Transhepatic venous cardiac catheterization David Shim, MD

1,250 views

Published on

  • Be the first to comment

  • Be the first to like this

Transhepatic venous cardiac catheterization David Shim, MD

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

×