Introduction
Epicardial access for mapping and ablation of the epicardial substrate may be required
in catheter ablation of ventricular tachycardias (VT). However, high complication
rates are associated with the standard epicardial access approach. Recently, a novel
method of intentional coronary vein (CV) exit with pericardial CO2 insufflation to facilitate epicardial access has been described. This study describes
our initial experience with this technique.
Methods
Patients undergoing epicardial VT ablation between 1 February 2021 to 31 May 2022
at the Royal Prince Alfred Hospital, Sydney, NSW, were included in this study. Via
femoral venous access, a branch of the coronary sinus was sub-selected and intentional
CV exit was performed with a high tip load coronary angioplasty wire. A microcatheter
was then advanced over the wire into the pericardial space, followed by pericardial
CO2 insufflation, facilitating subxiphoid pericardial puncture.
Results
Five (5) patients underwent epicardial access for VT mapping and ablation. All patients
had successful intentional CV exit and CO2 facilitated epicardial access. The mean time to successful epicardial access was
37.2±17.5 minutes. With increasing operator experience, there was improvement in epicardial
access times, with the fifth case requiring only 13 minutes. There was one case of
inadvertent right ventricular puncture (without haemodynamic or ventilatory compromise)
due to inappropriate CO2 insufflation into the right ventricle. Epicardial access was successful on the second
attempt.
Conclusion
This is the first case series of epicardial access facilitated by CO2 insufflation in Australia. This technique enabled successful epicardial access in
all patients in our early experience, with no adverse outcomes from epicardial access.
With increasing operator experience, this technique may allow for more widespread
adoption of up-front epicardial access for the treatment of VT.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Heart, Lung and CirculationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy.J Am Coll Cardiol. 2009; 54: 799-808
- Combined endocardial-epicardial versus endocardial catheter ablation alone for ventricular tachycardia in structural heart disease: a systematic review and meta-analysis.JACC Clin Electrophysiol. 2019; 5: 13-24
- Epicardial substrate and outcome with epicardial ablation of ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy/dysplasia.Circulation. 2009; 120: 366-375
- A new technique to perform epicardial mapping in the electrophysiology laboratory.J Cardiovasc Electrophysiol. 1996; 7: 531-536
- Unusual complications of percutaneous epicardial access and epicardial mapping and ablation of cardiac arrhythmias.Circ Arrhythm Electrophysiol. 2011; 4: 882-888
- Epicardial mapping and ablation techniques to control ventricular tachycardia.J Cardiovasc Electrophysiol. 2005; 16: 449-452
- Epicardial ventricular tachycardia ablation a multicenter safety study.J Am Coll Cardiol. 2010; 55: 2366-2372
- “Needle-in-needle” epicardial access: preliminary observations with a modified technique for facilitating epicardial interventional procedures.Heart Rhythm. 2015; 12: 1691-1697
- Differences in complication rates between large bore needle and a long micropuncture needle during epicardial access: time to change clinical practice?.Circ Arrhythm Electrophysiol. 2015; 8: 890-895
- Intentional right atrial exit and carbon dioxide insufflation to facilitate subxiphoid needle entry into the empty pericardial space: first human experience.JACC Clin Electrophysiol. 2015; 1: 434-441
- Coronary vein exit and carbon dioxide insufflation to facilitate subxiphoid epicardial access for ventricular mapping and ablation: first experience.JACC Clin Electrophysiol. 2017; 3: 514-521
- A new era in epicardial access for the ablation of ventricular arrhythmias: the Epi-Co(2) Registry.JACC Clin Electrophysiol. 2021; 7: 85-96
- Influence of steroid therapy on the incidence of pericarditis and atrial fibrillation after percutaneous epicardial mapping and ablation for ventricular tachycardia.Circ Arrhythm Electrophysiol. 2014; 7: 671-676
- Elimination of local abnormal ventricular activities: a new end point for substrate modification in patients with scar-related ventricular tachycardia.Circulation. 2012; 125: 2184-2196
- Electrical substrate elimination in 135 consecutive patients with brugada syndrome.Circ Arrhythm Electrophysiol. 2017; 10e005053
- Open versus closed establishment of pneumoperitoneum in laparoscopic surgery.Br J Surg. 1997; 84: 599-602
- Venous gas embolism during gynaecological laparoscopy.Can J Anaesth. 1992; 39: 748-749
- Experimental carbon dioxide pulmonary embolization after vena cava laceration under pneumoperitoneum.Surg Endosc. 1995; 9: 1065-1069
- Gas embolism: a comparative study of air and carbon dioxide as embolic agents in the systemic venous system.Am J Obstet Gynecol. 1959; 78: 259-265
- Carbon dioxide embolism during laparoscopic surgery.Yonsei Med J. 2012; 53: 459-466
- Body position in relation to venous air embolism: a roentgenologic study.Am J Med Sci. 1954; 227: 509-520
Article info
Publication history
Published online: December 03, 2022
Accepted:
September 3,
2022
Received in revised form:
August 21,
2022
Received:
July 1,
2022
Identification
Copyright
© 2022 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
