Alcohol septal ablation to overcome shock

A 69-year-old man, known with hypertrophic obstructive cardiomyopathy (HOCM), was referred to our hospital because of progressive hypoxaemia and sepsis after admission for respiratory infection. Once at the emergency department, cardiopulmonary resuscitation, intubation and mechanical ventilation were necessary. Despite vasopressors and colloids the patient remained haemodynamically unstable. Because of the conviction that the distributive shock, caused by sepsis, was worsened by an associated obstructive shock related to the HOCM, an alcohol septal ablation (ASA) was attempted in these acute circumstances. Immediately after the ASA the gradient over the left ventricular outflow tract disappeared and the mean arterial pressure and oxygenation increased. Despite his cardiovascular recuperation the patient died a couple of days later. Nevertheless we achieved an improvement of the haemodynamic situation of this patient with HOCM by performing an urgent ASA

Impact of gender difference in hospital outcomes following percutaneous coronary intervention. Results of the Belgian Working Group on Interventional Cardiology (BWGIC) registry

peer reviewedAims: To determine whether there are gender-based differences in in-hospital outcomes among patients undergoing percutaneous coronary intervention (PCI). Methods and results: We studied a large cohort using clinical data from a registry of 130,985 PCI procedures in Belgium, from January 2006 to February 2011. Compared to males, females were significantly older (70.3 vs. 64.8 years), and were more frequently diabetic or hypertensive. Men smoked more and more frequently had previous myocardial infarction (MI), previous PCI or previous coronary artery bypass graft (CABG) surgery. Coronary artery disease (CAD) was less severe in women, and PCI to the left anterior descending artery was more common in female patients. Unadjusted in-hospital mortality rates were higher in females versus males (2.5% for women and 1.6% for men, p<0.0001). After multivariable analysis, female gender remained an independent predictor of mortality (odds ratio 1.35, 95% CI: 1.22-1.49, p<0.0001). Conclusions: Gender-based differences in hospital mortality rates after PCI were observed in this large registry. Female sex remained an independent predictor of mortality after multivariable adjustment

Impact of gender difference in hospital outcomes following percutaneous coronary intervention. Results of the Belgian Working Group on Interventional Cardiology (BWGIC) registry

International audienceAIMS:To determine whether there are gender-based differences in in-hospital outcomes among patients undergoing percutaneous coronary intervention (PCI).METHODS AND RESULTS:We studied a large cohort using clinical data from a registry of 130,985 PCI procedures in Belgium, from January 2006 to February 2011. Compared to males, females were significantly older (70.3 vs. 64.8 years), and were more frequently diabetic or hypertensive. Men smoked more and more frequently had previous myocardial infarction (MI), previous PCI or previous coronary artery bypass graft (CABG) surgery. Coronary artery disease (CAD) was less severe in women, and PCI to the left anterior descending artery was more common in female patients. Unadjusted in-hospital mortality rates were higher in females versus males (2.5% for women and 1.6% for men, p<0.0001). After multivariable analysis, female gender remained an independent predictor of mortality (odds ratio 1.35, 95% CI: 1.22-1.49, p<0.0001).CONCLUSIONS:Gender-based differences in hospital mortality rates after PCI were observed in this large registry. Female sex remained an independent predictor of mortality after multivariable adjustment

Development of a transseptal puncture technique in horses: Exploring the transhepatic and jugular vein approach

Introduction: The advent of advanced electrophysiological procedures such as 3D electro-anatomical mapping and radiofrequency ablation currently allows for diagnosis and treatment of right atrial arrhythmias in horses.1,2 In contrast, left atrial arrhythmias are scarcely studied3 due to the perilous arterial approach that is needed to access the left atrium. In small animal and human medicine, the transseptal puncture, which is performed via the femoral vein, is a commonly used technique to access the left atrium via the oval fossa in a safe and efficient way. In human medicine, the transhepatic approach has been reported as an alternative to the femoral approach, as the oval fossa is accessed from a similar direction and ensures similar catheter manipulations. Indeed, a caudal approach towards the oval fossa is favourable to position the puncture assembly into the pouchlike anatomy of the oval fossa and direct it towards the left atrium. In contrast, the majority of catheterizations in horses is performed via the jugular vein, which implies a cranial instead of a caudal access to the heart. Moreover, fluoroscopy, which is most commonly used to perform the transseptal puncture in small animals and humans, provides limited to no imaging guidance to allow catheter manipulation in horses due to the size of the equine thorax. Similarly, computed tomography or magnetic resonance imaging cannot be used either to provide insight into the detailed anatomy of the interatrial septum in an adult horse. Therefore, the goal of this study was to develop a transseptal puncture protocol using a transhepatic and a jugular vein approach under ultrasound guidance. Methods: All horses in the study were donated for scientific research and owner informed consent was obtained. In 17 horses, a transseptal puncture was performed under general anaesthesia: in nine horses the jugular vein approach was performed, in six horses both the jugular vein and transhepatic approach was performed, and in two horses the transhepatic approach was performed. For the jugular vein approach, a 0.035″ J-tipped or pigtail guidewire followed by 8.5F steerable sheath-dilator assembly was introduced via the right jugular vein and positioned in front of the oval fossa. For the transhepatic approach, a puncture site for transhepatic access was determined on the left or right abdominal wall by locating a clearly visible hepatic vein of at least 8mm in diameter using transthoracic ultrasound. The hepatic vein was punctured using a 9cm long 18G needle, allowing the introduction of a 0.032″ guidewire and subsequent dilator and 8.5F steerable sheath and positioning in front of the oval fossa. The 0.032″ guidewire was then exchanged for a 0.035″ J-tipped or pigtail guidewire. For both approaches, the procedure continued with positioning of the distal tip of the guidewire against the oval fossa and puncture by applying radiofrequency energy on the guidewire, after which dilator and sheath were advanced into the left atrium. The entire procedure was guided using transthoracic and intracardiac echocardiography, and continuous ECG-monitoring was performed. The horses were euthanized at the end of the procedure and lesion size and permeability were evaluated post-mortem. Results: In 13/17 horses, a successful transseptal puncture was achieved, accounting for 14/15 jugular vein approaches and 5/8 transhepatic approaches (total of 23 punctures). In four horses, the transhepatic puncture was performed on the right side, in the other four on the left side. On post-mortem evaluation, permeable lesions of 1-5 mm were visible in all horses in the oval fossa on the right atrial side and ventral to pulmonary vein ostium III on the left atrial side. The most challenging part of the procedure was the over-the-wire insertion of the dilator-sheath assembly into the left atrium due to the thickness of the equine interatrial septum and limited catheter support. In five horses, atrial fibrillation was already present before the puncture, in 12 procedures paroxysmal atrial fibrillation or paroxysmal atrial tachycardia occurred in response to the puncture and in one horse persistent atrial fibrillation developed. Procedural failure in four horses was due to inability to advance dilator-sheath assembly (N=2), termination of the procedure due to technical failure (N=1), and inability to advance the guidewire towards the heart during a transhepatic approach (N=1). Ultrasound guidance, and especially intracardiac echocardiography (Figure 1), was adequate to guide the procedure. Limitations: Although care was taken to perform the second puncture on another location in the oval fossa in the horses in which both methods were applied, it cannot be excluded that the second puncture was realised via the first puncture site. Not all procedures were performed with the same devices. Post-operative complications could not be evaluated as the horses were euthanized for reasons not related to the study. Conclusion: Both transseptal puncture techniques allowed to access the left atrium in a minimally invasive way. Further research is needed to establish in which cases which approach would be most appropriate, to investigate which devices yield the most effective results and to determine post-operative complication rate

Transseptal puncture guided by intracardiac ultrasound to access the left atrium in adult horses

Introduction: Successful 3D mapping and radiofrequency ablation of right atrial tachycardia in horses has become a standardized procedure. Access to the left atrium currently requires a perilous retrograde arterial approach via the carotid artery, which is difficult to achieve using commercially-available catheters. Transseptal puncture (TSP) is a minimally-invasive, routine procedure for left heart catheterizations in human patients, during which the left atrium is accessed from the right atrium by puncturing the fossa ovalis (FO). Our aim was to develop a reproducible procedure to access the left atrium by TSP from a jugular vein approach. Methods: In 12 horses, admitted for euthanasia for non-cardiovascular reasons and after informed owner consent, TSP was performed under general anaesthesia. A cranial approach via the right jugular vein was performed under transthoracic and intracardiac ultrasound guidance. Puncture lesions were evaluated post-mortem. Results: In 11/12 horses, TSP was achieved and evaluated post-mortem. The general approach consisted of over-the-wire positioning of a sheath with dilator against the FO, followed by application of radiofrequency energy on the guidewire tip for FO perforation. The guidewire was advanced into the left atrium, allowing over-the-wire insertion of dilator and sheath. Intracardiac ultrasound was essential to guide TSP (Fig. 1). On post-mortem evaluation, the puncture lesions could be identified as a 2-5mm opening in the FO, located ventral to pulmonary vein ostium III. The over-the-wire insertion of dilator and sheath after guidewire advancement into the left atrium was the most challenging part of the procedure, due to the thick FO and limited catheter support due to the jugular vein approach, and failed in one horse. Conclusions: Via a jugular vein approach, TSP is feasible in horses using intracardiac ultrasound guidance. Clinical relevance: TSP provides minimally-invasive access to the left heart for procedures such as 3D mapping and ablation of left atrial arrhythmias

Transseptal puncture in the horse using intracardiac ultrasound guidance : first results with follow-up

Background – Radiofrequency catheter ablation has been successfully applied to treat right atrial tachycardia in horses. Ablation of left-sided arrhythmias is complicated by the perilous retrograde arterial approach needed for left-sided catheterization. In human medicine, the left atrium is accessed femorally through transseptal puncture (TSP) of the fossa ovalis (FO). Recently a TSP technique via the jugular vein was developed for horses. Hypothesis/Objectives – To determine efficacy, complications and closure process of TSP in horses. Animals – Three horses without cardiovascular disease, and two horses admitted for ablation of atrial fibrillation (AF). Methods – Descriptive experimental study. TSP was performed under general anaesthesia by radiofrequency energy application on a guidewire to perforate the FO and allow advancement of a deflectable sheath under transthoracic and intracardiac echocardiographic (TTE and ICE) guidance. In three horses without cardiovascular disease, puncture closure was evaluated during four weeks by TTEand ICE. Results – All TSPs were successful. Time from sheath positioning in front of the FO until successful transseptal access was 19-97 minutes. In two horses, balloon dilation of the puncture opening was needed for sheath advancement. Minor complications included transient atrial premature depolarisations (n=1), self-terminating atrial tachycardia (n=1) and self-terminating AF (n=1) during radiofrequency energy application for puncture in the horses without pre-existing AF. Follow-up of the closure process (n=3) using ICE showed closure 1-3 weeks after puncture. Conclusions and clinical importance – TSP could be performed safely in horses using ICE guidance, which opens perspectives for management of left-sided atrial arrhythmias

Transseptal puncture in the horse using intracardiac ultrasound guidance : first results with follow-up

BACKGROUND Radiofrequency catheter ablation has been successfully applied to treat right atrial tachycardia in horses. Ablation of left-sided arrhythmias is complicated by the perilous retrograde arterial approach needed for left-sided catheterization. In human medicine, the left atrium is accessed femorally through transseptal puncture (TSP) of the fossa ovalis (FO). Recently a TSP technique via the jugular vein was developed for horses. HYPOTHESIS/OBJECTIVE To determine efficacy, complications and closure process of TSP in horses. ANIMALS Three horses without cardiovascular disease, and two horses admitted for ablation of atrial fibrillation (AF). METHODS Descriptive experimental study. TSP was performed under general anaesthesia by radiofrequency energy application on a guidewire to perforate the FO and allow advancement of a deflectable sheath under transthoracic and intracardiac echocardiographic (TTE and ICE) guidance. In three horses without cardiovascular disease, puncture closure was evaluated during four weeks by TTE and ICE. RESULTS All TSPs were successful. Time from sheath positioning in front of the FO until successful transseptal access was 19–97 minutes. In two horses, balloon dilation of the puncture opening was needed for sheath advancement. Minor complications included transient atrial premature depolarisations (n=1), self-terminating atrial tachycardia (n=1) and self-terminating AF (n=1) during radiofrequency energy application for puncture in the horses without pre-existing AF. Follow-up of the closure process (n=3) using ICE showed closure 1–3 weeks after puncture. CONCLUSIONS AND CLINICAL IMPORTANCE TSP could be performed safely in horses using ICE guidance, which opens perspectives for management of left-sided atrial arrhythmias