Transatrial Approach Research Articles

A preliminary study of pulmonary vein implant applicability and safety as a potential ablation platform in a follow-up study in pigs.

Recurrence of atrial fibrillation after an ablation procedure remains a major problem which emphasizes the need for improved pulmonary vein isolation techniques. The aim of this study was to describe an implantation procedure of a pulmonary vein-stent which may possibly serve as an ablation technique in the future and to examine stent safety in a follow-up study in pigs. Eight pigs were catheterized and nine self-expanding nitinol stents were implanted through a transfemoral or transatrial approach into the antra of the pulmonary veins. After 3 months' follow-up, the animals were euthanized for further examination. During the follow-up phase, no complications were observed. Absence of thrombus formation or pulmonary vein wall dissection was noticed during anatomical and histological evaluation of the heart-lung packages. All implants were almost completely covered by neo-intima, of which thickness varied between 0.2 and 3.9mm. Stents can safely be positioned and deployed into the antra of the pulmonary veins without any acute or long-term (3 months) adverse effects. In the future, these implants could function as a permanently implanted ablation device and provide new therapeutic strategies for pulmonary vein isolation in patients with atrial fibrillation.

Transcatheter Tricuspid Valve Implantation of NaviGate Bioprosthesis in a Preclinical Model

Patients with isolated functional or recurrent tricuspid regurgitation are often denied surgery because they are considered to be at high risk. Transcatheter valve therapy provides a less invasive alternative for tricuspid regurgitation associated with right heart failure. We have evaluated the feasibility of transcatheter tricuspid valve implantation of the NaviGate valved stent in a long-term swine model. The valved stent was successfully implanted through transjugular and transatrial approaches on the beating heart with excellent hemodynamic and valve performance. No conduction disturbance or coronary obstruction was observed. This technology could provide an alternative treatment for patients who are at high surgical risk with severe tricuspid regurgitation and compromised right ventricular function.

Surgical strategies protecting against right ventricular dilatation following tetralogy of Fallot repair

BackgroundRight ventricular (RV) volume overload increases morbidity and mortality after tetralogy of Fallot (TOF) repair. Surgical strategies like pulmonary leaflets sparing and tricuspid valve repair at time of primary repair may decrease RV overload. Our objective is to evaluate early and midterm results of pulmonary leaflets sparing with infundibular preservation and tricuspid valve repair in selected TOF patients with moderate pulmonary annular hypoplasia.MethodsFrom 2011 to 2016; 46 patients with TOF and moderate pulmonary annular hypoplasia had surgical repair with sparing of the pulmonary valve leaflets. Concomitant tricuspid valve repair was performed in 33 patients (71.8%). Mean age was 13.1 ± 4.8 months, 68% were males (n = 31) and mean weight was 9.5 ± 2.3 kg. Preoperative McGoon ratio was 1.9 ± 0.4 and pulmonary valve z-score ranges from − 2 to − 3. Preoperative pressure gradient of RVOT was 80.9 ± 7.7 mmHg and 10.9% had minor coronary anomalies (n = 5).ResultsAll repairs were performed through trans-atrial trans-pulmonary approach. 87% had pulmonary valve commissurotomy (n = 40). Mean cardiopulmonary bypass time was 71 ± 6.3 min and ischemic time 42.4 ± 4.9 min. Hospital mortality occurred in 4.3% (n = 2). Mean RVOT pressure gradient decreased significantly postoperatively (28.8 ± 7.2 mmHg, p-value< .001) and at the last follow up (23.6 ± 1.8 mmHg, p-value< .001). Pulmonary regurgitation progressed by one grade in 2 patients compared to the postoperative grade. 1 patient (2.5%) had late mortality and reintervention was required in 5 patients (12.5%).ConclusionPulmonary leaflets sparing, and tricuspid valve repair are safe for TOF repair with no added morbidity or mortality. These procedures could contribute to reducing right ventricular volume overload over time after TOF repair.

Transatrial approach for total tetralogy of Fallot TOF correction: analysis of 24 cases.

Background: Tetralogy of Fallot TOF is the most common cause of congenital cyanotic heart disease. It is the most common congenital lesion that is likely to result in survival to adulthood and encountered in adult after repair. Tetralogy of Fallot comprises around 7.5 % of all congenital heart diseases in Iraq.Objective: The aim of this study is to analyse the transatrial strategy for total correction of tetralogy of Fallot TOF.Methods: Cross-sectional study was done during the period between 2012-2014 for twenty-four patients that admitted to Ibn Al-Bitar hospital in Baghdad with amenable TOF pathology for transatrial repair.Results: Twenty-four patients, 16 were males and 8 were females. Ages ranged from 2-31 years. There was no early or late postoperative mortality in this review for follow-up period ranged from 6 – 24 months. The early and late postoperative echocardiography data in regard to pulmonary and tricuspid regurgitation and right ventricle RV function were delineated. Normal pulmonary valve (62.5%, 58.3%), mild pulmonary regurgitation (29.2%, 37.5%), moderate pulmonary regurgitation (8.3%, 4.2%). Normal tricuspid valve (75%, 70.8%), mild tricuspid regurgitation (20.8%, 20.8%), moderate tricuspid regurgitation (4.2%, 8.3%) respectively. No severe pulmonary or tricuspid regurgitation was reported. Postoperative RV function was normal in (87.5%, 83.3%), mild RV dysfunction in (8.3%, 12.5%), moderate RV dysfunction in (4.2%, 4.2%) respectively. No severe RV dysfunction was reported. The mean RVOT pressure gradient was 36.8 mmHg. This gradient decreased on follow-up echocardiography, mean 24.5 mmHg. P values were less than 0.05%.Conclusion: The transatrial approach is a feasible technique for total repair of TOF in adequate pulmonary annulus size with satisfactory late postoperative echocardiography performance.&#x0D; الخلفية:ان رباعية فالوت هي اكثر اسباب مرض ازرقاق الدم الولادي شيوعآ. وهو اكثر تشوهات القلب الخلقية التي تستمر في الحياة الى البلوغ، وتصادف عند البالغين بعد عمليات التصليح. ويشكل تشوه رباعية فالوت حوالي ٧.٥٪ من امراض القلب الخلقية في العراق. &#x0D; الهدف:ان الهدف من هذه الدراسة هو اجراء تحليل لطريقة عبر الاذين في عملية التصليح الكامل لرباعية فالوت.&#x0D; الطرائق. هي دراسة مستعرضة تمت للفترة من ٢٠١٢ ولغاية ٢٠١٤. تم دراسة ٢٤ طفل ادخلوا في مستشفى ابن البيطار في بغداد، كان لديهم تشوه يسمح بالتداخل عبر الاذين.&#x0D; النتائج: ٢٤ حالة، ١٨ ذكور و ٨ اناث. الاعمار تتراوح من ٢ ـ٣١ سنة. لم تسجل حالة موت بدائية او متقدمة في الدراسة الحالية ولمدة متابعة ٦ الى ٢٤ شهرا. معدل وقت دوران ماكنة القلب الصناعية كان ١٢٧ دقيقة. ومعدل غلق الشريان الابهر كان ١٠٣ دقيقة. ان مشاهدات فحص الامواج الصائتة القلبية مبكرا و متأخرا بعد العملية كان كما يلي، صمام رئوي طبيعي ٦٢.٥٪ و ٥٨.٣٪ ، تهدل الصمام الرئوي البسيط ٢٩.٢٪ و ٣٧.٥٪، تهدل الصمام الرئوي المعتدل ٨.٣٪ و٤.٢٪. صمام ثلاثي طبيعي ٧٥٪ و ٧٠.٨٪، تهدل الصمام الثلاثي البسيط ٢٠.٨٪ و ٢٠.٨٪، تهدل الصمام الثلاثي المعتدل ٤.٢٪ و ٨.٣٪. لاتوجد حالة تهدل صمام رئوي او ثلاثي شديد. كانت فعالية البطين الايمن الطبيعية ٨٧.٥٪ و ٨٣.٣٪، بسيطة الاعتلال ٨.٣٪ و ١٢.٥٪ معتدلة الاعتلال٤.٢٪ و ٤.٢٪، ولم تسجل شديدة الاعتلال. ان معدل نسب فرق الضغط عبر منفذ البطين الايمن كان ٣٦.٨ ملم زئبق. ان هذا الفرق يتضائل مع امتداد الفترة الزمنية، معدل ٢٤.٥ ملم زئبق. قيم معامل p كانت اقل من ٠.٠٥ ٪.&#x0D; الاستنتاج: ان طريقة عبر الاذين هي الية ممكنة في الاصلاح الكامل لرباعية فالوت بوجود حجم حلقة رئوية كافي مع اداء مرضي لفحص الامواج الصائتة القلبية المتأخر.

Innovative mirror image transatrial techniques for biventricular repair in inverted dextrocardia

Background: Correction of hearts with situs inversus dextrocardia represent technical challenges due to mirror image anatomy and altered conduction pathway. Ventriculotomy has been the traditional approach for biventricular repair. We report our experience of trans-atrial approach in these patients employing an easily reproducible preoperative delineation of the anatomy. In addition we also discuss our way of surgical execution for these complex subsets. Methods and Findings: 15 patients (M:F=7:8) with situs inversus dextrocardia with diverse congenital cardiac anomalies underwent biventricular repair through our trans-atrial approach from left side of patient with detailed pre-operative evaluation of the anomalies. Orientation of intra-cardiac anatomy was obtained pre-operatively by rendering standard illustrations in reversed and inverted way. Median age and weight were 12 months (4.5 months-31 years) and 5.8 kg (3.4-59 kg) respectively. The surgical spectrum included closure of ventricular septal defects (n=6), repair of double outlet right ventricle (n=3), repair of tetralogy of Fallot (n=5) and double switch operation for congenitally corrected transposition of great arteries, routable ventricular septal defect and pulmonary stenosis. Tricuspid valve leaflet detachment was performed frequently to aid the repair (n=7). Mean hospital stay was 12.4 ± 2.6 days with no hospital mortality. On follow-up, all patients remained in sinus rhythm and in New York Heart Association class I. One patient had a small residual ventricular septal defect with insignificant shunt. Another patient with tetralogy of Fallot correction underwent right pulmonary artery balloon plasty. Patient with double switch operation needed re-admission for supraventricular tachycardia and medical management. Another patient of tetralogy of Fallot re-developed infundibular gradient, awaiting intervention. Conclusions: Trans-atrial biventricular repair is feasible and reproducible in these subsets. The inverted illustrations facilitate in enabling successful repairs while avoiding heart blocks and ventriculotomy. Short-term results are satisfactory.

Abstract 20942: Non-Invasive Isolation of the Pulmonary Veins in an Animal Model

Introduction: Pulmonary vein isolation (PVI) is well established as the preferred treatment for symptomatic paroxsysmal atrial fibrillation (pAF). We introduce a novel technique in which PVI is aimed for in a pig model, by non invasive heating of the proximal ring of an implant inserted in the pulmonary veins. Hypothesis: Non-invasive heating of an implant in the PV is feasible and safe Methods: A self-expanding nitinol-based implant was positioned in the common inferior pulmonary vein of 11 pigs, using a fluoroscopy guided transatrial approach. In a second part of the experiment, implants were positioned in the superior caval vein through a transfemoral approach of another 6 animals. Ablation was performed through a contactless energytransfer from a primary extracorporal coil to a secondary heatring (HR) embedded in the proximal part of the implant. Electrophysiological properties were assessed prior to and post ablation. Histological samples were obtained after 3 months. Results: In total, eightteen PV-implants were succesfully positioned. Ablation was performed in a safe manner, without injury of adjacent structures. PVI and bidirectional block was confirmed in all PV cases, and bidirectional block in 5 of the 6 caval vein implants (entry block shown in the figure-the heatring is at the level of the white arrow). Only mild neointimal proliferation was observed 3 months post ablation. Conclusions: Non-invasive ablation using self-expanding stents in the PV is safe and feasible, bidirectional isolation can be demonstrated in almost all cases, whilst no significant neointimal formation is observed:

Long-term outcomes following transatrial versus transventricular repair on right ventricular function in tetralogy of Fallot.

Outcomes after repair of tetralogy of Fallot (TOF) are good with either a transventricular (TV) or transatrial (TA) approach. We sought to determine if there is a relationship between the TV or TA approach and right ventricular (RV) function, and the role of residual pulmonary regurgitation (PR) on the long-term outcomes. This was a retrospective cohort multicentric study on survivors after surgical repair of TOF (TA versus TV approach, ±transannular patch) between 1990 and 2004. All patients underwent magnetic resonance imaging to assess RV volume, function, and PR. Patients were matched for length of follow-up and age. Clinical adverse events were retrieved from institutional databases. Seventy-nine patients (TA/TV = 37/42, median age 0.3 and 1.0 yrs, respectively) were included. At a median follow-up of 16.6 years (12.5-20.3), there were no differences in freedom from reintervention (either catheter or surgical), RV volumes, function, and PR between the TA and TV groups. Pulmonary valve (PV) replacement was significantly less frequent in the TA subgroup (P = 0.033) and patients with a preserved PV showed significantly lower RV volumes and less adverse events at follow-up. There is no significant difference in RV volumes and function between the TA and TV. However, the TA approach seems to be protective against PV replacement in the long-term. When PV is not preserved at repair, residual pulmonary regurgitation is a significant cause of late RV dysfunction and dilation, and is associated with a higher rate of late adverse events.

P1516A minimally invasive, transatrial approach is an effective alternative for failed transvenous laser lead extractions

P1516A minimally invasive, transatrial approach is an effective alternative for failed transvenous laser lead extractions

TCT-644 Transcatheter Balloon Expandable SAPIEN Valve Implantation Using Transatrial Approach in Patients With Mitral Stenosis and Severe Mitral Annular Calcification

TCT-644 Transcatheter Balloon Expandable SAPIEN Valve Implantation Using Transatrial Approach in Patients With Mitral Stenosis and Severe Mitral Annular Calcification

Submitral aneurysm in children.

We report a surgical series of submitral aneurysm in children. Between March 2011 and December 2015, eight consecutive patients less than 18 years old with submitral aneurysm underwent surgical correction. Six patients were female, the mean age was 7 ± 3.8 years old, and mean weight was 21.4 kg. Six patients were in NYHA functional class III or IV. Six patients underwent repair via a transatrial approach, another with a transatrial combined with transaneurysmal approach, and another with a transventricular approach. There were no in-hospital deaths but one 30-day mortality. One patient required reoperation. Two patients required mitral valve replacement. At discharge, one patient had severe and another had moderate mitral regurgitation. The mean follow-up time was 26.4 months and five patients were alive. No reintervention was required. Submitral aneurysm is not restricted to adults. Heart failure is the commonest clinical presentation in the pediatric age. The transatrial approach is feasible, safe, and associated with good short-term results. The mitral valve can be preserved in the majority of cases.

Ministernotomy for correction of ventricular septal defect.

BackgroundThe development of minimally invasive surgery in the adult has created motivation for similar approaches in the congenital heart domain. Over the past 20 years, this type of surgery has been advocated in an effort to reduce costs related to hospital stay, and to improve the cosmetic results. We report our experience with ventricular septal defect repair utilizing a ministernotomy incision.MethodsFrom August 2014 to August 2015, 26 patients underwent ministernotomy for correction of ventricular septal defect at our center. All patients were between the ages of 14 months-old to 24 years-old with weight ranged from 7.5 to 54 kg (median weight 12 kg). Diagnoses were confirmed with echocardiography. We analysed in-hospital and 6 months follow-up outcomes of the group.ResultsAll defects were corrected successfully with satisfactory exposure. The median cardiopulmonary bypass time was 64 min, and median cross clamp time was 42 min. The intensive care unit stay ranged from 1 day to 3 days (median ICU stay, 1.5 days) and the hospital stay ranged from 4 to 13 days (median hospital stay, 5 days). There were no deaths during the operation or severe postoperative complications. No residual shunts were observed.ConclusionOur results demonstrated the safety and efficacy of ministernotomy for the correction of ventricular septal defect with improved cosmetic results in patients greater than 7.5 kg. This aprroach can be used in either the transatrial or transarterial approach, and in smaller weight infants.

Transmural Placement of Endocardial Pacing Leads in Patients With Congenital Heart Disease

This study evaluates the feasibility and outcomes of transmural placement of endocardial leads (TML) in patients with congenital heart disease. Between October 2009 and May 2015, 29 TML procedures were performed in 27 patients. Leads are grouped according to their pacing site: atrial (TML-A, n= 24) or ventricular (TML-V, n= 12). The TML-V includes transatrial and transventricular approaches. Clinical outcome, functional properties of TML, and Kaplan-Meier freedom from lead dysfunction were evaluated. Median age was 4 years (range, 29 days to 43 years). Median follow-up duration was 2 years (range, 1 day to 5.7 years). There was no early mortality. Three late deaths were observed (2 unrelated, 1 related to pacing). In group TML-A, no lead dysfunction was noted. In group TML-V, there were 3 lead dislodgements and 1 lead fracture. Kaplan-Meier freedom from lead dysfunction after 0.5, 1, and 5 years, respectively, was 100% in group TML-A and 82% ± 11%, 73% ± 13%, and 59% ± 17% in group TML-V (log rank p < 0.01). Mean acute (at implantation) and chronic (at last follow-up) sensing thresholds were 3.1 ± 2.3 mV and 3.5 ± 2.5 mV in group TML-A and 11.6 ± 4.9 mV and 7.5 ± 4.6 mV in group TML-V, respectively. Mean acute and chronic pacing thresholds at 0.5 ms were 1.1 ± 0.6 V and 0.6 ± 0.3 V in group TML-A and 1.0 ± 0.6 V and 0.9 ± 0.5 V in group TML-V, respectively. The transmural approach provides an alternative method in patients with congenital cardiac defects who cannot receive transvenous leads and who have extensive epicardial scarring. Subanalysis shows superior midterm performance for TML-A compared with TML-V.

Repair of Tetralogy of Fallot in Infancy via the Atrioventricular Approach.

BackgroundTetralogy of Fallot (TOF) is a well-recognized congenital heart disease. Despite improvements in the outcomes of surgical repair, the optimal timing of surgery and type of surgical management of patients with TOF remains controversial. The purpose of this study was to assess outcomes following the repair of TOF in infants depending on the surgical procedure used.MethodsThis study involved the retrospective review of 120 patients who underwent TOF repair between 2010 and 2013. Patients were divided into three groups depending on the surgical procedure that they underwent. Corrective surgery was done via the transventricular approach (n=40), the transatrial approach (n=40), or a combined atrioventricular approach (n=40). Demographic data and the outcomes of the surgical procedures were compared among the groups.ResultsIn the atrioventricular group, the incidence of the following complications was found to be significantly lower than in the other groups: complete heart block (p=0.034), right ventricular failure (p=0.027) and mediastinal bleeding (p=0.007). Patients in the atrioventricular group had a better postoperative right ventricular ejection fraction (p=0.001). No statistically significant differences were observed among the three surgical groups in the occurrence of tachycardia, renal failure, and tricuspid incompetence. The one-year survival rates in the three groups were 95%, 90%, and 97.5%, respectively (p=0.395).ConclusionCombined atrioventricular repair of TOF in infancy can be safely performed, with acceptable surgical risk, a low incidence of reoperation, good ventricular function outcomes, and an excellent survival rate.

Transatrial Approach for the Repair of the Posterior Post-Infarct Ventricular Septal Rupture.

Ventricular septal rupture (VSR) is a disastrous mechanical complication of myocardial infarction. Although several surgical interventions have been developed, mortality due to surgical management remains high, especially in the case of posterior VSR. We report a successful case of repair of posterior VSR using an alternative transatrial approach to avoid the complications related to ventricular incision.

Percutaneous Vacuum-Assisted Thrombectomy Device Used for Removal of Large Vegetations on Infected Pacemaker and Defibrillator Leads as an Adjunct to Lead Extraction.

This case series reports our early experience with a minimally invasive percutaneous method of safely removing large vegetations during lead extraction in septic cardiac implantable electronic devices (CIED). Debate exists concerning the management of vegetations involving these devices. Lead extraction is mandated for infections, but vegetations may embolize, causing complications. Surgical debridement is recommended; alternatives include cardiopulmonary bypass, minimally invasive thoracotomy, or transatrial approaches. The AngioVac device allows percutaneous right heart bypass and suction removal of vegetations under echocardiographic and fluoroscopic guidance. This case series describes our first 20 patients, all critically ill with persistent sepsis and vegetations despite long-term antibiotics. This series includes patients who would not have been eligible for alternative procedures due to contraindications and highlights the potential role of this new technology.

Valve-in-Valve in the Tricuspid Position for a Stenosed Bioprosthesis

The strategy of transcatheter valve-in-valve implantation into failing mitral and aortic bioprosthetic valves is a documented approach. It allows one to avoid performing a high-risk repeat cardiac surgery in elderly patients with multiple comorbidities. Tricuspid valve-in-valve implantation has been documented only a few times in the literature. We report the case of a 65-year-old woman with a failing bioprosthetic tricuspid valve who had undergone 3 prior open heart operations. We attempted a transatrial transcatheter approach and successfully deployed a 29-mm Edwards Sapien balloon-expandable bioprosthesis into a severely stenotic tricuspid bioprosthesis. This case demonstrates the technical feasibility and safety of this approach.

Repair of very severe tricuspid regurgitation following detachment of the tricuspid valve

We report on the case of 5-year-old girl with severe tricuspid regurgitation following previous repair of double outlet right ventricle with subaortic ventricular septal defect, performed through trans-atrial approach using detachment of tricuspid valve leaflet. The severe tricuspid regurgitation was found to be due to dehiscence at the site of the previous detachment and was repaired using a pericardial patch. In this report, we discuss the relative merits and risks of using this technique.

Defibrillation lead placement using a transthoracic transatrial approach in a case without transvenous access due to lack of the right superior vena cava

A 65-year-old woman with a history of syncope was diagnosed with hypertrophic cardiomyopathy. She had previously undergone mastectomy of the left breast owing to breast cancer. Holter electrocardiogram (ECG) and monitor ECG revealed sick sinus syndrome (Type II) and non-sustained ventricular tachycardia. Sustained ventricular tachycardia and ventricular fibrillation were induced in an electrophysiological study. Although the patient was eligible for treatment with a dual chamber implantable cardioverter defibrillator (ICD), venography revealed lack of the right superior vena cava (R-SVC). Lead placement from the left subclavian vein would have increased the risk of lymphedema owing to the patient׳s mastectomy history. Consequently, the defibrillation lead was placed in the right ventricle by direct puncture of the right auricle through the tricuspid valve. The atrial lead was sutured to the atrial wall, and the postoperative course was unremarkable. Defibrillation lead placement using a transthoracic transatrial approach can be an alternative method in cases where a transvenous approach for lead placement is not feasible.

Surgical Management of Complete Atrioventricular Septal Defect with Tetralogy of Fallot

The objective of this report is to evaluate our surgical approach to complete atrioventricular septal defect with tetralogy of Fallot (TOF) and to determine the best treatment for this malformation. From 2007 to 2012, 17 children underwent surgical correction of complete atrioventricular septal defect with TOF. Nine of these patients underwent complete correction, two underwent one and a half ventricle repair, and six underwent univentricular repair. There was 1 in-hospital death and 1 late death. Patients with lower weight required longer intensive care unit stay (P <0.05; r = -0.834). Follow-up data were available for all patients who survived the operation (range, 3-60 months). The Kaplan-Meier curve indicated that 5-year survival was 88.2%. All survivors remained in good condition in New York Heart Association (NYHA) class I or II. Complete repair of atrioventricular septal defect with TOF has got favorable outcomes in terms of mortality and reoperation rate. Unbalanced atrioventricular septal defect with TOF can be managed well with one and a half ventricle repair. Two-patch technique through a transatrial approach alone is a good treatment choice for patients. Management of right ventricular outflow tract (RVOT) is similar to that of isolated TOF.

Native Pulmonary Valve Restoration After Remote Tetralogy of Fallot Repair

Methods to repair tetralogy of Fallot have evolved from large ventriculotomy, large transannular patch placement techniques to smaller, transatrial approaches with valve-sparing strategies in select patients. Despite these advances, there continue to be patients in whom transannular patch is inevitable, and the management of the resulting pulmonary insufficiency that develops from this has been the source of considerable discussion. Techniques aimed at restoring pulmonary valve competence utilizing the remaining valve leaflets after transannular patch placement have recently been proposed for very select patient populations. We review the technical aspects of the operation including removal of the transannular patch and bicuspidization of a formerly tricuspid pulmonary valve, which results in a competent, nonstenotic valve. This report confirms the feasibility of these operative details and highlights the importance of planning before initial repair of tetralogy of Fallot as a way to prepare for a future valve restoration procedure and therefore avoid prosthetic valve placement.