In patients with combined mitral and aortic mechanical values and recurrent VT related to diseased LV substrate, traditional retrograde aortic or antegrade transmitral LV access approaches for catheter ablation are impossible. Researchers have developed a novel technique to access the LV via direct puncture of the inferior-septal process of the LV (ISP-LV) from the adjacent right atrium (RA) in these patients. This video shows the fourth step of the technique. After confirming position and angle of incidence of the distal aspect of the catheter sheath, puncturing the ISP-LV from the RA with 15 W to 25 W of radiofrequency (RF) energy, advancing the RF wire to the LV apex, and exchanging the RF wire with a stiffer Amplatz wire, the access site is dilated with a noncompliant balloon over the Amplatz wire to facilitate advancement of the sheath through the ISP-LV. Positioning and inflation of the balloon across the ISP-LV is verified by fluoroscopy and intracardiac echography. With the ISP-LV access site appropriately dilated, the balloon is deflated and the deflectable sheath advanced over the balloon into the LV. Click the Related Article link for complete details of the procedure and outcomes in a case series of patients and related video links for illustrations of additional steps of the technique. Left panel: right anterior oblique (RAO) fluoroscopic view. Right panel: intracardiac echography view.
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