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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3597_Библиотеки_им_академика_М_И_Перельмана
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Special Techniques
A1
A
A2
B
Figure 7-10
fluoroscopy. CTA images are registered using “internal markers” (A) such
as mitral annular calcification/prosthetic valve (yellow outline) in two dif ferent views performed at least 30 degrees apart (A1, lef t anterior oblique
[LAO] 30 degrees; A2, right anterior oblique [RAO] 30 degrees). When “internal markers” are not available, aortography can be performed (B).
Registration of computed tomographic angiography (CTA) with
Pressure Sensor Guidewire to
Assess Pressure Across Mechanical
Prosthetic Valves
An alternative method to obtain LV pressure across mechanical prosthetic valves is to use a 0.014-inch pressure sensor guidewire. The use
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Special Techniques 343
A
B
Figure 7-11
roscopy for transapical access. Once registered, the volume- rendered threedimensional (3D) image is replaced with an outlined view of the cardiac
structures and is overlayed, along with landmarks, onto fluoroscopy. CTA
images are displayed in the same perspective as the C-arm and move with
C-arm rotations. A, For transapical access, the C -arm is in the left anterior
oblique (L AO) view, where the landmarks (skin entr y, left ventricle [LV] entr y,
and mitral prosthetic valve center) are lined up. The “safe path” (yellow
cylinder) becomes a bull’s-eye for 21-gauge micropuncture needle entry. B,
The right anterior oblique (RAO) view confirms needle trajectory and angula tion before puncture. The mitral annular calcification/prosthetic valve
(yellow) and paravalvular leak (red) can also be visualized.
Overlay of computed tomography angiography (CTA) onto fluo-
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A
Special Techniques
B
Figure 7-12 Overlay of computed tomography angiography (CTA) onto fluo-
roscopy for trans-septal access. Orange, Outlined view of the aorta and
coronary arteries. Their positioning is confirmed by the presence of a pig tail
catheter placed into the aor tic root. A, The trans-septal needle/sheath is
visualized crossing the interatrial septum at the site of landmark placement
(blue circle), with contrast staining of septum noted. B, Once needle position -
ing is confirmed by imaging and hemodynamics, the sheath is advanced into
the left atrium (LA). The site of sheath passage can be visualized at the
site of intended puncture.
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Special Techniques 345
A
B C
Figure 7-13 Echocardiography-fluoroscopy fusion for percutaneous trans-
septal –transapical mitral valve -in -valve implantation. B, The transesophageal echocardiography (TEE) probe is automatically registered to fluoroscopy
in reference to the faceplate (green probe). C, The landmark is placed at
the site of directed trans-septal puncture (blue circle), visualized on the echo
view (A). Free (B) and x-ray (C) views are displayed with the C- arm angulations (B and C, bottom right). In the x-ray view, the three-dimensional (3D)
volume space is overlayed directly onto fluoroscopy showing successful
valve-in- valve implantation with trivial paravalvular regurgitation. Arrowheads,
Arteriovenous rail from the trans -septal and transapical access points.
of a catheter to cross a mechanical prosthetic valve is generally prohibited because of the potential for catheter entrapment. However, a
fine-diameter (0.014-inch) guidewire with a high-fidelity pressure
sensor has been used safely in several reports. It is important to note
that there can be error in pressure measurement due to the inability
to zero the electronic pressure transducer once it has been placed
into the LV. Caution should be used when passing the guidewire
through the mechanical valve and retrieving it. An example of a pressure guidewire used to cross an aortic prosthetic valve is shown in
Figure 7-14.
Endomyocardial Biopsy
Indications, Contraindications,
and Complications
Monitoring cardiac transplant rejection and determining anthracycline cardiotoxicity are the only two definitive indications for endomyocardial biopsy (Box 7-2). Other indications include evaluation
for infiltrative cardiomyopathy, myocarditis that may benefit from
immunosuppressive therapy, and occasionally, differentiation between
restrictive and constrictive cardiomyopathies. Relative contraindications to endomyocardial biopsy are anticoagulation and anatomic
abnormalities.
Complications of endomyocardial biopsy can be access site
related (3%), valvular regurgitation (3%), arrhythmia (1%), conduction
abnormalities (1%), cardiac perforation (0.7%), and death (0.4%). Complication rates are higher for patients with cardiomyopathy than for
heart transplant recipients (Table 7-1).
Biopsy Devices
There are two basic types of bioptomes: (1) stiff shaft (preshaped)
devices (Konno, Kawai, and Stanford bioptomes; Fig. 7-15) and (2)
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Special Techniques
A
C
B
Figure 7-14 The cineframe shows a St. Jude valve with a Radi 0.014 pres-
sure wire across the valve, advanced through a multipurpose catheter. The
tilting disk valve (DV) in the mitral position made a trans-septal approach
impossible. A, 6- F multipurpose catheter; B, Radi pressure wire; C, leaflet
of St. Jude valve.
Box 7-2 Indications for Endomyocardial Biopsy
Definitive
• Cardiac transplantation follow- up
• Monitoring of anthracycline cardiotoxicity
Possible
• Viral myocarditis
• Secondary cardiomyopathies (sarcoidosis, hemochromatosis, and
amyloidosis)
• Differentiation of restrictive versus constrictive cardiac disease
• Endocardial fibrosis
• Hypereosinophilic syndrome
• Malignancies involving the hear t
floppy shaft devices (King and Cordis bioptomes; Fig. 7-16) that are
positioned with the aid of a long sheath. The femoral sheath dilator is
94 cm long, and the long sheath is 85 cm long. Biopsy sheaths come
in 5- and 7-cm curves (for hearts with large right atria or transplanted
hearts).
Technique
Endomyocardial biopsy can be performed under fluoroscopic or
echocardiographic guidance from the femoral or internal jugular
approach.
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Table 7-1
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Special Techniques 347
Major Complications of 2505 Retrospective and 543
Prospective Endomyocardial Biopsy Procedures
Retrospective
(Absolute/%)
Pericardial tamponade with
pericardiocentesis
Permanent complete AV block with
permanent pacemaker required
Urgent cardiac surgery 0/0 0/0
Advanced cardiac life suppor t 0/0 0/0
Hemothorax or pneumothorax 0/0 0/0
Death 0/0 0/0
From Holzmann M, Nicko A, Kuhl U, et al: Complication rate of right ventric ular
endomyocardial biopsy via the femor al approach: a retrospective and p rospec tive
study analy zing 3048 diagnostic procedures over an 11-year per iod. Circulation
118:1722–1728, 2008.
AV, Atrioventricular.
2/0.08 0/0
1/0.04 0/0
Prospective
(Absolute/%)
A
B
Figure 7-15 Scholten bioptome. A, Open; B, closed. (From Tilkian AG, Daily
EK: Cardiovascular procedures: diagnostic techniques and therapeutic procedures, St Louis, 1986, Mosby.)
Femoral Approach
After the patient is given local anesthesia, the right or left femoral vein
is punctured by the modified Seldinger technique and a 0.038-inch
guidewire is advanced into the femoral vein. A 7-F biopsy sheath with
a 7-F dilator is advanced over the guidewire. A large-curve (7-cm)
sheath is used when the atrium is dilated, as in cardiac transplantation.
In some systems, the dilator is not completely radiopaque. The sheath
and dilator are advanced into the RA. The dilator is withdrawn into
the sheath. With the help of the guidewire, the sheath is advanced
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Special Techniques
Handle down-jaws open
Figure 7-16 Disposable biopsy forceps with formable tip, pivoting jaws,
clear wire–braided body, stainless-steel cutting jaws, stainless-steel wire
coil, and a spring-loaded, three-ring plastic handle that controls the operation of the jaws. The thumb ring of the handle is flexible and rotates to
accommodate any thumb position, reducing manual stress.
Handle up-jaws closed
across the tricuspid valve and into the right ventricle (RV). The biopsy
sheath is equipped with a valve and side arm for flushing. The sheath
is flushed and connected to the pressure monitor, and a RV pressure
tracing is identified. A floppy shaft biopsy forceps is advanced through
the sheath and into the RV. The sheath is pointed horizontally toward
the intraventricular septum, which should be confirmed in the LAO
projection to ensure that the bioptome has not inadvertently entered
the CS. The RV outflow tract (upward sheath angle) and (usually) the
inferior (downward sheath angle) and RV free wall should be avoided.
To reduce the chance of perforation, the operator opens the biop-
tome jaws inside the sheath before the bioptome exits the sheath (Fig.
7-17). The bioptome is carefully advanced with the jaws fully open until
contact with the ventricular wall is made and the bioptome shaft is
slightly bent. The bioptome jaws are then closed. After 2 to 3 seconds,
to permit tissue excision, the “bite” is slowly withdrawn into the sheath
as the sheath is advanced. A tugging sensation is often felt by the
operator on full extraction of the bioptome into the sheath. After the
bioptome is removed from the patient, the sheath should be aspirated
and flushed to eliminate air bubbles. (Flushing can be minimized if
saline is free to flow into the sheath as the bioptome is being withdrawn. Otherwise, air fills the negative space of the bioptome through
the valve.) The procedure is repeated until an adequate number of
specimens (usually four to six) are obtained. RV pressures are measured before and after the biopsy. The biopsy sheath is removed, and
hemostasis is secured.
For heterotopic heart transplantation (i.e., piggyback hearts), the
RA of the donor’s heart is located in the right hemithorax. Its connection to the atrium of the recipient’s heart may be marked with a radiopaque ring. The biopsy sheath is advanced over the guidewire and
into the RV of the donor’s heart, and biopsy samples are taken as
described.
Internal Jugular Approach
Extensive experience in performing endomyocardial biopsies under
echocardiographic guidance and fluoroscopy has been reported
(Figs. 7-17 and 7-18). An 8-F short sheath is inserted into the right inter-
nal jugular vein by the standard Seldinger technique. A rigid, curved
bioptome is inserted through the venous sheath and into the RA. A
counterclockwise (anterior) rotation helps guide the bioptome past
the tricuspid valve. Further counterclockwise rotation straightens the
curve and orients the bioptome toward the central ventricular septum.
The operator should readily target the apical septum to avoid trauma
to the tricuspid valve, which is abundant in chordae. On fluoroscopy,
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Figure 7-17 Internal jugular approach. The bioptome tip is in the right
ventricular (RV) apex, pointing toward the ventricular septum. (From Tilkian
AG, Daily EK: Cardiovascular procedures: diagnostic techniques and therapeutic procedures, St Louis, 1986, Mosby.)
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Special Techniques 349
the RAO view facilitates apical placement, whereas the LAO view
ensures positioning against the ventricular septum. When biopsy of
other segments is desired, echocardiography can be used to target
those segments to increase the diagnostic yield of the procedure.
Some operators use echocardiography alone, which allows portability
for performance of biopsies at the bedside and also avoids exposure
to radiation. Following completion of the biopsies, the sheath is
removed, and hemostasis is secured.
Pericardiocentesis
Pericardiocentesis may be required for the diagnosis and management
of acute and chronic pericardial effusions. In cardiac tamponade, this
is a lifesaving technique. Pericardiocentesis is usually preceded by
echocardiographic confirmation of the pericardial effusion. In cases
in which a pericardial effusion is known or suspected with acute
hemodynamic compromise, echocardiographic assessment should
not delay the performance of pericardiocentesis.
Approach
The most common approach is subxiphoid, but other access routes
are acceptable depending on the depth from the skin and the location
and volume of the pericardial effusion (Fig. 7-19). The advantage of
the subxiphoid approach is a decreased likelihood of laceration of the
coronary and internal thoracic arteries. Placement of the needle
approximately a finger width below the edge of the rib is necessary to
avoid difficulty in advancing the catheter through fibrous tissue near
the xiphoid process.
Setup and Positioning
The patient is positioned at a 30- to 45-degree, head-up angle to permit
pericardial fluid to pool on the inferior surface of the heart. Local
anesthetic is given at the needle puncture site and more is instilled
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A
C
IVS
Bx
RV
LV
B
D
RFW
IVS
Bx
LV
FE
Figure 7-18 A, Anteroposterior cineangiographic image of femoral endo-
myocardial bioptome location. B, Corresponding left anterior oblique (LAO)
view. C, Simultaneous two-dimensional (2D) echocardiographic image
shows position of bioptome against the right ventricular (RV) side of the
interventricular septum (IVS). D to F, Same views in another transplant
recipient show nearly identical angiographic location but positioning of
bioptome and sheath against the RV free wall (RFW). Bx, Bioptome; LV, left
ventricle. (A to C, From Bell CA, Kern MJ, Aguirre FV, et al: Superior accuracy
of anatomic positioning with echocardiographic over fluoroscopic -guided
endomyocardial biopsy. Cathet Cardiovasc Diagn 28:291–294, 1993.)
through the pericardial needle as it is advanced perpendicularly to
the skin initially, then lowered to an angle nearly parallel with the floor
moving under the xiphoid process toward the left shoulder. If the
patient is obese, a larger needle and some force may be required
to tip the syringe under the subxiphoid process toward the heart
(Fig. 7-20).
For elective procedures, right-heart pressures are measured with
a balloon-tipped catheter positioned in the pulmonary artery to assess
equalization of diastolic right-sided pressures (and to document the
change with intervention) and then withdrawn into the RA for continuous monitoring of RA pressure during pericardial puncture and effusion drainage. A peripheral arterial line (e.g., radial line or 5-F sheath
placed in a femoral artery) often is used for monitoring systemic
pressure.
Puncture of the Pericardium
A long 16- or 18-gauge needle connected to a stopcock, and tubing to
a pressure transducer, can be used. When using this needle, it is
important to note that aspiration during passage through the skin may
block the needle with subcutaneous tissue. An alternative access
needle is an Angiocath (14 to 24 gauge; Becton, Dickinson and
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Special Techniques 351
5
4
6
1
Figure 7-19 Locations for pericardiocentesis. 1 to 3, Xiphoid approaches;
4, fifth left intercostal space at sternal border; 5, fifth right intercostal space
at the sternal border; 6, apical approach; 7, approach for major fluid accumulation on the right side. (Modified from Spodick DH: Acute pericarditis,
New York, 1959, Grune & Stratton.)
3
2
Lung
Pericardial
space
J-curve
guidewire
Figure 7-20 Passing a flexible J tip of the guidewire through the pericardial
needle into the pericardial space. (From Tilkian AG, Daily EK: Cardiovascular
procedures: diagnostic techniques and therapeutic procedures, St Louis,
1986, Mosby.)
Company, Franklin Lakes, NJ), which contains an inner stylet that is
removed once puncture of the pericardium has been performed. The
pericardial puncture feels similar to a lumbar puncture. The operator
should exercise care when advancing the needle. Excessive forward
pressure may result in crossing suddenly through the pericardium and
Liver
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