Transhepatic venous cardiac catheterization David Shim, MD Division of Pediatric Cardiology The...
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Transcript of Transhepatic venous cardiac catheterization David Shim, MD Division of Pediatric Cardiology The...
Transhepatic venous cardiac catheterization
David Shim, MDDivision of Pediatric Cardiology
The Heart Center Children's Hospital Medical Center
Cincinnati, Ohio
Indications for right heart catheterization
Hemodynamics right heart pressures pulmonary vascular resistance thermodilution cardiac output
Angiography right ventricular function pulmonary valve and artery
anatomy
Electrophysiology radiofrequency ablation
Interventions ASD occlusion balloon atrial septostomy endomyocardial biopsy prograde PDA coil embolization pulmonary artery balloon
dilation/stent
Indications for right heart catheterization
Interventions (continued) pulmonary valve balloon dilation RV-PA conduit balloon
dilation/stent SVC balloon dilation/stent transseptal puncture
Indications for right heart catheterization
Reasons for no access
previous central lines or catheterization
interrupted inferior vena cava obstructed superior vena cava bidirectional Glenn/Hemifontan infection at site of access devices (eg, Greenfield filter)
Background
Percutaneous Transhepatic Cholangiography (PTC)
has been performed for 2 decades with low morbidity
other transhepatic procedures portal venous system
hemodynamics localize occult neuroendocrine
tumors embolization of varices
Contraindications
Abnormal clotting/prothrombin time
Active liver disease or peritonitis
Abnormally draining hepatic veins
Transhepatic technique
1. 22 gauge Chiba needle inserted to midlliver under fluoroscopic guidance
2. needle withdrawn with small injections of contrast until hepatic vein identified
3. 0.018” Cope wire advanced to RA
4. 4F coaxial dilator placed and wire exchanged for a 0.035-0.038” guidewire
Transhepatic technique (continued)
5. dilator removed and curved sheath placed
6. cardiac catheterization performed
7. Gianturco coil placed in liver parenchyma upon removal of sheath
8. puncture site dressed with opsite dressing and post-catheterization care as routine
Shim D, et al. Circulation 1995;92:1526-1530
Patient population (N=42)
Evaluation of Efficacy and Safety
Range Median
Age 1 day - 41 yrs 25 months
Weight 2.4 - 74 kg 11 kg
RA mean pressure 0 - 24 mm Hg 9 mm Hg
Diagnoses
univentricular heart (25)critical pulmonary stenosis (5)tetralogy of Fallot (3)AV canal (2)
One each: atrial septal defect, mitral stenosis,peripheral pulmonary stenosis,Shone’s complex, status post transplant,transposition of the great arteries,and truncus arteriosus
Limitations to access
bilateral femoral venous occlusion (30)
bidirectional Glenn/Hemifontan (9)
interrupted inferior vena cava (7)
obstructed superior vena cava (4)
preferred route for intervention (3)
Greenfield filter (1)
Efficacy
Range Median
number of hepatic punctures 1 - 7 3 attempts
time to enter right atrium 1 - 21 min 4 min
fluoroscopy time 0.1 - 9.2 min 2.3 min
Safety
Parameter Pre-Cath Post-Cath p value
ALT (IU/L) 47.2 41.5 52.3 22.3 NS
AST (IU/L) 51.1 44.0 69.1 30.8 NS
HGB (gm/dL) 14.4 2.6 13.4 2.4 NS
Safety (continued)
Chest radiographs no effusions no pneumoperitoneum/pneumothorax
Liver ultrasound (n=34) small amount of peritoneal fluid (n=4) no subcapsular hematoma
Clinical hemorrhage (n=2; 5%)
29/30 (97%) successful interventions
angioplasty ± stent pulmonary (10) Fontan baffle (3) superior vena cava (2)
valvuloplasty pulmonary valve (2) transseptal mitral valve (1)
radiofrequency ablation ± transseptal puncture (4)
Shim D,et al. Cathet Cardiovasc Interv 1999;47:41-5
Transhepatic interventions
Others
atrial septal defect device occlusion (2) Fontan fenestration device occlusion (2) coil embolization of pulmonary artery
pseudoaneurysm(2) device retrieval (1) endomyocardial biopsy (1)
Sheath sizes: 4-14 French
Conclusions
The transhepatic approach is effective as a route for right sided cardiac catheterization and can be performed with relative safety
The transhepatic approach will allow therapeutic procedures to be performed in a subset of children where this has been previously not possible
Speculations
Transhepatic access will allow larger sheaths to be used in smaller patients
The transhepatic approach may allow better sheath stability in the right ventricular outflow tract for pulmonary valvuloplasty and angioplasty
The transhepatic approach may also allow a more perpendicular approach to the atrial septum