Catheter Ablation of Ventricular Tachycardia (VT) in Patients With Left-Sided Mechanical Valves скачать в хорошем качестве

Catheter Ablation of Ventricular Tachycardia (VT) in Patients With Left-Sided Mechanical Valves

In patients with combined mitral and aortic mechanical values and recurrent ventricular tachycardia (VT) related to diseased left ventricular (LV) heart muscle, traditional catheter approaches for ablation procedures are impossible. Clinician-researchers at @Penn Medicine have developed a novel technique to access the LV via the adjacent right atrium (RA) in these patients. [00:00] This video illustrates intracardiac views during important steps of the procedure: [00:05] Optimal LV Access Site: The optimal site to access the LV from the RA is the inferoseptal RA adjacent to the most inferior portion of the inferior-septal process of the LV (ISP-LV) at the level of the inferior third of the coronary sinus ostium. [00:28] Step 1: The catheter sheath is advanced to the RA, the dilator and wire are removed, and the sheath is deflected applying clockwise torque to obtain contact with the inferomedial aspect of the RA adjacent to the inferior portion of the ISP-LV. It is important to validate the position and angle of incidence of the distal aspect of the sheath in relation to the ISP-LV to confirm a perpendicular approach. [00:47] Step 2: The ISP-LV is punctured from the RA side with a dedicated radiofrequency (RF) wire delivering 15 to 25 watts of RF energy for 4 to 5 seconds. Validation of LV access is performed via direct visualization of the wire entering the LV from the ISP-LV as well as imaging of LV "bubbles" associated with RF application. The wire is then advanced to the LV apex. [01:40] Step 3: The RF wire is exchanged with a stiffer Amplatz wire by advancing a hydrophilic 4F microcatheter over the RF wire inside the LV, keeping the tip of the deflectable sheath in contact with the RA site of access. With the microcatheter advanced in the LV over the RF wire, the RF wire is exchanged with the stiffer Amplatz wire. [02:18] Step 4: The access site is dilated with a noncompliant balloon over the Amplatz wire to facilitate advancement of the sheath through the ISP-LV. Positioning and inflation of the balloon across the ISP-LV is verified by fluoroscopy and intracardiac echography. With the ISP-LV access site appropriately dilated, the balloon is deflated and the deflectable sheath advanced over the balloon into the LV. [03:30] Gerbode Defect: Intracardiac echography shows a Gerbode defect, defined as an LV-RA shunt, that is the iatrogenic residual of the procedure after the catheter ablation and after the deflectable sheath and ablation catheter have been withdrawn into the RA. Click https://ja.ma/3i0M5WE for complete details of the procedure and outcomes in a case series of patients. Left panels: anterior oblique (RAO) fluoroscopic views (right and/or left). Right panels: intracardiac echography view. RV = Right Ventricle TV = septal leaflet of the Tricuspid Valve.