Santangeli Pasquale, Hyman Matthew C, Muser Daniele, Callans David J, Shivkumar Kalyanam, Marchlinski Francis E
Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California.
JAMA Cardiol. 2021 Mar 1;6(3):326-331. doi: 10.1001/jamacardio.2020.4414.
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.
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.
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.
Feasibility and safety of a trans-RA access to the LV for catheter ablation of VT.
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).
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.
对于主动脉瓣和二尖瓣位植入机械瓣膜的患者，经股动脉途径经皮进入左心室（LV）以进行室性心动过速（VT）导管消融被认为是不可行的。
描述一种通过股静脉途径经皮经右心房（RA）进入LV，用于主动脉瓣和二尖瓣位植入机械瓣膜患者VT导管消融的结果。
设计、设置和参与者：这项观察性研究纳入了主动脉瓣和二尖瓣位植入机械瓣膜且与LV基质相关的复发性单形性药物难治性VT的连续患者。在心脏内超声引导下，通过直接穿刺RA的下内侧，靠近LV的下间隔突（ISP-LV），借助可弯曲鞘管和射频导线，经股静脉途径进行经皮LV穿刺。一旦导线进入LV，对心室切开部位进行球囊扩张（使用非顺应性球囊；直径8至10mm），以利于鞘管在LV内通过。
对于主动脉瓣和二尖瓣位植入机械瓣膜的患者，经穿刺ISP-LV经皮经RA进入LV以进行VT导管消融。
经RA进入LV进行VT导管消融的可行性和安全性。
共有4例患者（平均[标准差]年龄，60[7]岁；平均[标准差]LV射血分数，31%[9%]），其与LV基质相关的复发性VT（缺血性心肌病，3例；非缺血性心肌病，1例），且主动脉瓣和二尖瓣位植入机械瓣膜，接受了经ISP-LV经RA进入LV进行VT导管消融。获得LV穿刺的时间从60分钟（首例）到22分钟（末例）不等（平均[标准差]，36[15]分钟）。未发生与穿刺相关的并发症。特别是，在3例基线时房室传导保留的患者中，穿刺后未观察到新的传导异常。3例患者在程控心室刺激时实现了完全VT不能诱发，在中位随访14个月（范围6至21个月）时，无患者发生VT复发。
对于主动脉瓣和二尖瓣位植入机械瓣膜的患者，经股静脉途径经皮经RA进入LV进行VT导管消融是可行的，且似乎是安全的。这项新技术可能使在无法通过逆行主动脉或经房间隔途径进行传统LV穿刺的患者群体中进行VT导管消融成为可能。
