IMPORTANCE: In 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 PARTICIPANTS: This 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 MEASURES: Feasibility 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 RELEVANCE: A 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.
IMPORTANCE: In 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 PARTICIPANTS: This 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 MEASURES: Feasibility 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 RELEVANCE: A 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.
Authors: Clifford G Robinson; Pamela P Samson; Kaitlin M S Moore; Geoffrey D Hugo; Nels Knutson; Sasa Mutic; S Murty Goddu; Adam Lang; Daniel H Cooper; Mitchell Faddis; Amit Noheria; Timothy W Smith; Pamela K Woodard; Robert J Gropler; Dennis E Hallahan; Yoram Rudy; Phillip S Cuculich Journal: Circulation Date: 2019-01-15 Impact factor: 29.690
Authors: Julian Wolfes; Christian Ellermann; Julia Köbe; Philipp S Lange; Patrick Leitz; Benjamin Rath; Kevin Willy; Fatih Güner; Gerrit Frommeyer; Lars Eckardt Journal: Herzschrittmacherther Elektrophysiol Date: 2022-05-13
Authors: Giovanni Volpato; Paolo Compagnucci; Laura Cipolletta; Quintino Parisi; Yari Valeri; Laura Carboni; Andrea Giovagnoni; Antonio Dello Russo; Michela Casella Journal: Front Cardiovasc Med Date: 2022-08-22
Authors: Joshua Hawson; Jonathan Kalman; John Goldblatt; Robert D Anderson; Troy Watts; Nick Hardcastle; Shankar Siva; Saurabh Kumar; Geoffrey Lee Journal: J Cardiovasc Electrophysiol Date: 2022-07-21 Impact factor: 2.942