Transhepatic venous cardiac catheterization David Shim, MD Division of Pediatric Cardiology The Heart Center Children's Hospital Medical Center Cincinnati,

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 needle withdrawn with small injections of contrast until hepatic vein identified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

Transhepatic technique (continued)

Transhepatic technique (continued)

Transhepatic technique (continued)

Transhepatic technique (continued)

Transhepatic technique (continued)

Transhepatic technique (continued)

Transhepatic technique (continued)

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

Pulmonary valvuloplasty

Pulmonary valvuloplasty(continued)

Pulmonary valvuloplasty(continued)

Pulmonary valvuloplasty(continued)

Pulmonary valvuloplasty(continued)

Fontan stent placement

Fontan stent placement (continued)

Fontan stent placement (continued)

Fontan stent placement (continued)

Fontan stent placement (continued)

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