Electrophysiologists at Penn Medicine have developed a unique approach to perform radiofrequency ablation (RFA) for ventricular tachycardia (VT) in patients with mechanical valves. Ordinarily, percutaneous procedures are contraindicated for patients with double mechanical aortic and mitral valves as a result of the risk of catheter entrapment within the mechanical valves.
Efforts to perform VT ablation in patients with double mechanical valves have focused traditionally on open heart surgical ablation and, more recently, on less invasive surgical procedures that avoid traversing the valves altogether via a direct ventricular apical puncture. The latter, while reportedly successful, have been hampered by a substantial incidence of access-related bleeding complications, that together with the need for oral anticoagulation discontinuation, present a significant risk for acute valve thrombosis, stroke and death. Thus, safer methods remain in demand.
At Penn, electrophysiologists Pasquale Santangeli, MD, PhD, and Francis E. Marchlinski, MD, have pioneered a novel percutaneous approach to VT ablation that avoids open-heart surgery in patients with double mechanical valves. The technique, which combines direct septal visualization with intracardiac echocardiography coupled with a three-dimensional magnetic navigation system, does not involve surgical access nor the requirement for oral anticoagulation discontinuation, thus preventing the risk of valve thrombosis and/or periprocedural thromboembolism.
Mr. G was referred to the Division of Electrophysiology at Penn with drug refractory VT arising from a left ventricular apical aneurysm in the presence of two mechanical valves (aortic and mitral position).
Because Mr. G had dense apical calcifications, he was not an ideal candidate for surgical transapical access. Moreover, the risk of valve thrombosis associated with oral anticoagulation discontinuation meant he could not have open heart surgical ablation. Given the complexity presented by these issues and the presence of double mechanical valves, it was decided to approach the LV by direct puncture of the muscular interventricular septum via the right internal jugular vein.
The procedure (shown in Fig. 2) used custom-made radiofrequency wires and intracardiac echocardiography to guide the access and was completed in three hours without surgery or the need to the stop systemic anticoagulation.
Mr. G was released home several days later, and has experienced no further episodes of VT since the procedure.
Inpatient Electrophysiology Locations
Hospital of the University of Pennsylvania
9 Founders Building
3400 Spruce Street
Philadelphia, PA 19104
Outpatient Electrophysiology Locations
Penn Heart & Vascular Care
Perelman Center for Advanced Medicine
East Pavilion, 2nd Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104
Penn Medicine Radnor
250 King of Prussia Road
Radnor, PA 19087