Transhepatic venous cardiac catheterization

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Transhepatic venous cardiac catheterization

• David Shim, MD
• Division of Pediatric Cardiology
• The Heart Center
• Children's Hospital Medical Center Cincinnati,
  Ohio

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Indications for right heart catheterization

• Hemodynamics
• right heart pressures
• pulmonary vascular resistance
• thermodilution cardiac output
• Angiography
• right ventricular function
• pulmonary valve and artery anatomy

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Indications for right heart catheterization

• Electrophysiology
• radiofrequency ablation
• Interventions
• ASD occlusion
• balloon atrial septostomy
• endomyocardial biopsy
• prograde PDA coil embolization
• pulmonary artery balloon dilation/stent

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Indications for right heart catheterization

• Interventions (continued)
• pulmonary valve balloon dilation
• RV-PA conduit balloon dilation/stent
• SVC balloon dilation/stent
• transseptal puncture

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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)

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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

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Contraindications

• Abnormal clotting/prothrombin time
• Active liver disease or peritonitis
• Abnormally draining hepatic veins

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Transhepatic technique

• 22 gauge Chiba needle inserted to midlliver under
  fluoroscopic guidance
• needle withdrawn with small injections of
  contrast until hepatic vein identified
• 0.018 Cope wire advanced to RA
• 4F coaxial dilator placed and wire exchanged for
  a 0.035-0.038 guidewire

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Transhepatic technique (continued)

• dilator removed and curved sheath placed
• cardiac catheterization performed
• Gianturco coil placed in liver parenchyma upon
  removal of sheath
• puncture site dressed with opsite dressing and
  post-catheterization care as routine

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Transhepatic technique (continued)
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Transhepatic technique (continued)
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Transhepatic technique (continued)
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Transhepatic technique (continued)
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Transhepatic technique (continued)
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Transhepatic technique (continued)
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Transhepatic technique (continued)
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Shim D, et al. Circulation 1995921526-1530
Evaluation of Efficacy and Safety

• Patient population (N42)

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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,
• Shones complex, status post transplant,
• transposition of the great arteries,
• and truncus arteriosus

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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)

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Efficacy
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Safety
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Safety (continued)

• Chest radiographs
• no effusions
• no pneumoperitoneum/pneumothorax
• Liver ultrasound (n34)
• small amount of peritoneal fluid (n4)
• no subcapsular hematoma
• Clinical hemorrhage (n2 5)

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• 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
19994741-5
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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

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Pulmonary valvuloplasty
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Pulmonary valvuloplasty(continued)
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Pulmonary valvuloplasty(continued)
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Pulmonary valvuloplasty(continued)
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Pulmonary valvuloplasty(continued)
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Fontan stent placement
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Fontan stent placement (continued)
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Fontan stent placement (continued)
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Fontan stent placement (continued)
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Fontan stent placement (continued)
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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

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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