Ventricular Access Research Articles

Letter: Craniometrics and Ventricular Access: A Review of Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's Points.

Letter: Craniometrics and Ventricular Access: A Review of Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's Points.

Craniometrics and Ventricular Access: A Review of Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's Points.

Intraventricular access is frequently required during neurosurgery, and when neuronavigation is unavailable, the neurosurgeon must rely upon craniometrics to achieve successful ventricular cannulation. In this historical review, we summarize the most well-described ventricular access points: Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's. Additionally, we provide multiview, 3-dimensional illustrations that provide the reader with a novel understanding of the craniometrics associated with each point.

Standardizing treatment of preterm infants with post-hemorrhagic hydrocephalus at a single institution with a multidisciplinary team.

Preterm infants with post-hemorrhagic hydrocephalus (PHH) are often treated with temporizing measures such as ventricular access devices (VADs) in order to drain cerebrospinal fluid (CSF) prior to permanent diversion with ventriculoperitoneal shunt (VPS) placement. There is little consensus on the timing and management of VADs and VPSs. This leads to marked practice variations among treating services that can adversely affect patient outcomes. This is a quality improvement study evaluating practices from February 2011 to September 2017 including infants with PHH in a single level IV NICU. A multidisciplinary team created a local clinical pathway modified from the Hydrocephalus Clinical Research Network's Shunting Outcomes in Post-Hemorrhagic Hydrocephalus protocol to manage infants with PHH. Methods of CSF diversion and shunt timing were based on weight. Neonatal care providers performed VAD aspiration; timing was guided by imaging and clinical exam criteria. Surgical procedures were performed in the NICU. There were 78 patients eligible for the study. Prior to pathway implementation, infections occurred in 4% of VAD and 3% of VPS patients. There have been no infections since inception of the pathway. With pathway implementation, treatment compliance improved from 55 to 86% while conversion compliance rate improved from 89 to 100%. Standardization of care for PHH infants leads to improvement in patient outcomes such as a decrease in time to VAD placement. Reservoir aspirations by the neonatology team did not result in an increase in infection rate.

A LC–MS/MS method for the quantification of caffeine, betamethasone, clonidine and furosemide in cerebrospinal fluid of preterm infants

BackgroundNewborns, admitted to the Neonatal Intensive Care Unit (NICU), are exposed to a large number of medications, the majority of which are not labeled for use in infants, especially in preterm newborns, because clinical trials on their benefits and harms are lacking. There is a huge gap in knowledge on pharmacokinetic (PK) data in sick preterm infants, including that of drug penetration to cerebrospinal fluid (CSF). One of the issues is related to the lack of reliable analytical methods for the measurement of drugs in CSF. MethodsIn this paper we describe a specific and sensitive LC–MS/MS method for the simultaneous quantification in CSF of four commonly prescribed drugs in NICUs: caffeine, betamethasone, clonidine and furosemide. ResultsThe method was validated following EMA guidelines and applied to several CSF samples of preterm infants with post-hemorrhagic ventricular dilatation in which a ventricular access device was applied. The range of the concentrations of the four drugs measured in the CSF was wide. ConclusionsOur method can be considered useful for further clinical studies to describe the PK aspects of these drugs in neonatal medicine.

Parietooccipital Transventricular Approach for Thalamic Cavernous Malformation: 2-Dimensional Operative Video.

The highly eloquent nature of the thalamus and the depth of the surgical field make thalamic cavernous malformations exceptionally challenging entities for surgical management, necessitating stereotactic navigation and lighted instruments for successful resection. This case demonstrates a patient with a large right dorsal thalamic cavernous malformation that is approached using the well-tolerated transparietooccipital lobule approach for ventricular access and subsequent resection of the lesion along the intraventricular surface. Stereotactic neuronavigation permits this transcortical approach with minimal transgression of normal parenchyma. The trajectory permits approach to the cavernous malformation along its greatest dimension to augment removal. A complete removal of the lesion is achieved. The patient remained at neurological baseline postoperatively. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

The neochord mitral valve repair procedure: Numerical simulation of different neochords tensioning protocols

Transapical off-pump mitral valve repair with neochord implantation is an established technique for minimally-invasive intervention on mitral valve prolapse/flail. The procedure involves the positioning of artificial chords, whose length/tension is adjusted intraoperatively, adopting different methods based on the experience of the surgeon. This unsystematic approach occasionally leads to complications such as leaflet rupture and excessive/insufficient load on the neochords. In this study, finite element models of a generalized prolapsing mitral valve are used to verify the effect of two alternative tensioning approaches (AT – All together and 1-by-1 – one by one sequences) on the coaptation area and valve biomechanics, comparing results with a corresponding healthy configuration. The total force of about 1 N is exerted by the chords in both strategies, but the maximum stress and coaptation area are closer to those of the healthy configuration in the 1-by-1 sequence. However, the analysis also provides an explanation for the chords unloading in the 1-by-1 strategy observed in the clinical practice, and suggests an optimum tensioning methodology for NeoChord procedures. The study also reveals the potential power of the implemented numerical approach to serve as a tool for procedural planning, supporting the identification of the most suitable ventricular access site and the most effective stitching points for the artificial chords.

Bedside placement of ventricular access devices under local anaesthesia in neonates with posthaemorrhagic hydrocephalus: preliminary experience

PurposePosthaemorrhagic ventricular dilatation in preterm infants is primarily treated using temporising measures, of which the placement of a ventricular access device (VAD) is one option. Permanent shunt dependency rates are high, though vary widely. In order to improve the treatment burden and lower shunt dependency rates, we implemented several changes over the years. One of these changes involves the setting of the surgery from general anaesthesia in the OR to local anaesthesia in bed at the neonatal intensive care unit (NICU), which may seem counterintuitive to many. In this article, we describe our surgical technique and present the results of this regimen and compare it to our previous techniques.MethodsRetrospective study of a consecutive series of 37 neonates with posthaemorrhagic ventricular dilatation (PHVD) treated using a VAD, with a cohort I (n = 13) treated from 2004 to 2008 under general anaesthesia in the OR, cohort II (n = 11) treated from 2009 to 2013 under general anaesthesia in the NICU and cohort III (n = 13) treated from December 2013 to December 2017 under local anaesthesia on the NICU.ResultsThe overall infection rate was 14%; the VAD revision rate was 22% and did not differ significantly between the cohorts. Procedures under local anaesthesia never required conversion to general anaesthesia and were well tolerated. After an average of 33 tapping days, 38% of the neonates received a permanent ventriculoperitoneal (VP) shunt. The permanent VP shunt rate was 9% with VAD placement under local anaesthesia and 52% when performed under general anaesthesia (p = 0.02).ConclusionBedside placement of VADs for PHVD under local anaesthesia in neonates is a low-risk, well-tolerated procedure that results in at least equal results to surgery performed under general anaesthesia and/or performed in an OR.

Technical Note: Endoscopic Evacuation of Intraventricular Hemorrhage During Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

Abstract INTRODUCTION Intraventricular hemorrhage (IVH) associated with intracerebral hemorrhage (ICH) predicts increased mortality and morbidity. The use of minimally invasive endoscopic ICH evacuation has been proposed to directly address these conditions in recent years. It is unclear if IVH evacuation should be performed during minimally invasive ICH evacuation, and if so, then with what technique. Here we present a series of minimally invasive endoscopic IVH evacuations performed concurrently with ICH evacuation. METHODS A retrospective review of a prospectively collected database was performed on patients who underwent minimally invasive endoscopic ICH evacuation from December 2015 to August 2018 in a single health system. The severity of IVH was assessed using the modified Graeb (mGraeb) score as reported by Morgan et al. Hemorrhage volume was measured using the ABC/2 method. Descriptive statistics were performed. RESULTS A total of 40 patients with ICH and concurrent IVH (41.7%) were identified in a population of 96 patients who underwent minimally invasive endoscopic evacuation for spontaneous supratentorial ICH. The average preoperative mGraeb score was 9.2, while the average postoperative mGraeb score was 6.8. Of these 40 patients, 23 (57.5%) underwent minimally invasive endoscopic IVH evacuation. An anterior approach was used in 52.2% of patients, while a posterior approach was used in 47.8% of patients. Direct ventricular access was performed in 17.4% of approaches, while a transhematomal approach was used 82.6% of the time. Successful reduction of IVH measured by mGraeb score occurred in 73.9% of cases. Seventeen percent of patients without a preoperative external ventricular drain (EVD) required an intra- or postoperative EVD and 26.1% of patients eventually needed a ventriculo-peritoneal shunt (VPS). CONCLUSION The SCUBA technique provides a high percentage of successful IVH evacuation with a subsequent low need for permanent VPS. Multiple approaches to removing IVH are possible and need further study.

Cerebrospinal Fluid Access Devices in Pediatric Diffuse Midline Glioma Patients: Literature Review and Evaluation of Institutional Practices

Abstract INTRODUCTION Diffuse midline gliomas (DMG) are the number one cause of cancer death in children. H3K27M mutations occur in 80% of DMG, with distinct tumor biology and poorer response to treatment. H3K27M is detectable in cerebrospinal fluid (CSF) circulating tumor DNA (ctDNA), depending on CSF tumor proximity, and correlates with tumor volume and treatment response. Ventricular access devices (VAD) for serial CSF sampling (liquid biopsy) could therefore play a significant role in DMG management. Here, we set to characterize VAD placement practices in pediatric DMG. METHODS A retrospective review of patients <21 yr treated for DMG at our institution was performed (1984-2019). A MEDLINE search was conducted to identify reports of VAD placement in DMG. Full-text English reports of patients = 21 yr with VAD outcomes were analyzed. RESULTS A total of 106 DMG patients at our institution were identified. In total 49% had brainstem disease (n = 52). A total of 46.23% (n = 49) had VADs: 32.65% transient (ETV n = 5, EVD n = 11), 67.35% permanent (reservoir n = 7, shunt n = 26). A total of 17 had ETV at biopsy, 7 with concurrent reservoir placement. Of 10 ETV patients without initial reservoir, 5 ultimately underwent permanent VAD placement (reservoir n = 1, shunt n = 4). A total of 9 patients received EVDs at tumor surgery, 8 required EVD for acute hydrocephalus (HCP), with 6 converted to shunts. A total of 15 shunts were placed at tumor diagnosis: 4 required revision (27%). A total of 14 articles describing 240 DMG patients cited HCP in 22%-100%, with VAD placement in 22%-63%, and shunt-induced extraneural metastases in 7. Ventricular chemotherapy via indwelling reservoirs (481 patients) was associated with 29 infectious and 50 noninfectious complications. Standardized reservoir access procedures decreased infection rates. CONCLUSION VAD placement is clinically indicated in a significant proportion of pediatric DMG patients, with low morbidity. Ventricular CSF is superior to lumbar for ctDNA sequencing and quantification. VAD placement should therefore be considered to facilitate liquid biopsy in DMG.

The use of a high-resolution mapping system may facilitate standard clinical practice in VE and VT ablation.

First experiences using a 64-electrode mini-basket catheter (BC) paired with an automatic mapping system (Rhythmia™) for catheter ablation (CA) of ventricular ectopy (VE) and ventricular tachycardia (VT) have been reported. We aimed to evaluate (1) differences in ventricular access for the BC and (2) benefit of this technology in the setting of standard clinical practice. Patients (pts) undergoing CA for VE or VT using the Intellamap Orion™ paired with the Rhythmia™ automated-mapping system were included in this study. For LV access, transseptal and retrograde access were compared. All 32 pts (29 men, age 63 ± 15years) underwent CA for VE (17 pts) or VT (15 pts). For mapping of VE originating from the left ventricle (LV) in 10 out of 13 pts, a transaortic access was feasible. The predominant access for CA of VT was transaortic (5/7). Feasibility and safety seem to be equal. The total procedure time was 179.1 ± 21.2min for VE ablation and 212.0 ± 71.7min for VT ablation (p = 0.177). For VE, an acquisition of 1602 ± 1672 map points and annotation of 140 ± 98 automated mapping points sufficed to abolish VE in all pts. During a 6-month follow-up (FU) after CA for VE, a VE burden reduction from 18.5 ± 2.1% to 2.8 ± 2.2% (p = 0.019) was achieved. In VT pts, one patient showed recurrence of sustained VT episodes during FU. Use of a high-resolution mapping system for VE/VT CA potentially facilitates revelation of VE origin and VT circuits in the setting of standard clinical practice. Feasibility and safety of a venous, transaortic, transseptal, or a combined approach seem to be equal.

Drainage, Irrigation and Fibrinolytic Therapy (DRIFT) in Premature Infants with Post-Haemorrhagic Ventricular Dilatation: 10-Year Follow-Up of a Randomised Controlled Trial

Background: Progressive ventricular dilatation after intraventricular haemorrhage (IVH) in preterm infants has a very high risk of severe disability and death. Drainage, irrigation and fibrinolytic therapy (DRIFT), in a randomised trial, reduced severe cognitive impairment at two years. No intervention has been shown objectively to improve cognitive outcome at school-age. Methods: Objective: To assess if the cognitive advantage of DRIFT seen at two years persisted until middle school-age. Participants: The randomised controlled trial in four neonatal intensive care units, recruited 77 preterm infants with IVH and progressive ventricular enlargement over specified measurements. Follow up was at a median age of ten years (range 8-12). Intervention: Intraventricular injection of a fibrinolytic followed by continuous ventricular drainage via one catheter and continuous infusion with artificial cerebrospinal fluid via a second catheter. Ventricular lavage was continued until the drainage was clear. Standard care consisted of controlling expansion by lumbar punctures and if expansion persisted via a ventricular access device. Primary outcome: Cognitive Quotient (CQ) derived from the British Ability Scales and Bayley Scales III and survival without severe cognitive disability. Findings: Of the 77 children randomized; 12 died, two could not be traced, ten did not respond and one declined at ten years follow up. 28 in the DRIFT group and 24 in the standard treatment group were assessed by examiners blind to the intervention. Mean CQ was 69·3 (sd=30·1) in the DRIFT group and 53·7 (sd=35·7) in the standard treatment group (unadjusted p=0·1; after adjustment for the pre-specified variables sex, birthweight and grade of IVH, adjusted p=0·01). Survival without severe cognitive disability, over the ten-year period, was 66% in the DRIFT group and 35% in the standard treatment group (unadjusted p=0·019; adjusted p=0·003). Interpretation: DRIFT is the first intervention to objectively demonstrate sustained cognitive improvement. Trial registration: ISRCTN80286058 Funding: NIHR HTA Declaration of Interest: None reported. Ethical Approval: Research ethics approval (14/SW/1078) was granted by the NRES Committee South West-Central Bristol and by the Faculty of Psychology Research Ethics Committee (University of Warsaw).

P94 Ventricular subgaleal shunting is a safe and effective temporising measure for the treatment of neonatal post haemorrhagic hydrocephalus

ObjectivesThe use of a temporising device to facilitate neonatal maturation prior to permanent ventricular peritoneal shunt (VPS) remains gold standard treatment for neonatal posthaemorrhagic hydrocephalus (PHH). The relative superiority of ventricular access device (VAD) or ventricular subgaleal shunt (VSG) remains contentious.DesignRetrospective case note review.Subjects49 neonates born between Sept 2012 to April 2018: (M:F 34:15); Average: gestation 26+3 (23 to 32+5); birth weight 870 g (±355 g); Papile grade 3:4 (ratio ≈ 1:2).MethodsComputer records from neonatal VSG at a single tertiary care children’s hospital reviewed.ResultsEarly complications associated with VSG seen in 13 cases (27%). Migration of shunt n=3, infection n=2, inadequate control of ventricular volume n=5, decompression haemorrhage n=2, wound leak n=1. All patients managed on NICU with an average inpatient stay of 5 days (range 2 to 15). 5 outcome groups defined: 1. Patient died (non neurological cause) (n=4) 2. VSG in situ for <1 year (n=7) 3. VSG and no VPS (n=6 16%) 4. VSG and VPS X1 never revised (n=17 45%) 5. VSG and VPS with revisions (n=15 39%) Rate of shunting in patients with VSG >1 year=84%. All patients that needed permanent VPS were operated within the first year. The average time elapsed prior to VPS was 86 days with over 80% of cases shunted within 100 days.ConclusionsVSG remains a safe method of temporary CSF drainage for the treatment of neonatal PHH with rates of shunting in line with the published literature.

TROPHY registry study design: a prospective, international multicenter study for the surgical treatment of posthemorrhagic hydrocephalus in neonates.

Among children with hydrocephalus, neonates with intraventricular hemorrhage (IVH) and posthemorrhagic hydrocephalus (PH) are considered a group with one of the highest complication rates of treatment. Despite continued progress in neonatal care, a standardized and reliable guideline for surgical management is missing for this challenging condition. Thus, further research is warranted to compare common methods of surgical treatment. The introduction of neuroendoscopic lavage has precipitated the establishment of an international registry aimed at elaborating key elements of a standardized surgical treatment. The registry is designed as a multicenter, international, prospective data collection for neonates aged 41weeks gestation, with an indication for surgical treatment for IVH with ventricular dilatation and progressive hydrocephalus. The following initial temporizing surgical interventions, each used as standard treatment at participating centers, will be compared: external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). Type of surgery, perioperative data including complications and mortality, subsequent shunt surgeries, ventricular size, and neurological outcome will be recorded at 6, 12, 36, and 60months. An online, password-protected website will be used to collect the prospective data in a synchronized manner. As a prospective registry, data collection will be ongoing, with no prespecified endpoint. A prespecified analysis will take place after a total of 100 patients in the NEL group have been entered. Analyses will be performed for safety (6months), shunt dependency (12, 24months), and neurological outcome (60months). The design and online platform of the TROPHY registry will enable the collection of prospective data on different surgical procedures for investigation of safety, efficacy, and neurodevelopmental outcome of neonates with IVH and hydrocephalus. The long-term goal is to provide valid data on NEL that is prospective, international, and multicenter. With the comparison of different surgical treatment modalities, we hope to develop better therapy guidelines for this complex neurosurgical condition.

TCT-275 Percutaneous Transapical Left Ventricular Access to Treat Paravalvular Leak and Ventricular Septal Defect is Clinically Effective and Associated with Infrequent Adverse Events

TCT-275 Percutaneous Transapical Left Ventricular Access to Treat Paravalvular Leak and Ventricular Septal Defect is Clinically Effective and Associated with Infrequent Adverse Events

2118Optimal left ventricular access route for scar-related VT ablation in patients with ischemic cardiomyopathy: Insights from contact force sensing

2118Optimal left ventricular access route for scar-related VT ablation in patients with ischemic cardiomyopathy: Insights from contact force sensing

Current developments in cardiac rhythm management devices.

Endocardial pacing has experienced a tremendous evolution since the 1960s. A lot of challenges associated with pacemaker and ICD devices have already been successfully targeted. However, a relevant number of problems have not been solved to date. Not all patients with accepted indication for biventricular pacing have benefited from cardiac resynchronisation therapy (CRT) despite extensive efforts to reduce the rate of non-responders. Current strategies to optimize lead position, multipolar left-ventricular (LV) pacing leads, new strategies to gain access to the left-ventricle (atrial transseptal or ventricular transseptal access) or alternative right-ventricular (septal, His bundle pacing) pacing sites, and "leadless" LV pacing have the potential to increase response to device-based heart-failure treatment. The opportunity of pacemaker and ICD remote monitoring led to relevant improvements in therapy management by timely detection of events requiring medical or invasive interventions (e.g., external cardioversion of atrial fibrillation, increasing effective biventricular pacing, catheter ablation of ventricular tachycardias, or changes in heart-failure medication). Two completely endocardial leadless "all-in-one" pacemaker systems recently became available. Besides these innovations, new "synergistic" therapy concepts combining catheter ablation and device therapy proved to affect clinical endpoints (e.g., ATAAC study and CASTLE-AF study).

Role of contact force in ischemic scar-related ventricular tachycardia ablation; optimal force required and impact of left ventricular access route.

Contact force-sensing technology has become a widely used addition to catheter ablation procedures. Neither the optimal contact force required to achieve adequate lesion formation in the ventricle, nor the impact of left ventricular access route on contact force has been fully clarified. Consecutive patients (n = 24) with ischemic cardiomyopathy who underwent ablation for scar-related ventricular tachycardia were included in the study. All ablations (n = 25) were performed using irrigated contact force-sensing catheters (Smart Touch, Biosense Webster). Effective lesion formation was defined as electrical unexcitability post ablation at sites which were electrically excitable prior to ablation (unipolar pacing at 10mA, 2ms pulse width). We explored the contact force which achieved effective lesion formation and the impact of left ventricular access route (retrograde aortic or transseptal) on the contact force achieved in various segments of the left ventricle. Scar zone was defined as bipolar signal amplitude < 0.5mV. Among 427 ablation points, effective lesion formation was achieved at 201 points (47.1%). Contact force did not predict effective lesion formation in the overall group. However, within the scar zone, mean contact force ≥ 10g was significantly associated with effective lesion formation [OR 3.21 (1.43, 7.19) P = 0.005]. In the 12-segment model of the left ventricle, the retrograde approach was associated with higher median contact force in the apical anterior segment (31 vs 19g; P = 0.045) while transseptal approach had higher median force in the basal inferior segment (25 vs 15g; P = 0.021). In the 4-segment model, the retrograde approach had higher force in the anterior wall (28 vs 16g; P = 0.004) while the transseptal approach had higher force in the lateral wall (21 vs 18g; P = 0.032). There was a trend towards higher force in the inferior wall with the transseptal approach, but this was not statistically significant (20 vs 15g; P = 0.063). In patients with ischemic cardiomyopathy, a mean contact force of 10g or more within the scar zone had the best correlation with electrical unexcitability post ablation in our study. The retrograde aortic approach was associated with better contact force over the anterior wall while use of a transseptal approach had better contact force over the lateral wall.

Early surgical management and long-term surgical outcome for intraventricular hemorrhage-related posthemorrhagic hydrocephalus in shunt-treated premature infants.

OBJECTIVE Perinatal intraventricular hemorrhage (IVH) in premature neonates may lead to severe neurological disability and lifelong treatment requirement for consecutive posthemorrhagic hydrocephalus (PHHC). Early CSF diversion as a temporizing measure, or a permanent ventriculoperitoneal shunt (VPS), is the treatment of choice. Preterm neonates are not only at high risk for different perinatal but also for treatment-related complications. The authors reviewed their institutional neurosurgical management for preterm neonates with IVH-related PHHC and evaluated shunt-related surgical outcome for this particular hydrocephalus etiology after completion of a defined follow-up period of 5 years after initial shunt insertion. METHODS The authors retrospectively analyzed early surgical management for preterm newborns who presented with IVH and PHHC between 1995 and 2015. According to the guidelines, patients received implantation of a ventricular access device (VAD) for temporizing measures or direct VPS insertion as first-line surgical treatment. Surgical outcome was evaluated for a subgroup of 72 patients regarding time to first shunt revision and the mean number of shunt revisions during a time span of 5 years after initial shunt insertion. Gestational age (GA), extent of IVH, and timing and modality of initial surgical intervention were analyzed for potential impact on corresponding surgical outcome. RESULTS A total cohort of 99 preterm newborns with GAs ranging from 22 to 36 weeks (mean 28.3 weeks) with perinatal IVH-related PHHC and a median follow-up duration of 9.9 years postpartum could be selected for further investigation. Extent of perinatal IVH was defined as grade III or as periventricular hemorrhagic infarction in 75% of the patient cohort. Seventy-six patients (77%) underwent VAD insertion and temporizing measures as initial surgical treatment; for 72 (95%) of these a later conversion to permanent ventriculoperitoneal shunting was performed, and 23 patients received direct VPS insertion. Etiological and treatment-related variables revealed no significant impact on revision-free shunt survival but increased the mean numbers of shunt revisions after 5 years for low GA, higher-order IVH in the long term. CONCLUSIONS Low GA and higher-order IVH in preterm neonates with PHHC who are treated with VPSs show no significant impact on time to first shunt revision (i.e., revision-free shunt survival), but marked differences in mean revision rates evaluated after completion of 5 years of follow-up. Temporizing measures via a VAD represent a rational strategy to gain time and decision guidance in preterm patients with PHHC before permanent VPS insertion.

Initial experience of catheter ablation of ventricular tachycardia originate from endocardium via direct ventricle puncture access in patients underwent mechanical valve implantation

Objective: To evaluate the results of catheter ablation of ventricular tachycardia (VT) via direct ventricle puncture access in patients without traditional approach. Methods: Two idiopathic left fasicular VT patients with mechanical aortic and mitrial valve repalcement and 1 patient with right ventricular originated VT post mechanical tricuspid valve repalcement from March 2010 to July 2012 in Fuwai hospital were enrolled in this study. For left fasicular VT patients, catheter ablation was performed using transapical left ventricular access via minithoracotomy. For the patient with right ventricular originated VT, catheter ablation was performed via percutaneous right ventricle puncture at xiphoid. Abaltion was guided under EnSite NavX mapping system. The feasibility of VT ablation via direct ventricle puncture access and long-term VT recurrence were investigated. Results: Catheter ablation was successful in all patients, and all clinical VTs were eliminated. The procedure time was 53, 62 and 74 minutes respectively with radiation time 11, 16 and 20 minutes. The ablation time was 130, 170 and 240 seconds individually. No procedure related complication occurred. After a follow-up time of 76, 55 and 82 months respectively, no VT recurrence was found in patients with left fasicular VT. New-onset VT with different morphology with previous VT was recorded in the patient with right ventricular originated VT, subcutaneous implantable defibrillator was implanted finally in this patient. Conclusions: For patients with endocardial origined ventricular arrhythmias which could not be ablated via traditional approaches, direct ventricle puncture access with hybrid techniques provides a new approach foreliminating VTs in these patients.

Wellington Regional Hospital Experience of His-Bundle Pacing

Background: His-bundle pacing is a newly revisited alternative to cardiac resynchronisation therapy that may help to protect against the known long-term complications associated with high right ventricular pacing burdens. His pacing may be attractive as an alternative to cardiac resynchronisation therapy due to complexities associated with left ventricular access and anatomy to gain an ideal pacing site. We describe here early experience and safety for His-bundle pacing within our service and current resources.