Safety and efficacy of pericardial endoscopy by percutaneous subxyphoid approach in swine heart in vivo Takehiro Kimura, MD, Shunichiro Miyoshi, MD,

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Safety and efficacy of pericardial endoscopy by percutaneous subxyphoid approach in swine heart in vivo Takehiro Kimura, MD, Shunichiro Miyoshi, MD, PhD, Seiji Takatsuki, MD, PhD, Kojiro Tanimoto, MD, PhD, Kotaro Fukumoto, MD, PhD, Kyoko Soejima, MD, PhD, Keiichi Fukuda, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 142, Issue 1, Pages 181-190 (July 2011) DOI: 10.1016/j.jtcvs.2010.09.050 Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 List of the sheaths used. Internal diameter in French, model name, material, stiffness, shape of the tip, durability of the check valve, and an image of the sheath (white scale bars = 5 cm). ID, Internal diameter; F, French. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 181-190DOI: (10.1016/j.jtcvs.2010.09.050) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 List of the endoscopes used. Models of the endoscope, visual angle, direction of lens (angle along the longitudinal axis), outer diameter, inner diameter of utility port, adequate sheath, whether CCD camera is mounted on the tip or not, features of the endoscope, images of the endoscope (scale bars = 5 mm), and the performance of the endoscope in the pericardial space. CCD, Charge-coupled device; OD, outer diameter. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 181-190DOI: (10.1016/j.jtcvs.2010.09.050) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Systolic blood pressure, pulse oxymetry, and heart rate as a function of time during procedures of representative cases. Upper white bars in the graphs denote period of endoscope insertion, and black bars denote insertion of laparoscopic forceps. Upper gray arrows denote the time of insertion of each sheath, and lower gray arrows denote the timing of administration of atropine, suction, and injection of air/saline into the pericardial space. Hemodynamic parameters during procedure are well within tolerable limits. Sys-BP, Systolic blood pressure; SpO2, pulse oxymetry; HR, heart rate; ES, endoscope; fc, forceps; SH, sheath. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 181-190DOI: (10.1016/j.jtcvs.2010.09.050) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 A–F, Representative images of left anterior descending artery observed by each endoscope (denoted right bottom, number corresponding to it in Figure 1). It is difficult to front-view the endoscope with a narrow visual angle (A, B). Images of the endoscope without mounting the CCD on the tip (C, E) are fuzzy. Images of the endoscope with the CCD on the tip (D, F) are vivid. G, H, Schematic diagram of spatial configuration of endoscope in the pericardial space and its visual field. G, If the head of the front-view endoscope is directed to the heart surface, the objective lens gets too close to the heart surface. On the other hand, if the endoscope is tipped away from the heart surface, the visual field of the endoscope also tips away from the heart. H, The relation between the visual field and the direction of the objective lens. LAD, Left anterior descending artery; LV, left ventricle; ES, endoscope; RV, right ventricle. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 181-190DOI: (10.1016/j.jtcvs.2010.09.050) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Representative images obtained by endoscopy and fluoroscopy. Endoscopic images (A, C, E, G, I, K) obtained by ES3 and corresponding fluoroscopic images (B, D, F, H, J, L, respectively). A, Left atrial appendage and lateral wall of left ventricle. C, Right atrial appendage and lateral wall of right ventricle. E, Superior vena cava and right atrium. G, Left inferior pulmonary vein. I, Pericardium at the diaphragm looks pale compared with pericardium at the lungs. K, Left ventricular outflow tracts. Aortic root and left atrium can be observed. M–P, Endoscopic images obtained by ES5. Left atrial appendage (M, P), left inferior pulmonary vein (N), and pulmonary artery outflow tract (O, P). Q, R, Endoscopic images obtained by ES4. Right atrial appendage (Q), right ventricle (Q, R), and ventricular apex (apex, R). S–W, Endoscopic images obtained by ES6. S, T, Sequential image showing dynamic motion of left atrial appendage. U, Left atrial appendage and body of fiber itself. V, Pericardial puncture site and the body of fiber itself. W, Pericardium at the diaphragm. The quality of the images obtained by ES6 is superior to that obtained by ES3. X, Image obtained by ES1. By using the front-view ES with a narrow visual angle, it is difficult to observe the heart surface without significant halation. Ao, Aortic; ES, endoscopy; LA, left atrium; LAA, left atrial appendage; LiPV, left inferior pulmonary vein; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RAA, right atrial appendage; RV, right ventricle; S, diastole; SVC, superior vena cava; T, systole. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 181-190DOI: (10.1016/j.jtcvs.2010.09.050) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 A–E, Sequential fluoroscopic images during changing I-shape configuration to inverted U-shape configuration. See details in text. F–H, Schematic diagram of I-shape configuration, inverted U-shape configuration of pericardial endoscope, and how to steer the tip of the endoscope in the pericardial space. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 181-190DOI: (10.1016/j.jtcvs.2010.09.050) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 7 A–C, Indian ink was injected into the left ventricular epicardium with a needle. B, Immediately after injection of Indian ink, there was no active bleeding. D, Two weeks after the pericardial endoscopy, there was no coronary injury and no marked adhesion of pericardium. E, Laparoscopic forceps used. F, G, Endoscopic (ES6) images during implantation of pacing lead (I) in the left ventricular muscle by using laparoscopic forceps and fluoroscopic images during procedure (H). Implanted pacemaker lead immediately after the implantation (J–L). LV, Left ventricle. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 181-190DOI: (10.1016/j.jtcvs.2010.09.050) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions