A Novel Strategy for Left Ventricular Interventions in Patients With Double Mechanical Valves: Stylet-Driven Lead-Guided Transventricular Access.

Abstract

Background: Left ventricular (LV) interventions in patients with double mechanical valves represent one of the most formidable challenges in contemporary practice. Standard routes are unavailable in these "no-entry LV" scenarios, necessitating alternative access strategies.

Objectives: To evaluate the feasibility, safety, and reproducibility of a novel stylet-driven pacing lead system (SDL) -guided transventricular access technique in patients with double mechanical valves undergoing ventricular tachycardia (VT) ablation or structural interventions.

Methods: This multicenter case series included five consecutive patients (mean age 69 ± 8 years) with mechanical prostheses in both aortic and mitral positions. A SDL, originally designed for left bundle branch area pacing (LBBAP), was used to cross the interventricular septum under electrogram and fluoroscopic guidance. Subsequent interventions included VT ablation in four patients and transcatheter paravalvular leak (PVL) closure in one patient.

Results: Transventricular access was successfully established in all patients, with a mean access time of 13.4 ± 4.0 minutes. One patient required re-access which was rapidly re-established. All four VT ablation procedures were completed with acute noninducibility after substrate modification or adjunctive ethanol ablation. In the PVL case, two mitral paravalvular leaks were closed successfully. Postprocedural TTE revealed small ventricular septal shunts (mean size 1.5 ± 0.6 mm), which resolved spontaneously within one week in all patients. No major complications, conduction disturbances, or thromboembolic events occurred.

Conclusions: The SDL -guided transventricular access technique is a feasible, safe, and reproducible method for achieving LV entry, with promising applicability to both electrophysiologic and structural interventions in "no-entry LV" scenarios.