Retrograde Left Ventricular Catheterization Research Articles

Transseptal antegrade transcatheter aortic valve replacement in a patient with severe aortic stenosis: a case report

We described a case report of transcatheter aortic valve replacement in conditions when the aortic stenosis anatomy does not make it possible to perform retrograde left ventricular catheterization, and the patient’s condition severity does not allow performing transapical or surgical aortic valve replacement. The presented technique of interatrial septal puncture with antegrade passage of the guidewire through the mitral and aortic valves and the venoarterial looping demonstrates an elegant way to solve this clinical situation, and can be adopted by specialists performing transcatheter interventions in severe aortic stenosis.

Direct intraoperative measurement of residual pressure gradient after resection of discrete subaortic stenosis

Transesophageal echocardiography (TEE) plays an important role for congenital cardiac surgery, such as measurement of residual shunt, residual regurgitation, residual pressure gradient (PG), and so on. For discrete subaortic stenosis, it could be a simple and effective option to check residual PG by direct intraoperative periaortic retrograde left ventricular catheterization if infantile TEE is not available.

Catheter ablation of left accessory atrioventricular connections: the transseptal approach.

In the past few years, there has been a relative explosion of activity in the realm of interventional cardiology. The high rate of success of radiofrequency energy ablation have transformed catheter ablation from an investigational procedure into the first-line therapy for symptomatic Wolff-Parkinson-White syndrome. Radiofrequency catheter ablation for preexcitation syndrome is commonly based on a ventricular approach. Such an approach might be associated with the risk of prolonged arterial catheter manipulation, retrograde left ventricular catheterization, and production of multiple, potentially arrhythmogenic, ventricular lesions created during ablation. Potential risks can be avoided using atrial insertion ablation procedures. The transseptal procedure that was developed in the 1950s and 1960s as a diagnostic procedure and then shelved in the 1970s and early 1980s has now come back into prominence as a therapeutic technique in the treatment of valvular heart disease, and then in the ablation of the left accessory atrioventricular connections. Atrial aspect of mitral annulus is a relatively smooth, nonobstructed surface that simplifies catheter movement, thereby permitting rapid and accurate accessory pathway location. Although primary use of earliest endocardial retrograde atrial activation as a marker of accessory pathway atrial insertion is sufficiently accurate to permit successful ablation, direct recording of an accessory pathway potential is an important predictor of successful ablation site. Moreover, the analysis of the unipolar atrial electrogram, recorded during sinus rhythm from the tip of the ablation catheter, provides further information for localizing the atrial insertion of the accessory pathways. Shortest atrial-accessory pathway and negative delta-accessory pathway intervals have been found to be the best predictors of the successful site. A 90.5% success of the transseptal approach on an overall population of 328 patients, higher for overt than for concealed pathways, is comparable with the results of the retrograde. Complications are 0.5%. In conclusion, the transseptal approach for ablation at the atrial site is very safe and highly effective, and avoids prolonged arterial cannulation and catheter manipulation in the ascending aorta and left ventricle.

Radiofrequency endocardial catheter ablation of accessory atrioventricular pathway atrial insertion sites.

High rates of success using radiofrequency ablation energy have rapidly transformed catheter ablation from an investigational procedure to the nonpharmacological therapy of choice for symptomatic Wolff-Parkinson-White syndrome. Prior studies of radiofrequency accessory pathway ablation were based on a ventricular approach. Risks associated with prolonged arterial catheter manipulation, retrograde left ventricular catheterization, and production of ventricular lesions required for successful ventricular insertion ablation can be avoided using atrial insertion ablation procedures. The purpose of the present study was to define the safety and efficacy of accessory pathway ablation using radiofrequency energy delivered solely to accessory atrioventricular pathway atrial insertion sites. One hundred fourteen patients with accessory pathway-mediated tachycardia underwent attempted radiofrequency current ablation at the accessory pathway atrial insertion site. All catheters were introduced transvenously. Left-sided accessory pathways were approached using transseptal left atrial catheterization techniques. Retrograde localization of the atrial insertion site during reentrant tachycardia was characterized by 40 +/- 15-msec local ventriculoatrial and 79 +/- 17-msec surface QRS to local atrial electrogram intervals. Presumed accessory pathway potentials were present in only 30% of ablation site electrograms. Successful ablation required 6.2 +/- 5.3 radiofrequency energy applications. Cumulative energy dose required for success was 2,341 +/- 2,233 J. There were no complications associated with transseptal catheterization. Energy delivery to accessory pathway atrial insertion sites was associated with non-life-threatening complications in two patients. Recurrent conduction requiring repeat ablation occurred in 10 of 115 (9%) successfully ablated accessory pathways, all within 1 month of the ablation procedure. After 21.2 +/- 4.6 months of follow-up, 108 of 114 (95%) patients are asymptomatic and without evidence of accessory pathway conduction. The atrial insertion approach to accessory pathway ablation is safe and highly effective. This approach compares favorably with the retrograde ventricular insertion ablation technique. Atrial insertion ablation eliminates the need to produce ventricular lesions and avoids the risks of prolonged arterial catheter manipulation and retrograde left ventricular catheterization.

Retrograde catheterization of left ventricle through mechanical aortic prostheses.

Twenty-three patients who had undergone aortic valve replacement with a mechanical aortic valve prosthesis (ball-valve: 17, tilting-disc: 6) were investigated by retrograde left ventricular catheterization using a 6 F pigtail catheter. Twelve of these 23 patients also had had combined aortic and mitral valve replacement. To assess the magnitude of the catheter-induced aortic regurgitation and its effect on left ventricular and mitral valve function, 10 patients (group 1) were simultaneously investigated by the transseptal route (8 patients) or direct left ventricular puncture. The 13 other patients (group 2) were studied only by the retrograde crossing of the aortic valve prosthesis. In group 1, placement of the catheter across the valve induced an increase in heart rate (+12%), in left ventricular end-diastolic pressure (from 17.2 +/- 9.6 to 33.3 +/- 12.0 mmHg), a decrease in aortic systolic (-19%) and diastolic (-25%) pressures, and left ventricular systolic pressure (-10%). Transvalvular aortic pressure gradient increased from 15.4 +/- 8.2 to 23 +/- 12.1 mmHg. Pre- and post-crossing pressure gradients were linearly correlated (r = 0.93). Left ventricular end-diastolic volume increased slightly but significantly (+9%), ejection fraction remained unchanged. Pre- and post-crossing regurgitation fractions were linearly related (r = 0.98). Hence, the magnitude of catheter-induced aortic regurgitation averaged 27% whether or not a pre-crossing regurgitation was noted. In group 2, retrograde crossing of the aortic valve prosthesis induced similar hemodynamic changes. There were no catheterization-related complications.(ABSTRACT TRUNCATED AT 250 WORDS)

(Percutaneous) retrograde left ventricular catheterization in aortic valve stenosis.

(Percutaneous) retrograde left ventricular catheterization in aortic valve stenosis.

A modified catheter system for retrograde left ventricular catheterization in aortic valve stenosis.

Conventional retrograde catheterization of the left ventricle using a single large catheter through severely stenotic aortic valves or prostheses has recognized difficulties. An alternative method is described. This method incorporates a coronary angioplasty guide catheter and coronary probing catheter attached to separate pressure transducers allowing simultaneous recording or aortic and LV pressures. This technique was used in seven patients with aortic stenosis in whom a conventional approach had failed. The movable probing catheter permits alterations of the catheter orientation and angulation while the guiding catheter stabilizes the system within the high velocity jet formed in the ascending aorta. This stabilization and the small size of the coronary probing catheter permit exploration of the valve surface and allow for insertion through a tilting disc valve or a severely stenotic valve without significantly altering hemodynamic function. In our laboratory this technique allowed us safely and reliably to assess aortic valve dynamics in each of the patients in whom the technique was attempted without resorting to either transseptal or direct left ventricular puncture.

An improved method for transseptal left ventricular catheterization

It is difficult to perform a retrograde left ventricular catheterization in patients having an aortic valve replacement. An improvement of the conventional transseptal catheterization (Brockenbrough method) led to a better success rate of catheterization. The fulcrum of the improved catheter was located 7 cm from the tip. Its curvature was approximately 270 degrees. Its tip was bent inward to form a pig-tail shape to prevent myocardial injury. This catheterization was performed 33 times in 32 patients. A 97% success rate was achieved. An exercise loading test was performed with a bicycle ergometer while this catheter was maintained in the left ventricle of a patient placed in a supine position. The catheter was well retained in the left ventricle and produced a minimal number of arrhythmias during exercise. The modification of this catheter has proved to be a better method of left ventricular catheterization in patients with an aortic valve replacement.

A safe, rapid method of transfemoral retrograde left ventricular catheterization in valvular aortic stenosis.

We report our experience with the use of a standard left Amplatz coronary catheter and a guidewire to cross the aortic valve in 34 patients being evaluated for valvular aortic stenosis. A number of 2 Amplatz left coronary catheter inserted via the femoral artery was positioned above the noncoronary aortic valve cusp with the tip aligned toward the aortic valve. This catheter allowed a soft-tipped, Teflon-coated guidewire to be guided through the aortic valve orifice. The catheter was then advanced over the guidewire into the left ventricle. This technique was successful within six minutes in 32 of 34 patients (94%). The stenotic aortic valve was crossed in less than two minutes in 15 patients (42%) and in less than four minutes in 31 (91%). The aortic valve was not crossed in two patients. Twenty-one patients (62%) had an aortic valve area of less than 0.75 cm2. There were no complications. We conclude that this technique provides a method for safe, rapid transaortic left ventricular catheterization in patients with aortic stenosis of all degrees of severity.

Transseptal and retrograde left ventricular catheterization in patients with the stent-mounted porcine xenograft valve prosthesis in the aortic position.

Cardiac catheterization techniques for measuring the systolic pressure gradient across the stent-mounted porcine xenograft in the aortic position and accomplishing left ventriculography are described. The transseptal technique is a rapid and predictable means of entering the left ventricle but requires a highly skilled operator. Retrograde left ventricular catheterization via the femoral artery is a technique familiar to all invasive cardiologists. Usually a pitfall catheter is used. In patients with the stent-mounted procine xenograft in the aortic position, we have found the A2 Multipurpose catheter to be the fastest and most predictable means of entering the left ventricle from the groin. Potential complications of retrograde left ventricular catheterization in patients with aortic valve prostheses are discussed.

Retrograde left ventricular catheterization in patients with an aortic valve prosthesis

Twenty-seven consecutive patients with an aortic valve prosthesis were evaluated with retrograde left ventricular Catheterization. The prosthesis was successfully crossed, permitting hemodynamic and angiographic evaluation of function of the prosthetic valve, left ventricle and mitral valve in all 27 cases. No complications were encountered. In patients with active endocarditis or recent embolization, the retrograde technique was avoided when possible and attempts were made to utilize other techniques for study. However, three such patients were evaluated with the retrograde technique without complication. Examination of pressure tracings and cineangiographic films suggested only minor interference with valve poppet movement induced by the catheter traversing the valve. In three cases, hemodynamic data were recorded with the catheter crossing the prosthesis at one time and a paraprosthetic valve defect at another time. Identical gradients were recorded. This series documents the safety and efficacy of the retrograde approach, which is proposed as an alternative to the transseptal technique and left ventricular puncture.

Thrombogenicity of guide wires

Three patients undergoing retrograde left ventricular catheterization experienced cerebral emboli with catastrophic neurologic consequences. In each instance, a Teflon-coated guide wire was used to facilitate passage through the aortic valve. This finding led to a detailed investigation of the procedures and materials used. The thrombogenicity of both Teflon and stainless steel guide wires was determined in 10 mongrel dogs. Clot formation was readily identified within a few minutes on all guide wires. In each instance clotting was significantly less on steel than on Teflon-coated wires ( P Although our experiments may not be directly applicable to man, we recommend that the increased thrombogenicity of Teflon-coated wires be considered, When such wires are needed, they should be used with caution and preferably only in the descending aorta for brief periods, or in conjunction with systemic hepatization.

Mediastinal and Retropharyngeal Hemorrhage

Upper mediastinal and retropharyngeal hemorrhage complicated retrograde left ventricular catheterization in two patients. The clinical signs of shock associated with upper airway obstruction were dramatic and presented diagnostic problems. In one patient, recognition of an enlarging neck circumference and visual examination of the oral pharynx aided in establishing the proper diagnosis, which was later confirmed by x-ray films of the chest and lateral aspects of the neck. Both patients were successfully treated with blood replacement and maintenance of an adequate airway. Anticoagulant therapy may be a cause of serious hemorrhage following arterial perforation.

Traumatic right coronary artery occlusion incident to retrograde left ventricular catheterization with a stiff catheter ∗

Right coronary arterial occlusion occurred during or after retrograde left ventricular catheterization and angiocardiography in a 55 year old woman with chronic rheumatic heart disease. Ventricular fibrillation developed eight hours later, and she could not be resuscitated. Necropsy showed the occlusion to be due to subintimal hemorrhage at the site of a small atheromatous plaque near the origin of the artery, with dark red thrombus beyond the intimai lesion. The fatal lesion was ascribed to intimai trauma caused by the tip of a Gensini catheter seen to enter the artery during the early stages of the investigation. Eleven other major nonfatal complications were encountered during 97 retrograde catheterizations for left ventricular angiocardiography.

INTRAMURAL DEPOSITION OF CONTRAST AGENT DURING SELECTIVE ANGIOCARDIOGRAPHY.

Intramyocardial injection of contrast agent is a unique complication of selective angiocardiography and has been recognized with increasing frequency in recent years. Its potential gravity prompted us to investigate its cause, effects, and possible prevention, and this report comprises the results of this study. Bjöork et al. (2) report 3 intramyocardial injections with 1 death in a series of 142 transthoracic needle punctures. In a review article, Greenberg and Knox (5) cite 19 instances of intramural injection in a total of 437 percutaneous ventriculographies, with 3 fatalities. From experience with the catheter approach, Keith et al. (6) mention 3 cases of subintimal injection, all in infants, apparently producing no significant clinical manifestations. Also in reference to catheter studies, Bagger et al. (1) found 4 right ventricular intramural injections in a series of 1,375 angiocardiograms, with no late sequelae. Dotter et al. (4) report 1 case in which the intramural injection through a catheter was held responsible for the patient's death eight hours later. Davidsen et al. (3), in a series of 500 selective studies, and Kjellberg et al. (7), in a series of 728 angiocardiograms (the number of selective studies is not stated), do not refer to this complication. Clinical Material and Methods During the past five years, the present authors have recognized 16 intramural injections. Of 248 selective catheter angiocardiographic studies made between June 1957 and September 1962, 13 gave evidence of partial intramural injection. Of 4 transthoracic needle injections into the left ventricle during this same period, 3 were partially intramural. Side-hole catheters were either #5 or #6 Eppendorf or NIH aortographic. End-side-hole catheters were #8 Teflon except for one #6 woven nylon. All catheter injections were performed at pressures between 525 and 675 lb. per square inch. The contrast agent was usually Ditriokon, but in some of the earlier studies, 70 per cent Urokon or 75 per cent Hypaque was used. Clinical Manifestations: Clinical manifestations were apparent in only 2 of the 16 cases of intramural injection. These will be briefly reported. Case I: In B. S., a four-year-old boy with severe aortic valvular stenosis, retrograde left ventricular catheterization revealed a 90 mm. gradient across the aortic valve. A selective left ventricular angiocardiogram was planned. Prior to the high-pressure injection of contrast medium, several hand injections of saline failed to provoke ectopic ventricular systoles, and the catheter tip was thought to lie freely within the left ventricular cavity. Accordingly, 20 c.c. of Ditriokon was injected at a pressure of 675 lb. per square inch through a #6 side-hole catheter.

Serum glutamic oxaloacetic and pyruvic transminases in a case of cardiac arrest resuscitated by external cardiac massage.

Serial serum transaminase determinations were made before and following cardiac arrest encountered during retrograde left ventricular catheterization and successfully managed by external cardiac massage. Prompt, significant elevation of serum glutamic oxaloacetic transaminase and slight rise in serum pyruvic transaminase occurred without evidence of myocardial infarction. Skeletal muscle trauma appeared the most likely cause.