The default technique for muscular septum device implantation starts with advancing a Judkins right catheter retrograde via the aortic valve to the left ventricle from a peripheral arterial access point. The defect is then crossed from left to right ventricle using a soft exchange wire which is advanced to the pulmonary artery or superior vena cava. The wire may then be exchanged for a more supportive 260-cm exchange wire. Venous access is established via the right internal jugular vein, where a snare via a 6 Fr standard wedge-catheter is introduced to capture and exteriorize the transseptal exchange wire creating an arteriovenous guidewire circuit.
A delivery sheath is then advanced from the venous side to the left ventricular cavity over the wire, and the dilator and wire are gently removed. The selected occluder device will be delivered to the left ventricle, extruded from the sheath until the left ventricular disc is opened and then withdrawn toward the interventricular septum and deployed. After satisfactory echocardiographic evaluation the device is released from the delivery cable.
Possible problems using this approach:
By using this technique we treated 19 patients in our center. In two of them we could not deliver the device into the ventricular septal defect (VSD). In one case with an apical location of the defect the arteriovenous guidewire had not enough backup that the delivery sheath could follow the sharp curve in the ventricular apex. In the other case the delivery sheath could be placed in the left ventricle but kinked while advancing the occluder and fell back into the right ventricle.
Modification the technique with a sheath to sheath approach:
The patient was a 71 year old man with a inferomedial postinfarct VSD. To overcome the mentioned difficulties we used a sheath in sheath tenchique for better stabilization of the delivery sheath (Figure). One advantage of the arteriovenous guidewire loop is that the wire could be accessed from both sides. After placing the Judkins right catheter through the defect into the right ventricle with access from the femoral artery we exchanced it with a standard 6 French Multipurpose guiding catheter. The guiding catheter is reinforsed for better backup during interventions (Figure 1a-1e). The 10 French delivery sheath is then pushed from the jugular vein over the wire directly to the guiding catheter sheath in a kissing position. This arrangement is kept tight anf than advanced into the left ventricle. While the right sided dilatator is pulled back the left 6 F sheath is advanced into the 10 F delivery sheath (Figure 2,3). When pushing the loaded occluder down in the 10F delivery sheath the 6F sheath is gently slided out (Figure 4). The occluder is placed from left to right in the defect (Figure 5-7).
Conclusion:
Advantages of the sheath to sheath technique:
- Stabilisation of the sheath when pushing from the right to left venticle
- Holding a smooth curve on the outer side of the ventricular defect
- Avoidance of sheath kinking be the reinforced guiding sheath while pushing the occluder
- Using a reinforced long sheath from the artery supports the non-kinking of the delivery sheath frm the right. Thereby the left sheath should be about 2 French smaller then the right sheath.
Our patient receives a 22 mm Amplatzer postinfarct occluder with almost complete occlusion of the defect and showed a good clinical recovery.
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