What are the findings and figures from the JACC (Journal of the American College of Cardiology) State of the Art Review article 2020 on transcatheter electrosurgery?

Key Findings and Figures from JACC State-of-the-Art Review on Transcatheter Electrosurgery (2020)

The 2020 JACC State-of-the-Art Review on transcatheter electrosurgery describes innovative techniques that use radiofrequency energy to vaporize, traverse, or lacerate cardiac tissue without open surgery, enabling novel therapeutic procedures for structural heart disease. 1

Principles of Transcatheter Electrosurgery

Tissue Traversal Technique

• Insulation Configuration: All but the tip of traversing guidewires is insulated to concentrate current at the point of tissue contact 1
• Energy Application: Radiofrequency energy is delivered in a focused manner to vaporize tissue despite flowing blood 1
• Medium Optimization: Non-ionic dextrose is used to flood the field, eliminating alternative current paths and improving energy delivery 1

Tissue Laceration Technique

• "Flying V" Configuration: A kinked guidewire concentrates current at the inner lacerating surface 1
• Wire Preparation: Selective denudation of insulation at the inner curve of the wire creates the cutting edge 1
• Alternative Method: Single-loop snares can also be energized during traction to cut tissue 2

Key Clinical Applications

Tissue Traversal Applications

1. Crossing Occlusions:

   • Pulmonary atresia
   • Arterial and venous occlusions
   • Iatrogenic graft occlusions 1

2. Traversing Tissue Planes:

   • Atrial and ventricular septal puncture
   • Transcaval aortic access
   • Creation of Potts and Glenn shunts 1

Leaflet Laceration Procedures

1. BASILICA (Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Coronary Artery obstruction) 1
2. LAMPOON (Laceration of the Anterior Mitral leaflet to Prevent Outflow ObstructioN) 1
3. ELASTA-Clip (Electrosurgical Laceration of Aortic leafletS To Aid Clip repair) 1
4. SESAME (Septal Scoring Along Midline Endocardium) - For LVOT obstruction treatment 3

Key Figures from the Review

Figure 11: Transcatheter Edge-to-Edge MV Clip Device

• Shows 3D en face view of flail posterior leaflet middle scallop (P2) with torn chords
• Demonstrates how transcatheter edge-to-edge clip creates tissue bridge between anterior and posterior leaflets
• Color flow image showing trace MR after edge-to-edge MV clip
• Continuous wave Doppler showing mean gradient 3 mm Hg after clip placement 4

Figure 13: Mitral Anatomy in Transcatheter Edge-to-Edge MV Clip

• Displays TEE images showing examples of mitral anatomy with varying degrees of difficulty for transcatheter edge-to-edge clip therapy
• Three views presented: Long-Axis, Bicommissural, and 3D En Face
• Top row: Shows flail posterior middle scallop - favorable anatomy for successful edge-to-edge repair
• Middle row: Shows challenging case with flail P1 and P3 segments
• Bottom row: Shows patient with severe mitral annular calcification and flail P3 segment 4

Clinical Outcomes and Considerations

Efficacy

• Transcatheter electrosurgery enables a range of novel therapeutic procedures for structural heart disease 1
• SESAME procedure has shown significant improvement in neo-LVOT measurements (from 42 mm² to 170 mm²) and reduction in LVOT gradients in HCM patients 3

Safety Considerations

• Potential complications include iatrogenic ventricular septal defects (3.9%), ventricular free wall perforations (3.9%), and need for permanent pacemakers (5.3%) 3
• Proper technique and patient selection are critical to minimize complications 1

Future Directions

• Transcatheter electrosurgery represents a promising advance toward transcatheter surgery 1
• With further experience, techniques like SESAME may benefit patients requiring septal reduction therapy or facilitate transcatheter valve implantation 3

Technical Tips for Optimization

• Concentrate current at the intended site of tissue interaction
• Use non-ionic dextrose to eliminate alternative current paths
• Ensure proper insulation of guidewires except at intended points of energy delivery
• Consider bipolar configuration for directional control in specific applications 5

Transcatheter electrosurgery has evolved from initial applications in crossing atretic valves to enabling complex structural heart interventions, representing a significant advancement in minimally invasive cardiac procedures.