Abstract
Endocardial mapping of the left ventricle (LV) using the NOGA® XP Cardiac Navigation System can identify chronically ischemic and viable myocardium in patients with coronary artery disease by generating electromechanical maps. These maps are very useful when targeting myocardial tissue for injection of stem cells. We present the case of a woman who developed a perforation at the site of an LV aneurysm during NOGA mapping prior to the transendocardial injection of stem cells, as part of a multicenter clinical trial. The presence of an LV aneurysm is currently not a contraindication (or caution) to the use the NOGA mapping catheter. As the field of stem cell therapy evolves and the use of this technique increases, operators must be aware that the presence of an LV aneurysm may increase the risk of perforation during a NOGA mapping procedure.
Highlights
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In clinical trials, endocardial mapping using the NOGA® XP Cardiac Navigation System is used to identify ischemic and viable myocardium in patients with coronary artery disease to guide the injection of stem cells or gene products.
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The presence of an LV aneurysm from a prior myocardial infarction may represent a site within the LV at greater risk for perforation with manipulation of the relatively stiff NOGA catheter.
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Therefore, greater caution is warranted during NOGA mapping in patients with an LV aneurysm.
1
Introduction
Over the past decade, there has been a growing interest in the use of stem cells for patients with refractory angina and chronic systolic heart failure . The preferred method for myocardial stem cell delivery has been transendocardial injections following NOGA® mapping of the LV chamber. Although usually safe and well tolerated, this procedure may be associated with serious complications, including myocardial perforation and pericardial tamponade .
2
Case presentation
A 65-year-old diabetic woman with two prior coronary artery bypass grafting (CABG) operations and several percutaneous coronary interventions presented with refractory angina pectoris. Despite optimization of her anti-anginal medications, she continued to report chronic Canadian Cardiovascular Society (CCS) class IV angina. She was not a candidate for further percutaneous or surgical revascularization, and elected to participate in the RENEW clinical trial (Efficacy and Safety of Targeted Intramyocardial Delivery of Auto CD34+ Stem Cells for Improving Exercise Capacity in Subjects with Refractory Angina) . The purpose of the study was to evaluate the safety and efficacy of autologous CD34+ stem cells in patients with chronic myocardial ischemia. As part of the protocol, she underwent LV mapping using the NOGA XP Cardiac Navigation System in preparation for subsequent transendocardial injections with the MyoStar catheter of autologous CD34+ stem cells (or placebo) that were previously collected via apheresis.
Right common femoral artery access was obtained. A left anterior oblique (LAO) and right anterior oblique (RAO) left ventriculography were initially performed for guidance during the mapping and cell injection procedure. The ventriculography demonstrated severe LV systolic dysfunction and a “wide mouth” out-pouching segment of the basal inferolateral wall, representing a true LV aneurysm ( Fig. 1 ). Thirty minutes later, during the LV mapping with the NOGA XP catheter, the patient developed sudden onset of severe chest pain and shortness of breath. A STAT transthoracic echocardiogram (TTE) demonstrated a new pericardial effusion with likely thrombus near the aneurysmal segment ( Fig. 2 A and B ). No effusion was seen on the pre-procedure TTE ( Fig. 2 C and D). These findings were consistent with an LV perforation from the NOGA catheter at the site of the aneurysm, despite routine careful manipulation of the mapping catheter by an experienced operator. The procedure was aborted and intramyocardial injection of stem cells was not performed; the MyoStar injection catheter was not used during this case. Protamine was administered to reverse the anticoagulation effect of unfractionated heparin. The patient remained hemodynamically stable and did not developed cardiac tamponade. Serial TTEs were performed over the next 24 h and confirmed that the pericardial effusion was not increasing in size. At the time of discharge, the patient’s symptoms had resolved and the effusion was minimal. Re-examination of the pre-procedural TTE identified the small basal inferolateral LV aneurysm ( Fig. 2 C and D).
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