Transseptal left heart catheterization
1. Severe aortic stenosis if the valve cannot be crossed and in patient
with aortic prosthesis., then transseptal catheterization is done to get
the left ventricular pressure and the aortic gradient.
2. To get the mitral valve gradient in patient with prosthetic mitral valve
3. To get the LVOT gradient in patients with HOCM
4. Mitral balloon valvuloplasty
5. Transcatheter Mitral valve repair
6. Left atrial appendage occlusion
7. Some cases of PFO closure
8. Mitral paravalvular leak closure
9. Radiofrequency ablation of atrial fibrillation, accessory pathways, AV
Percutaneous intervention in
1. Percutaneous pericardiocentesis (PPC)
2. Percutaneous balloon pericardiotomy
3. Surgical pericardial window
4. Intrapericardial injection of sclerosing agents
5. Percutaneous closed pericardial biopsy
6. Percutaneous pericardioscopy with biopsy
7. Percutaneous pericardial access for epicardial mapping and ablation of
Percutaneous closed pericardial
1. First developed by our group in Kuwait in 1988.
2. It is safe simple technique which will be done at the
same time of percutaneous pericardiocentesis.
3. Is very sensitive diagnostic technique especially in
malignant and tuberculous pericardial effusion.
4. Multiple biopsies from different parts of the parietal
pericardium can be obtained.
5. It is performed using fluoroscopic guidance in the
6. The overall sensitivity is 60%, but much higher in
malignant and tuberculous etiology.
Alcohol Septal Ablation (ASA)
Key Points to remember:
1. ASA relieves LVOT obstruction by creating a localized myocardial
infarction in the area of the basal septal muscle where SAM-septal
contact is occurring. Remodeling of this area of contact lead to widening
2. ASA improves symptoms, increase exercise capacity and improve long
3. Studies have shown that the procedure is safe and effective in most
4. Long term survival is comparable to historical reports of surgical
myectomy and approach that of general population.
5. ASA is a viable treatment for patients with HOCM.
6. ASA advantages include:
o Avoidance of surgical sternotomy
o Shorter recovery and shorter hospital stay
o Lower risk of occurrence of VSD as a complication
o Treatment of concomitant coronary stenosis by angioplasty
o Less expensive
o Can be repeated
The golden rules to avoid complications:
• Know your own limitations.
• Proper patient and lesion selection.
• Avoid oculostenotic reflex.
• Selection of proper equipments.
• Keep the procedure as simple as possible.
• Know when to stop and ask for early help when needed.
• Maintain highest level of concentration.
• Learn from your own and others mistakes.
Mitral Balloon Valvuloplasty (MBV)
Severe MS (MVA <1.5cm²)
1. Symptomatic patients with favorable valve morphology in the absence of
left atrial thrombus or moderate-severe MR.( Class I A)
2. Symptomatic patients with sub optimal valve pathology, with either
contraindications to or high risk for surgery (Class IIb C).
3. Symptomatic patients with unfavorable anatomy but favorable clinical
characteristics. (IIa C)
4. Asymptomatic patient with favorable morphology with very severe MS
(MVA < 1 cm²). (Class IIa C)
5. Asymptomatic patient with severe MS < 1.5cm² and having one of the followings: Previous history of embolism Dense spontaneous echo contrast in left atrium Paroxysmal atrial fibrillation Pulmonary hypertension (>50mmHg)
Patient in need of major non-cardiac surgery
A desire for pregnancy
Mitral Balloon Valvuloplasty (MBV)
Mitral balloon valvuloplasty can be performed in the
1. Organized left atrial mural thrombus
2. Intracavity, non-protruding, non-mobile left atrial
3. Bicommissural calcification
4. Associated severe rheumatic non-calcified aortic or
tricuspid valve stenosis
Aortic balloon valvuloplasty (ABV)
1. In selected adolescent and young adults with noncalcified
valve balloon valvuloplasty may be
2. In calcific aortic stenosis might be considered as a
bridge to surgery or TAVI. (Class IIb C)
3. As a routine procedure prior to TAVI
Transcatheter Aortic Valve
1. TAVI is recommended in patients who meet the indication for AVR
and who is having prohibitive risks for surgical AVR and predicted
survival greater than 12 months. (Class I B)
2. TAVI is reasonable alternative to surgical AVR in patients who
meet the indications for AVR and who have high surgical risk for
surgical AVR. (Class IIa B)
3. Percutaneous aortic balloon dilatation may be considered as
bridge to surgical AVR or TAVI. (Class IIb C)
4. TAVI is not recommended in patients in whom existing
Co-morbidities would prevent the expected benefit from correction of
aortic stenosis. (Class III) (No benefit)