1. Direct transthoracic access ports to the heart and non-surgical closure
Robert J. Lederman, MD Senior Investigator Cardiovascular & Pulmonary Branch, Division of Intramural Research National Heart, Lung, and Blood Institute National Institutes of Health Bethesda, MD, USA

2. Percutaneous large-bore myocardial access will facilitate certain structural heart interventions
Aortic valve implantation
“Hybrid” perventricular congenital repairs
Mitral valve repair
Major vascular complications ~30% even selecting for TAVR + 18Fr devices + iliac>8mm (Hayashida, JACC-Intv 2011)
Michel-Behnke, CCI 2010
Mitral valve replacement

3. Small incision, big procedure.
Direct left ventricular access requires thoracotomy and placement of purse-string sutures under direct vision
Small incision, big procedure.

4. MRI + AX Lab

5. Access

6. Active Needle Single channel elongated solenoid coil design
SNR Map
CE Saikus, JMRI 2011; 34:1159

7. Myocardial access: avoid critical structures
Interventricular septum
Internal thoracic arteries
Papillary muscle
Papillary muscles
Liver
Minimize lung traversal
CE Saikus, JMRI 2011; 34:1159

8. Needle Access Demonstration
IM Barbash, CE Saikus, JACC Intv 2011; 4(12):1318

9. Therapeutic procedure

10. Closure

11. “Permissive pericardial tamponade”
(through a separate catheter)
Needle access
Instill pericardial fluid to separate visceral & parietal layers (separate catheter)
Deploy closure device INSIDE pericardium
Withdraw pericardial fluid
IM Barbash, Cathet Cardiovasc Interven 2011; (7):1079

12. Pericardial entrapment “tethers open” the myocardial hole
Angio-Seal suture
Visceral pericardium
Parietal pericardium
Bleeding
IM Barbash, Cathet Cardiovasc Interven 2011; (7):1079
#27812 CIMG2102.JPG

13. MRI Closure Appliances
Active Delivery Cable
Nitinol Occluder (modified Amplatzer)
Stainless steel microscrew
Titanium microscrew
Cable
Occluder
Loopless antenna design
Nitinol rod and hypotube
Occluder becomes part of antenna whip
Occluder changes tuning
JA Bell, CE Saikus.. Ozgur Kocaturk [Under Review]

14. Nitinol Implant; “Active” delivery cable
IM Barbash, CE Saikus, JACC Intv 2011; 4(12):1318

15. Early hemostasis 3-months Preserved LV function
Complete endothelialization
IM Barbash, CE Saikus, JACC Intv 2011; 4(12):1318

16. Direct transthoracic VSD repair using real-time MRI: 1 Needle trajectory planning
Michel-Behnke, CCI 2010
New transjugular laser VSD model
K Ratnayaka, J Am Coll Cardiol Intv 2011;4(12):1326

17. Direct transthoracic VSD repair using real-time MRI: 2 VSD repair (simultaneous slices)
K Ratnayaka, J Am Coll Cardiol Intv 2011;4(12):1326

18. Direct transthoracic VSD repair using real-time MRI: 3 Closure of RV free wall
K Ratnayaka, J Am Coll Cardiol Intv 2011;4(12):1326

19. Access to the LV through the RV
Epicardial pressure gradient is RV, not LV magnitude
M. Halabi

20. Ruiz et al: CT roadmaps
Jelnin et al, J Am Coll Cardiol Intv 2011;4:868 –74

21. Other thoughts Performance requirement Tissue characteristics
Acceptable failure rate?
Surgical rescue?
Infarction
Hypertrophy
Heterogeneity
Simple withdrawal / no device
Subvalvar apparatus
Case series in post-operative pericardium
Intact pericardium: unattractive
Avoid entrapment
Procedure “security”
True apex vs para-apical
Intracameral retention sheaths
Drains
Apical danger zone: mechanical vulnerability
Apical entrapment/distortion of implants
Overnight drains
Mid-term effusions?

22. Transthoracic Myocardial Port Access & Closure
Closed-chest access ports are realistic development targets to introduce large devices into the heart
Real time MRI presents the entire thoracic context to the operator, visualizing targets and complications.
If the pericardium is intact, its walls should be separated; pericardial entrapment causes bleeding
Various “family members” are available as options