Transcaval Puncture for Access to the Pulmonary Venous Atrium After the Extracardiac Total Cavopulmonary Connection Operation

Abstract

MethodsAfter approval from the Institutional Review Board, the Pediatric Cardiology and Ahmanson/UCLA Adult Congenital Heart Disease databases were searched for all patients who had undergone prior E-TCPC between 2005 and 2015. Those patients without computed tomography (CT) imaging after the E-TCPC operation were excluded from further study. Patient characteristics including baseline demographics, congenital diagnosis, surgical history, arrhythmia history, and hemodynamic data were recorded.All postoperative CT studies were reviewed in blinded fashion by 1 electrophysiologist and 1 radiologist. Three-dimensional reconstructions of CT examinations were performed using DICOM viewer © 2015 American Heart Association, Inc. Original Article Circ Arrhythm ElectrophysiolBackground-Patients with surgically palliated total cavopulmonary connection are at risk for recurrent atrial arrhythmia requiring catheter ablation. Transcatheter procedures for those with extracardiac conduits (extracardiac-total cavopulmonary connection) are perhaps the most challenging because of exclusion of the venous circulation from the arrhythmia substrate. Puncture through the inferior vena cava to the pulmonary venous atrium may be an effective route for access in these patients. Methods and Results-The pediatric and adult congenital surgical databases were explored for patients with extracardiactotal cavopulmonary connection and postoperative computed tomography imaging to assess for the presence of clinically relevant (>3 mm) apposition between the inferior vena cava and pulmonary venous atrium (cavoatrial overlap). The degree of overlap between the structures was measured by 2 blinded reviewers. Patients were stratified by surgical repair in childhood versus adult congenital heart disease. Thirty-seven patients were identified, with cavoatrial overlap observed in 9 (36%) of pediatric and 1 (9%) of adult congenital heart disease-repaired patients. Time elapsed after surgery was associated with cavoatrial overlap in the pediatric cohort (P=0.034) and was identified in all pediatric patients with computed tomography imaging ≥8 years after surgery. Three patients underwent successful transcaval puncture during the study period without complication. Conclusions-Puncture through a region of overlap between the inferior vena cava and pulmonary venous atrium is feasible. Cavoatrial overlap is present in a substantial proportion of patients undergoing extracardiac-total cavopulmonary connection in childhood and is associated with a longer time elapsed since surgery. (Circ Arrhythm Electrophysiol.

Ultrahigh‐density mapping supplemented with global chamber activation identifies noncavotricuspid‐dependent intra‐atrial re‐entry conduction isthmuses in adult congenital heart disease

“…A multipolar reference electrode was placed from the internal jugular vein and into the coronary sinus (CSL or Livewire; Abbot Medical, Chicago, Illinois); and in cases without anatomic access to the coronary sinus, the catheter was placed either in the pulmonary artery or a stable position within the venous atrium. For patients in whom the tachycardia was expected to utilize the pulmonary venous atrium (eg, after extracardiac Fontan surgery), a transcaval or transbaffle puncture was performed before subsequent electrophysiology testing . Before introduction of the basket catheter, Heparin 100 units per kilogram were administered with an infusion to maintain the activated clotting time more than 300 seconds.…”

“…For patients in whom the tachycardia was expected to utilize the pulmonary venous atrium (eg, after extracardiac Fontan surgery), a transcaval or transbaffle puncture was performed before subsequent electrophysiology testing. 11 Before introduction of the basket catheter, Heparin 100 units per kilogram were administered with an infusion to maintain the activated clotting time more than 300 seconds. For all cases, a deflectable, long vascular sheath (Agilis NxT, Abbot Medical) was used for activation mapping.…”

Cryoballoon pulmonary vein isolation after extracardiac Fontan operation

“…Using a 4-F pigtail catheter, angiography was performed and a region of cavoatrial overlap was confirmed just below the extracardiac conduit. 1 …”

Electrophysiology and structural interventions in adults with congenital heart disease: Comparison of combined versus separate procedures

“…Likewise, the most common structural interventions were transcatheter valve replacement in 16 (pulmonary in 12; tricuspid in 4), angioplasty/stenting in 14 (SVC limb of a Mustard/Senning baffle in 7; ventricle-to-pulmonary artery conduit in 3; Fontan pathway in 2; native SVC in 1; and pulmonary vein in 1), device occlusion (8), liver biopsy(8), and other(8). Favorable outcome measures were observed in multiple procedural domains for case patients relative to controls(Figure 3).Case patients exhibited shorter total anesthetic exposure (P = 0.06), smaller contrast dose (P = 0.045), fewer venipunctures (4[3][4] vs. 6[5][6][7], P < 0.001), and fewer recommended work days missed (2[2- 5] vs. 4[4][5][6], P < 0.001). Favorable outcome measures were observed in multiple procedural domains for case patients relative to controls(Figure 3).Case patients exhibited shorter total anesthetic exposure (P = 0.06), smaller contrast dose (P = 0.045), fewer venipunctures (4[3][4] vs. 6[5][6][7], P < 0.001), and fewer recommended work days missed (2[2- 5] vs. 4[4][5][6], P < 0.001).…”

“…Favorable outcome measures were observed in multiple procedural domains for case patients relative to controls (Figure 3). Case patients exhibited shorter total anesthetic exposure (P = 0.06), smaller contrast dose (P = 0.045), fewer venipunctures (4 [3-4] vs. 6[5][6][7], P < 0.001), and fewer recommended work days missed (2[2- 5] vs. 4[4][5][6], P < 0.001). For the primary outcome measures, cases experienced a shorter hospital length of stay (P = 0.023) and a significant decrease in cost, with a 37% reduction in total charges (P = 0.039) and a 27% reduction in payments (P = 0.016).…”