Transhepatic venous cardiac catheterization David Shim, MD Division of Pediatric Cardiology The Heart Center Children's Hospital Medical Center Cincinnati, Ohio This talk will discuss the aspects of transhepatic venous cardiac catheterization in regards to the indications, technique, and safety of this procedure. Also, the widely varied interventions possible through this access will also be discussed.

Indications for right heart catheterization Hemodynamics right heart pressures pulmonary vascular resistance thermodilution cardiac output Angiography right ventricular function pulmonary valve and artery anatomy Indications to right heart catheterization are varied. General hemodynamic information such as right heart pressures, pulmonary vascular resistance, and thermodilution cardiac output are common to most catheterizations. Anatomic information of right ventricular function and pulmonary valve and artery anatomy can also be attained.

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 Right heart access also allows electrophysiologic evaluation of the conduction system and also allows therapeutic ablation of both right and left-sided accessory pathways. Therapeutic interventions have become the mainstay of many pediatric cardiology catheterization labs. Access to the right heart makes many of these interventions feasible. They include atrial septal defect occlusion, ...

Indications for right heart catheterization Interventions (continued) pulmonary valve balloon dilation RV-PA conduit balloon dilation/stent SVC balloon dilation/stent transseptal puncture Other interventions also include….

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) In children with complex congenital cardiac diseases, venous access can become problematic. Reasons for venous access to become compromised include previous central lines or catheterizations resulting in femoral vein or inferior vena cava occlusion. Other common obstacles to venous access include….

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 To overcome these limitations to venous access. Transhepatic venous catheterization has become popularized. Transhepatic punctures have been performed routinely by interventional radiologists for varied reasons. Percutaneous transhepatc cholangiography has been performed for 2 decades with low morbidity. Other transhepatic procedures include….

Contraindications Abnormal clotting/prothrombin time Active liver disease or peritonitis Abnormally draining hepatic veins In general, transhepatic punctures results in low morbidity however certain precautions need to followed. Contraindications to transhepatic catheterization include...

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 I will outline the transhepatic technique with further illustration later. A 22 gauge…..hepatic vein is identified. The hepatic vein will immediately be evident when the contrast flows quickly to the right atrium. If contrast is seen flowing to the periphery of the liver then either a portal vein, hepatic artery, or bile duct has been entered. Once the hepatic vein is entered...

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 Following cardiac catherization the sheath is slowly withdrawn with small injections of contrast until the parenchymal tract is identified. A gianturco coil is then placed to minimized the risk of bleeding. The puncture site...

Transhepatic technique (continued) This slide portrays the equipment required for transhepatic access. From left to right are the chiba needle, 0.018” cope wire, 4F coaxial dilator, and the curved transhepatic sheath. The curved transhepatic sheath was developed to allow better maneuverability of the catheter from the transhepatic approach.

Transhepatic technique (continued) This is a still frame from a cardiac catheterization performed in a 29 month old boy with pulmonary atresia and intact ventricular septum with documented bilateral femoral venous occlusions. The chiba needle is seen in the liver with the cope wire advanced to the right atrium. Note the contrast in the liver parenchyma which was injected during hepatic vein identification. The Cope wire is composed of nitinol wire which a short distance is seen at the end of the needle and the tip of the wire is composed of a very floppy, radioopaque platinum wire.

Transhepatic technique (continued) After a dilator and wire exchange, the sheath is placed into the right atrium. Note that this is a standard 5 F sheath since this catheterization was prior to the development of the curved transhepatic sheath.

Transhepatic technique (continued) A 5 F wedge catheter was then placed and advanced to the superior vena cava. Cardiac catheterization was performed on this patient with all information obtained.

Transhepatic technique (continued) Following catheterization, the sheath was slowly withdrawn with small injections of contrast to identify the parenchymal tract when the contrast no longer quickly flows to the right atrium. The tip of the sheath is seen in the parenchymal tract with a column of contrast.

Transhepatic technique (continued) A gianturco coil is then placed. The puncture site was dressed with opsite.

Transhepatic technique (continued) A hepatic ultrasound was obtained the following day. The apex of the image is over the puncture site and the echogenic coil is seen just below the apex. A hepatic vein branch is seen coursing towards the coil.

Shim D, et al. Circulation 1995;92:1526-1530 Evaluation of Efficacy and Safety Patient population (N=42) 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 In our first manuscript discussing transhepatic cardiac catheterizations in circulation, we reported on 42 patients who underwent attempted transhepatic access. Their ages ranged from a 1 day old to 41 yrs with a median weight of 11 kg. The right atrial pressure ranged from 0 to 24 mmHg with a median of 9 mmHg. Shim D, et al. Circulation 1995;92:1526-1530

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 The diagnoses of the 42 patients included primarily those with univentricular hearts. 5 newborns with critical pulmonary stenosis were also performed via the transhepatic route. The remainder diagnoses were varied as is seen on the slide.

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) The limitations to access were also varied and included one or more of the following reasons. Bilateral femoral venous occlusion was present in 30 patients. 9 patients were status post cavopulmonary anastomoses thus precluding the use of the subclavian or jugular vein. Heterotaxy with interrupted IVC was present in 7 patients. 4 patients suffered from occluded SVC. In 3 patients, the transhepatic approach was performed as the initial route of venous access to provide a more direct and stable route for their interventions which included pulmonary artery stent placement and atrial septal defect occlusion. Finally, 1 gentleman with a greenfield filter made transseptal mitral balloon valvuloplasty impossible from the standard femoral approach.

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 Transhepatic access was achieved in 41/42 patients with the one failure early in our experience in a nonintubated patient with marked liver excursions with respirations. The number of hepatic punctures to achieve access ranged…..

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 HGB (gm/dL) 14.4  2.6 13.4  2.4 To evaluate safety, certain parameters were followed prospectively. ALT and AST was shown to rise slightly after transhepatic catheterization however the change was neither statistically or clinically significant. Also the hemoglobin was shown to slightly fall again without statistical or clinical significance.

Safety (continued) Chest radiographs Liver ultrasound (n=34) no effusions no pneumoperitoneum/pneumothorax Liver ultrasound (n=34) small amount of peritoneal fluid (n=4) no subcapsular hematoma Clinical hemorrhage (n=2; 5%) Chest radiographs performed following catheterization revealed no evidence of effusions, pneumoperitoneum or pneumothorax. Liver ultrasound performed on the first 34 patients revealed small amount of peritoneal fluid in 4 which may have been ascites previously present and no subcapsular hmatoma. 2 patients were noted to have clinical hemorrhage during interventions and were both taken to the operating room for exploratory laparotomy. Neither patient had evidence of continued bleeding in the OR and both did well.

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) In Catheterization and cardiovascular diagnosis, we reported our experience of 30 transhepatic interventions. The one failure was a pt with pulmonary stenosis in which the catheter could not be maneuvered into the right ventricle from the transhepatic route prior to the development of the curved sheath. The patient underwent pulmonary balloon valvuloplasty via standard femoral access. The transhepatic interventions involved a wide range of therapies. 10 pts underwent pulmonary artery angioplasty with or without stent placement. One patient underwent 3 separate procedures involving stent placement or redilation of her stent in her fontan baffle. 2 patients received SVC stents. Valvuloplasty was performed on 3 pts and includes our one failure. Electrophysiology studies with or without ablation occurred in 4 procedures. 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 Other interventions involved occlusion of atrial septal defects, fontan fenestration device occlusion, coil embolization of a pulmonary artery pseudoaneurysm, device retrieval, and endomyocardial biopsy. Sheaths used for these interventions ranged from 4 to 14 French. No complications occurred in patients with the larger sheath sizes which were 6 F or larger.

Pulmonary valvuloplasty This neonate with near pulmonary valve atresia underwent transhepatic pulmonary valvuloplasty when neither femoral veins could be entered. The right ventricular angiogram reveals no flow of contrast into the pulmonary arteries. Note the sheath arising from the liver of this patient.

Pulmonary valvuloplasty (continued) The lateral view again confirms the anatomy of the pulmonary stenosis.

Pulmonary valvuloplasty (continued) A transhepatic valvuloplasty is performed. Note the relative straight catheter course in this patient which allowed easy manipulation of the balloon across the stenosis and also allowed more stability of the balloon during inflation.

Pulmonary valvuloplasty (continued) After balloon valvuloplasty, injection of contrast from the sidearm of the sheath reveals good pulmonary artery flow. The sheath is advanced here to the right ventricular outflow tract.

Pulmonary valvuloplasty (continued) The lateral view shows a widely patent pulmonary valve.

Fontan stent placement A transhepatic catheterization was performed in this 3 year old with hypoplastic left heart syndrome with a discrete stenosis in her Fontan baffle.

Fontan stent placement (continued) The lateral view shows the narrowing near the takeoff of the pulmonary arteries.

Fontan stent placement (continued) The stent was placed across the stenosis

Fontan stent placement (continued) Which produced a widely patent fontan baffle.

Fontan stent placement (continued) The lateral view reveals resolution of the narrowing seen before.

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 In conclusion, ….

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 We further speculate that….