemic TimesMinimizing cardiopulmonary bypass and ischemia may optimize early postoperative outcomes. In multiple studies, both prolonged cardioplegic arrest and extended cardiopulmonary bypass times have been associated with an increased risk of early postoperative death or Fontan failure. [2][3][4] The technique of Fontan construction often dictates whether cardiopulmonary bypass or a period of ischemic arrest are required. With the lateral tunnel Fontan, the right atrium is opened for creation of the inferior vena cava baffle, necessitating the use of cardiopulmonary bypass. In addition, a period of cardioplegic arrest is required to stop the heart to prevent air embolic events until the atrium is closed. With the extracardiac Fontan, the right atrium is not opened. Vascular control is achieved at the right atrial-inferior vena cava junction. The inferior vena cava is transected and sewn to the extracardiac conduit, and the cardiac opening is oversewn. Vascular control of the pulmonary arteries is then achieved, and the conduit is sewn to the right pulmonary artery. Last, side-biting clamps are placed on the right atrium and conduit to create a fenestration if desired. With the use of this

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“…Current techniques to access the PVA after E-TCPC include hybrid surgical, 5,6 retrograde aortic, 7,8 and direct puncture approaches through synthetic conduits. 9,10 Direct puncture is less invasive than surgical approaches, yet is a challenging procedure that may require multiple attempts, catheter balloon dilation, and occasionally prolonged procedure times.…”

mentioning

confidence: 99%

Transcaval Puncture for Access to the Pulmonary Venous Atrium After the Extracardiac Total Cavopulmonary Connection Operation

Moore

Hendrickson

Brunengraber

et al. 2015

Circ: Arrhythmia and Electrophysiology

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MethodsAfter approval from the Institutional Review Board, the Pediatric Cardiology and Ahmanson/UCLA Adult Congenital Heart Disease databases were searched for all patients who had undergone prior E-TCPC between 2005 and 2015. Those patients without computed tomography (CT) imaging after the E-TCPC operation were excluded from further study. Patient characteristics including baseline demographics, congenital diagnosis, surgical history, arrhythmia history, and hemodynamic data were recorded.All postoperative CT studies were reviewed in blinded fashion by 1 electrophysiologist and 1 radiologist. Three-dimensional reconstructions of CT examinations were performed using DICOM viewer © 2015 American Heart Association, Inc. Original Article Circ Arrhythm ElectrophysiolBackground-Patients with surgically palliated total cavopulmonary connection are at risk for recurrent atrial arrhythmia requiring catheter ablation. Transcatheter procedures for those with extracardiac conduits (extracardiac-total cavopulmonary connection) are perhaps the most challenging because of exclusion of the venous circulation from the arrhythmia substrate. Puncture through the inferior vena cava to the pulmonary venous atrium may be an effective route for access in these patients. Methods and Results-The pediatric and adult congenital surgical databases were explored for patients with extracardiactotal cavopulmonary connection and postoperative computed tomography imaging to assess for the presence of clinically relevant (>3 mm) apposition between the inferior vena cava and pulmonary venous atrium (cavoatrial overlap). The degree of overlap between the structures was measured by 2 blinded reviewers. Patients were stratified by surgical repair in childhood versus adult congenital heart disease. Thirty-seven patients were identified, with cavoatrial overlap observed in 9 (36%) of pediatric and 1 (9%) of adult congenital heart disease-repaired patients. Time elapsed after surgery was associated with cavoatrial overlap in the pediatric cohort (P=0.034) and was identified in all pediatric patients with computed tomography imaging ≥8 years after surgery. Three patients underwent successful transcaval puncture during the study period without complication. Conclusions-Puncture through a region of overlap between the inferior vena cava and pulmonary venous atrium is feasible. Cavoatrial overlap is present in a substantial proportion of patients undergoing extracardiac-total cavopulmonary connection in childhood and is associated with a longer time elapsed since surgery. (Circ Arrhythm Electrophysiol.

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Transapical left ventricular access for difficult to reach interventional targets in the left heart

Abstract: 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.

Cited by 53 publications

References 49 publications

Open Transapical Approach to Transcatheter Paravalvular Leakage Closure

Open Transapical Approach to Transcatheter Paravalvular Leakage Closure

Is the Extracardiac Conduit the Preferred Fontan Approach for Patients With Univentricular Hearts?

Transcaval Puncture for Access to the Pulmonary Venous Atrium After the Extracardiac Total Cavopulmonary Connection Operation

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