Medical Professional Publications

Using the Transjugular Approach for Melody Transcatheter Pulmonary Valve Placement

Columbus, OH - January 2016

The Melody™ Transcatheter Pulmonary Valve is implanted most often through the femoral venous route, but some studies have reported that clinicians sometimes choose the internal jugular (transjugular) venous approach instead. The reasons behind this, and the benefits to the patient, have not always been clear.

A recent study has found that a transjugular approach actually may be the best option for very small patients, for those with elevated right ventricular pressures or those with significant tricuspid regurgitation. Researchers now say it is important to consider the transjugular approach with these patients from the beginning.

“If we attempt to go through the leg with these patients, we may have to switch to a transjugular approach in the middle of the procedure,” says Aimee Armstrong, MD, director of Cardiac Catheterization and Interventional Therapies at Nationwide Children’s Hospital and senior author of the study. “That can be time consuming and expose the patient to more radiation than if the transjugular approach were attempted initially.”

The recent Melody study was completed while Dr. Armstrong was a member of the Division of Pediatric Cardiology at the University of Michigan. She joined Nationwide Children’s in the fall of 2015. 

The study examined 81 patients who underwent transcatheter pulmonary valve implantation at two institutions. The transjugular approach was used in 14 of them, and the transfemoral approach was used in 67. Nine of the transjugular patients were converted to the approach after valve implantation was unsuccessful from the transfemoral route. Only one implantation using the transjugular route failed.

Researchers found that members of the transjugular group:

  • Were younger (mean 11.9 years vs. 17.3 years)
  • Were smaller (mean 1.33 m² body surface area vs. 1.61 m²)
  • More often had at least moderate tricuspid valve regurgitation (29 percent vs. 7 percent)
  • Had a higher ratio of right ventricle-to-systemic systolic pressure (mean 82.4 vs. 64.7)

Elevated right ventricular pressure may be the result of conduit stenosis, branch pulmonary stenosis and/or pulmonary hypertension, all of which could make catheter maneuvering and maintaining wire position from a transfemoral route difficult. Tricuspid regurgitation could also affect catheter and wire positions from the transfemoral approach. And younger and smaller patients may have vascular limitations that may make valve implantation from the femoral veins difficult.

In all of those cases, the transjugular approach may be the best option. When the transjugular route was the only approach tried, procedures took an average time of 5.6 hours, comparable to the average transfemoral procedure time of 5.3 hours. The procedure took an average of nearly 8 hours, however, when a transfemoral approach was attempted and failed before a transjugular approach was tried. Fluoroscopy time in this conversion group was also substantially longer than for the other two groups. 

The transfemoral route likely will continue to be the first option for most patients, says Dr. Armstrong, who is also an associate professor of Pediatrics at The Ohio State University College of Medicine. Catheterization labs are usually organized so the femoral venous approach is the baseline approach, and the transjugular route exposes the operator to more radiation. With that in mind, Dr. Armstrong says the transjugular approach should be undertaken very early in the procedure if it appears necessary.

 “We put a small catheter in the leg in the beginning,” she says. “If we encounter any difficulty whatsoever, we go to the internal jugular route quickly.”

Dr. Armstrong’s co-author, Darren Berman, MD, participated in this study while an interventional cardiologist at Miami Children’s Hospital. He is now the co-director of Cardiac Catheterization and Interventional Therapies at Nationwide Children’s.

Citation
Zampi JD, Berman DP, Bocks ML, Yu S, Zahn EM, Lu JC, Shaya JA, Armstrong AK. Factors associated with the internal jugular venous approach for Melody™ Transcatheter Pulmonary Valve implantation. Cardiology in the Young. 2015 Nov 2. [Epub ahead of print]

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