title: Transapical left ventricular access for difficult to reach interventional targets in the left heart.
abstract: OBJECTIVE
  Interventional targets may be virtually "excluded" due to vascular access problems or complex previous surgical procedures. This study reviews our experience using transapical ventricular puncture to gain direct access to the systemic ventricle.
  
  
  METHODS
  Patient 1 (74 years, 2 previous sternotomies), patient 2 (66 years, 5 previous sternotomies), and patient 5 (69 years, 3 previous sternotomies) with prosthetic valves had paravalvular mitral valve leaks. Patient 3 (6.3 years, 2 previous sternotomies) with an extracardiac Fontan conduit, had a significant residual leak after two previous surgical attempts of patch closure of a severely regurgitant right atrioventricular valve. Patient 4 (10 months) had failure of standard ablation of the posteroseptal region of the mitral valve with persistent life-threatening episodes of ventricular tachycardia.
  
  
  METHODS
  Procedures were performed under general anesthesia. Entry site was percutaneous in three patients and in two (and one conversion) a mini-thoracotomy was used. Sheaths were placed (6 F) using standard Seldinger technique, followed by the procedure as required. Direct surgical closure of the puncture site was done in 4 patients and in patient 3, a percutaneous vascular occlusion device was used.
  
  
  RESULTS
  Easy and immediate access was obtained in all patients. The paravalvular leaks were crossed within seconds and completely closed with Amplatzer occluders. In patient 3 the valve was crossed using a Brokenbrough needle and a 12-mm Amplatzer device was placed in the patch leak. Patient 4 was successfully ablated using a 7-F irrigated catheter endo- and epicardially. Complications were in the percutaneous puncture group: in one patient a coronary artery was punctured and in one a hemothorax developed.
  
  
  CONCLUSIONS
  Direct left ventricular puncture offers a very useful alternative access site in selected patients to reach "inaccessible" targets for certain percutaneous interventions in patients where standard approaches may be impossible or difficult.
authors.affiliation: Department of Paediatric Cardiology, University of the Free State, South Africa.
authors.forename: S C
authors.initials: SC
authors.lastname: Brown
authors.forename: D E
authors.initials: DE
authors.lastname: Boshoff
authors.forename: F
authors.initials: F
authors.lastname: Rega
authors.forename: B
authors.initials: B
authors.lastname: Eyskens
authors.forename: W
authors.initials: W
authors.lastname: Budts
authors.forename: H
authors.initials: H
authors.lastname: Heidbüchel
authors.forename: B
authors.initials: B
authors.lastname: Meyns
authors.forename: M
authors.initials: M
authors.lastname: Gewillig
mesh_terms: D000368:Aged; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D017115:Catheter Ablation; D002648:Child; D005260:Female; D018729:Fontan Procedure / Q000009:adverse effects; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects; D006352:Heart Ventricles; D006489:Hemostatic Techniques / Q000295:instrumentation; D006801:Humans; D007223:Infant; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D011475:Prosthesis Failure; D011677:Punctures; D015641:Radiography, Interventional; D013249:Sternum / Q000601:surgery; D013908:Thoracotomy; D016896:Treatment Outcome