Direct transthoracic left ventricular puncture

  • Direct transthoracic left ventricular puncture is used to measure left ventricular pressure and to perform ventriculography in certain specific situations
  • If a patient has undergone both aortic and mitral valve replacement with mechanical prosthetic valves, retrograde arterial catheterisation and trans septal catheterisation is not possible
  • If catheterisation is attempted across tilting disc valves, it may result in catheter entrapment, valve occlusion or even dislodgement of the disc leading to embolisation

Direct transthoracic left ventricular puncture – Procedure

  • The left ventricular apex is located by palpation / echocardiography
  • Local anaesthetic is injected into the skin at the selected location
  • An 18 or 21 gauge Teflon catheter is used for the puncture
  • The catheter is inserted at the upper margin of the rib (to prevent damage to the neurovascular bundle located in the lower margin)
  • It is pushed posteriorly in the direction of the right second intercostal space, till the LV impulse is felt
  • The needle (with sheath) is inserted into the left ventricle
  • Once inside the LV, the needle is removed and the sheath can be used for measuring LV pressure and to preform ventriculography

Complications

  • Cardiac tamponade (risk is lower in those who had previous cardiac surgery, due to the presence of mediastinal fibrosis)
  • Hemothorax
  • Pneumothorax
  • Laceration of left anterior descending coronary artery
  • Embolisation of LV thrombus
  • Ventricular arrhythmias
  • Vagal reactions

 

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