Transthoracic left ventricular puncture for the assessment of patients with aortic and mitral valve prostheses: the Massachusetts General Hospital experience, 1989-2000

From Minimally to Maximally Invasive; VT Ablation in the setting of Mechanical Aortic and Mitral Valves

Double mitral and aortic mechanical valves present an access challenge when planning a ventricular tachycardia (VT) ablation. In this case report, we describe a patient who was considered for stereotactic ablative radiotherapy but was unable to proceed due to unfavorable anatomy making them at high risk of fistula formation. The patient went on to have an endocardial VT ablation via mini‐thoracotomy and transapical access without complication. This case highlights the need for careful consideration when planning treatment for patients with double mechanical valves.

Complete percutaneous apical access and closure: Short and intermediate term outcomes

OBJECTIVES

To examine the safety of utilizing transapical access during structural interventions.

BACKGROUND

Complex interventions of the mitral or aortic region sometimes require coaxial forces to orient and deliver devices. Apical access can provide coaxial countertraction for either transseptal or retrograde aortic access. This manuscript describes the single center experience of small bore transapical access.

METHODS

Retrospective review of cases from 2013 to 2018 at Henry Ford Hospital was performed. Patient demographics and procedure characteristics were abstracted to describe the safety of transapical access using small bore sheaths.

RESULTS

A total 21 cases were performed at Henry Ford, most of them for transcatheter mitral valve replacement (81%). The mean sheath size used was 4.7 ± 0.9 Fr and protamine was used at the end of 57% of cases. All patients received nitinol-based plugs, 80.1% were from the Amplatz Duct Occluder II type. Four major complications related apical puncture occurred, two pericardial effusions, two hemothorax. Over a median follow time of 430 days (IQR 50-652) a total of five deaths occurred, two related to the procedure and three late deaths with a median time of 362 days (range 205-628 days). No deaths were associated with transapical access. Echocardiographic follow up did not detect any late structural complications from occluder devices.

CONCLUSIONS

Transapical access and closure with nitinol-based devices is feasible and facilitates complex interventions where coaxial forces are need for device delivery and alignment. The most common complication is bleeding and this should be kept in perspective when treating high-risk patients.

Assessment of trans-aortic pressure gradient using a coronary pressure wire in patients with mechanical aortic and mitral valve prostheses

Accurate evaluation of trans-aortic valvular pressure gradients is challenging in cases where dual mechanical aortic and mitral valve prostheses are present. Non-invasive Doppler echocardiographic imaging has its limitations due to multiple geometric assumptions. Invasive measurement of trans-valvular gradients with cardiac catheterization can provide further information in patients with two mechanical valves, where simultaneous pressure measurements in the left ventricle and ascending aorta must be obtained. Obtaining access to the left ventricle via the mitral valve after a trans-septal puncture is not feasible in the case of a concomitant mechanical mitral valve, whereas left ventricular apical puncture technique is associated with high procedural risks. Retrograde crossing of a bileaflet mechanical aortic prosthesis with standard catheters is associated with the risk of catheter entrapment and acute valvular regurgitation. In these cases, the assessment of trans-valvular gradients using a 0.014˝ diameter coronary pressure wire technique has been described in a few case reports. We present the case of a 76-year-old female with rheumatic valvular heart disease who underwent mechanical aortic and mitral valve replacement in the past. She presented with decompensated heart failure and echocardiographic findings suggestive of elevated pressure gradient across the mechanical aortic valve prosthesis. The use of a high-fidelity 0.014˝ diameter coronary pressure guidewire resulted in the detection of a normal trans-valvular pressure gradient across the mechanical aortic valve. This avoided a high-risk third redo valve surgery in our patient. © 2017 Wiley Periodicals, Inc.

Surgical Transapical Approach for Prosthetic Mitral Paravalvular Leak Closure: Early Results

The objective is to demonstrate safety and early clinical results of surgical transapical closure of paravalvular leaks (PVLs) following mitral valve replacement in significant regurgitation. Between March 2014 and February 2015, 12 patients (mean age 52.1 ± 6.0 years, 66.6% male) with severe symptomatic mitral PVLs (n = 13) underwent surgical transapical closure procedure through left mini-thoracotomy. All patients were in NYHA functional class III-IV and median logistic EuroSCORE was 24.2 ± 6.4% (range, 13.5-34.6%). Indications were heart failure (n = 10) and symptomatic hemolysis (n = 2) due to severe mitral regurgitation (MR). Amplatzer Vascular Plug-III devices (n = 9) were used for smaller and regular defects; whereas Atrial Septal Defect closure devices (n = 4) were used for larger defects. Technical success was achieved in 10 (83.3%) patients. One (8.5%) patient with 2 + MR was treated medically. A patient with residual 4 + MR underwent re-operation. There was no procedure-related complication including mortality, device migration, embolization, or cardiac laceration. Mean procedure and fluoroscopy times were 166.4 ± 39.5 (range, 90-210) and 25.7 ± 17.3 (range, 16-64) minutes, respectively. The mean intensive care and hospital stays were 2.1 ± 1.3 and 10.3 ± 6.5 days, respectively. Clinical efficacy was achieved in 9 (75%) of 12 patients at early follow-up of 8.5 ± 2.1 months. NYHA status was class II in two patients, and no hemolytic anemia was diagnosed. Echocardiographic studies revealed a significant reduction of preoperative MR (3-4+) to less than 1+ MR after operations (P < 0.05). Surgical transapical approach to PVL closure is a safe and effective procedure following mitral valve replacement. Early results show that this procedure can be an alternative to re-operation for high-risk patients. Further studies are needed to prove its effectiveness in the long term.

Epicardial Catheter Ablation of Ventricular Tachycardia in No Entry Left Ventricle

Background—

In patients with mechanical aortic and mitral valves and left ventricular tachycardia, catheter ablation may be prevented by limited access to the left ventricle.

Methods and Results—

In our series of 6 patients, 2 patients underwent direct surgical ablation and 4 underwent epicardial catheter ablation via a pericardial window. All patients had abnormal low voltage areas with fractionated or delayed isolated potentials on the apical epicardium. Most of the ventricular tachycardias were targeted by pace mapping. Sites with a good pace match or abnormal electrograms were ablated using an irrigated radiofrequency ablation catheter. A microscopic pathological evaluation of the resected tissue from 2 of the open-heart ablation patients revealed dense fibrosis on the epicardium compared with the endocardium, supporting the feasibility of an epicardial ablation for the ventricular tachycardia.

Conclusions—

Epicardial catheter ablation of ventricular tachycardia is a potentially useful therapy in patients who have mechanical aortic and mitral valves.

Invasive hemodynamic evaluation in patients with mechanical aortic valves

Invasive hemodynamic evaluation in the patient with a mechanical aortic valve has in the past required transseptal or apical left ventricular puncture in order to obtain left ventricular pressure measurements. Over the last few years, several case reports have described the feasibility of using a coronary pressure-sensing guidewire to cross mechanical prosthetic aortic valves. In the current manuscript, we report four cases in which the use of a pressure-sensing guidewire was utilized for invasive hemodynamic diagnostic evaluation in patients with mechanical aortic valves. Furthermore, we present a detailed description of the technical approach to this technique and the limitations of this approach.

Successful application of a PressureWire retrogradely across an ATS prosthetic aortic valve to diagnose constrictive pericarditis

Assessment of the left ventricular pressure measured across an aortic valve prosthesis is occasionally necessary when noninvasive imaging and Doppler echocardiographic data are inconclusive or differ from the clinical findings for specific scenarios, such as diagnosing constrictive or restrictive physiology. We present a case in which we safely and effectively replicate the previous successful application of a PressureWire in diagnosing constrictive pericarditis in a patient with a bileafltet mechanical aortic and mitral valves.

Direct Transthoracic Access to the Left Ventricle for Catheter Ablation of Ventricular Tachycardia

Background— Percutaneous approaches for radiofrequency ablation of ventricular tachycardia (VT) in the left ventricle are typically transarterial retro-aortic, antegrade transmitral via an interatrial septal puncture, or epicardial. However, all 3 approaches may be contraindicated in certain cases. We describe 2 cases of VT ablation in which aortic and mitral valve replacements did not permit utilization of any of these techniques.

Methods and Results— Direct access to the left ventricular cavity was achieved with a percutaneous puncture through the intercostal space overlying the apex in the first case and through a left minithoracotomy in the second. A sheath was then inserted via the Seldinger technique, allowing catheter access for mapping and ablation of the VT. After successful ablation, the sheaths were withdrawn and hemostasis was achieved. A large left hemothorax occurred from the left ventricular apical puncture in the first case. Direct closure with a purse-string suture in the second case achieved hemostasis.

Conclusions— Direct percutaneous left ventricular puncture is a viable option for mapping and ablation of left ventricular VT. A minithoracotomy allows better hemostatic control. This technique has a role when other percutaneous approaches are contraindicated.

Utilization of a pressure sensor guidewire to measure bileaflet mechanical valve gradients: hemodynamic and echocardiographic sequelae

Suspected prosthetic valve dysfunction is a difficult clinical problem, because of the high risk of repeat valvular surgery. Echocardiographic measurements of prosthetic valvular dysfunction can be misleading, especially with bileaflet valves. Direct measurement of trans-valvular gradients is problematic because of potentially serious catheter entrapment issues. We report a case in which a high-fidelity pressure sensor angioplasty guidewire was used to cross prosthetic mitral and aortic valves in a patient, with hemodynamic and echocardiographic assessment. This technique was safe and effective, refuting the inaccurate non-invasive tests that over-estimated the aortic valvular gradient.