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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.

Case Study

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.

IVSA Figure 1: Intracardiac echocardiography image
Figure 1: Intracardiac echocardiography shows the access sheath as it enters the left ventricle (LV) via the interventricular (IV) septum.
IVSA Figure 2:  intraoperative fluoroscopic image
Figure 2: In this intraoperative fluoroscopic image, the access sheath and ablation catheter enter the left ventricle (LV) by direct puncture of the interventricular septum to avoid mechanical valves at the aortic and mitral positions.

Access

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
2nd Floor
Radnor, PA 19087

Published on: July 21, 2016

Penn Faculty Team

Francis E. Marchlinski, MD

Director of Electrophysiology, University of Pennsylvania Health System

Director of Electrophysiology Laboratory, Hospital of the University of Pennsylvania

Richard T. and Angela Clark President's Distinguished Professor

Pasquale Santangeli, MD, PhD

Associate Professor of Medicine at the Hospital of the University of Pennsylvania

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