Transseptal catheterization in adults: enhanced efficacy and safety by low-volume operators using a "non-standard" technique

Percutaneous transvenous mitral commissurotomy in mitral stenosis and left atrial appendage clot patients in special conditions: Hospital-based study

Background

The percutaneous transvenous mitral commissurotomy is an important procedure for the treatment of mitral stenosis. A lot of mitral stenosis cases have left atrial appendage clot which precludes the patient from the benefit of this procedure.

The aim of the study was to study the feasibility and safety of the procedure in a patient with appendage clot in the setup of certain urgent conditions.

Method

All cases of mitral stenosis with significant dyspnea and mitral valve area <1.5 cm² with left atrial appendage clot and a condition which would preclude the patient from continuing on anticoagulation and needed urgent intervention were included in the study. From January 2011 to December 2013, twenty patients coming to Shahid Gangalal National Heart Centre, Kathmandu were selected for the procedure with conventional sampling technique. Informed written consent was obtained from the patients explaining all possible complications. The approval of the study was taken from the ethical committee of the hospital.

Result

Mean mitral valve area increased from 0.90 cm² (SD ± 0.14) to 1.5 cm² (SD ± 0.21) (p = 0.02). Left atrial mean pressure decreased from mean of 20 to 10 mmHg. Subjective improvement was reported in all. All of the patients had fulfilled criteria for successful PTMC. There was no mortality during hospital stay or in one-week follow-up period. There were no neurological complications or any need for emergency surgery.

Conclusion

The immediate result of percutaneous transvenous mitral commissurotomy in selected cases of mitral stenosis with left atrial appendage clot is safe and acceptable in certain urgent situations in experienced hands.

Echocardiography-guided interventions

A major advantage of echocardiography over other advanced imaging modalities (magnetic resonance imaging, computed tomographic angiography) is that echocardiography is mobile and real time. Echocardiograms can be recorded at the bedside, in the cardiac catheterization laboratory, in the cardiovascular intensive care unit, in the emergency room-indeed, any place that can accommodate a wheeled cart. This tremendous advantage allows for the performance of imaging immediately before, during, and after various procedures involving interventions. The purpose of this report is to review the use of echocardiography to guide interventions. We provide information on the selection of patients for interventions, monitoring during the performance of interventions, and assessing the effects of interventions after their completion. In this document, we address the use of echocardiography in commonly performed procedures: transatrial septal catheterization, pericardiocentesis, myocardial biopsy, percutaneous transvenous balloon valvuloplasty, catheter closure of atrial septal defects (ASDs) and patent foramen ovale (PFO), alcohol septal ablation for hypertrophic cardiomyopathy, and cardiac electrophysiology. A concluding section addresses interventions that are presently investigational but are likely to enter the realm of practice in the very near future: complex mitral valve repairs, left atrial appendage (LAA) occlusion devices, 3-dimensional (3D) echocardiographic guidance, and percutaneous aortic valve replacement. The use of echocardiography to select and guide cardiac resynchronization therapy has recently been addressed in a separate document published by the American Society of Echocardiography and is not further discussed in this document. The use of imaging techniques to guide even well-established procedures enhances the efficiency and safety of these procedures.

Future of interventional cardiology in pediatrics

A trend toward use of less invasive, nonsurgical approaches to the treatment of congenital heart disease has developed. Although transcatheter valve replacements and ventricular septal defect closures have already been performed in children, many other techniques and devices are being developed for the palliation of children with a single ventricle. Several groups have already established catheter-based procedures for the creation of Fontan communications, and others have performed nonsurgical pulmonary artery banding. Additionally, fetal catheter-based interventions are being developed for the treatment of severe congenital heart disease in utero. Because this trend toward catheter-mediated treatment is certain to continue, care must be taken to regulate safely the introduction of novel techniques and devices into clinical use in pediatric cardiology.

Transcatheter creation of an atrial septal defect using radiofrequency perforation

Transseptal perforation using radiofrequency energy was performed successfully in a patient with congenital heart disease and a thickened interatrial septum. This was followed by balloon dilatation of the atrial septal defect. Radiofrequency is presented as a alternative to standard transseptal needle puncture. Cathet Cardiovasc Intervent 2001;54:83-87.

Anterior staircase manoeuvre for atrial transseptal puncture

OBJECTIVE

Assessment of an anterior staircase modification to the standard atrial transseptal technique.

DESIGN

Retrospective report on patients undergoing atrial transseptal puncture.

SETTING

A regional cardiac centre.

PATIENTS

A series of 658 patients catheterised between 1975 and 1991.

RESULTS

Needle entry to the left atrium was obtained in 647 (98.3%) patients with needle and catheter entry to the left atrial cavity in 637 patients (96.8%). Sustained atrial arrhythmia occurred in six patients (0.9%) and pronounced bradycardia in one. Cardiac perforation occurred in three patients (0.5%) but did not cause cardiac tamponade. There were no deaths or embolic complications caused by the transseptal puncture. The anterior staircase manoeuvre was particularly useful in patients with problem septa--that is, when the septum bulged into the right atrial cavity, lacked a detectable limbic edge, was tough or tender, or when the right atrium was considerably enlarged.

CONCLUSION

The anterior staircase technique is a useful modification to the atrial transseptal puncture technique because it allows repeated passage down the atrial septum without the need for guidewire and needle exchanges for repositioning in the superior vena cava.

Atrial septal puncture technique in percutaneous transvenous mitral commissurotomy: mitral valvuloplasty using the Inoue balloon catheter technique

Transseptal catheterization is a vital component of percutaneous transvenous mitral commissurotomy. Therefore, a well-executed transseptal catheterization is the key to a safe and successful percutaneous transvenous mitral commissurotomy. Two major problems inherent in atrial septal puncture for percutaneous transvenous mitral commissurotomy are cardiac perforation and puncture of an inappropriate atrial septal site. The former may lead to serious complication of cardiac tamponade and the latter to possible difficulty in maneuvering the Inoue balloon catheter across the mitral orifice. This article details atrial septal puncture technique, including landmark selection for optimal septal puncture sites, avoidance of inappropriate puncture sites, and step-by-step description of atrial septal puncture.

Transseptal catheterization update 1992

Resurgence of the transseptal procedure in the last decade has occurred coincident with the advent of therapeutic catheterizations and in particular mitral balloon vavuloplasty. As larger numbers of these procedures have been performed, experience shows that the position of intended septal puncture varies for each anticipated procedure and need not lie at the fossa ovalis, which is frequently displaced or inaccessible. Recognizing the dynamic alterations in septal and atrial anatomy that accompany the various combinations of valvular heart disease, the experienced interventionalist will use precatheterization echo and radiological techniques to enable precise and localized transseptal puncture. Using these techniques in 597 patients for valvular heart disease, we have had no deaths and a morbidity of 1.8% with the transseptal puncture.