Epicardial ablation of ventricular tachycardia: An institutional experience of safety and efficacy

Tung, Roderick; Michowitz, Yoav; Yu, Ricky; Mathuria, Nilesh; Vaseghi, Marmar; Buch, Éric; Bradfield, Jason S.; Fujimura, Osamu; Gima, Jean; Discepolo, William; Mandapati, Ravi; Shivkumar, Kalyanam

doi:10.1016/j.hrthm.2012.12.013

Cited by 138 publications

(94 citation statements)

References 24 publications

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“…5 Large pericardial effusion and consequent tamponade are the most feared complications and can be devastating if not emergently treated with frequent draining or with surgical repair. 11 In a single-center study by Tung et al, 12 major complications were seen in 8.8% of the patients, and epicardial bleeding from RV puncture seems to be the major complication. Inadvertent RV puncture ranged from 4.5% to 17% of the cases but majority of these cases had <80 mL pericardial bleeding without serious consequences.…”

Section: Study Findingsmentioning

confidence: 96%

Differences in Complication Rates Between Large Bore Needle and a Long Micropuncture Needle During Epicardial Access

Gunda

Reddy

Pillarisetti

et al. 2015

Circ: Arrhythmia and Electrophysiology

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Background-A dry epicardial access (EA) is increasingly used for advanced cardiovascular procedures. Conventionally used large bore needles (Tuohy or Pajunk needle; LBN) have been associated with low but definite incidence of major complications with EA. Use of micropuncture needle (MPN) may decrease the risk of complications. We intended to compare the outcomes of LBN with MPN for EA. Methods and Results-We report a multicenter observational study of consecutive patients who underwent EA for ventricular tachycardia ablation or Lariat procedure using the LBN or MPN. Oral anticoagulation was stopped before the procedure. Baseline characteristics and procedure-related complications were collected and compared. Of the 404 patients, LBN and MPN were used in 46% and 54% of patients, respectively. There was no significant difference in the incidence of inadvertent puncture of myocardium between LBN and MPN (7.6% versus 6.8%, P=0.76). However, there was a significantly higher rate of large pericardial effusions with LBN compared with MPN (8.1% versus 0.9%; P<0.001). The incidence of pleural effusions were not significantly different between both (1.6% versus 2.3%; P=0.64).

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Section: Study Findingsmentioning

confidence: 96%

Differences in Complication Rates Between Large Bore Needle and a Long Micropuncture Needle During Epicardial Access

Gunda

Reddy

Pillarisetti

et al. 2015

Circ: Arrhythmia and Electrophysiology

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“…13 In our experience, patients with ischemic cardiomyopathy also experience greater freedom from recurrence when epicardial ablation is performed in combination with endocardial ablation (Figure 2). 14 The yield of epicardial ablation in the postinfarct setting is dependent on prior ablation history, where enriched epicardial substrates may be selected due to referral bias after unsuccessful endocardial ablation. 15,16 …”

Section: Indications For Epicardial Mapping and Ablationmentioning

confidence: 99%

Epicardial Ablation of Ventricular Tachycardia

Tung

Shivkumar

2015

Methodist DeBakey Cardiovascular Journal

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Epicardial mapping and ablation via a percutaneous subxiphoid technique has been instrumental in improving the working understanding of complex myocardial scars in various arrhythmogenic substrates. Endocardial ablation alone may not be sufficient in patients with ischemic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy, and Chagas disease to prevent recurrent ventricular tachycardia. Multiple observational studies have demonstrated greater freedom from recurrence with adjunctive epicardial ablation compared with endocardial ablation alone. While epicardial ablation is performed predominantly at tertiary referral centers, knowledge of the technical approach, clinical indications, and potential complications is imperative to maximizing clinical success and patient safety.In 1996, Sosa and colleagues modified the pericardiocentesis technique to enable percutaneous access to the pericardial space for mapping and catheter ablation of ventricular tachycardia.1 Originally developed for patients with epicardial scarring due to chagasic cardiomyopathy and patients with ischemic cardiomyopathy refractory to endocardial ablationm, 2,3 this approach has since become an essential part of the armamentarium for the treatment of ventricular tachycardia. Myocardial scars are three-dimensionally complex with varying degrees of transmurality, and the ability to map and ablate the epicardial surface has contributed to a greater understanding of scar-related VT in postinfarction cardiomyopathy and nonischemic substrates including idiopathic dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy, and chagasic cardiomyopathy. In this review, we highlight the percutaneous approach and discuss clinical indications and potential complications.

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“…In a series that included 72 patients with post-MI VT, with endoepicardial ablation in 21 and endocardial ablation only in the remaining 51, both groups achieved similar acute complete or partial success (>90% in both groups), but 85% of the former and 56% of the latter were arrhythmia free at 12 months. 2 In a somewhat different approach and patient population, in patients with electrical storm, it was found that endo-epicardial scar homogenization (epicardial ablation in 33%) resulted in 19% recurrence rate when compared with 47% recurrence rate with the conventional endocardial approach. 16 Are the results of Izquierdo et al 11 convincing enough to adopt their experimental approach?…”

Section: Article See P 882mentioning

confidence: 99%

“…2 It has been recognized that in idiopathic dilated cardiomyopathy, an epicardial origin is frequent and amenable to ablation in some cases. 3,4 More recently, similar findings were described in arrhythmogenic right ventricular cardiomyopathy.…”

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confidence: 99%

Epicardial Ablation in Post–Myocardial Infarction Ventricular Tachycardia

Almendral

Castellanos

2015

Circ: Arrhythmia and Electrophysiology

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S ince its first description by Sosa et al, 1 catheter-based epicardial ablation has been increasingly used for catheter ablation of ventricular tachycardia (VT) due to a variety of substrates.2 It has been recognized that in idiopathic dilated cardiomyopathy, an epicardial origin is frequent and amenable to ablation in some cases. 3,4 More recently, similar findings were described in arrhythmogenic right ventricular cardiomyopathy. 5 Article see p 882However, the situation in VT related to chronic myocardial infarction (post-MI VT) seemed different. The surgical experience having a high success rate with subendocardial resection spoke for a subendocardial location of the VT substrate. 6 The initial series of catheter-based VT ablation, involving welltolerated VT ablated endocardially based on VT mapping during tachycardia, showed a relatively high acute success rate. However, VT recurrences were common. 7 The introduction of the concept of substrate ablation, based on locating the VT substrate during sinus rhythm, 8 has expanded catheter ablation to a larger number of VT patients, with reasonably good acute results, but the recurrence rate is still high.9,10 It has been suggested that this high recurrence rate could be related to a modification of the substrate over time because of the remodeling process, 10 but this has never been demonstrated and the fight for an improvement in results continues.In this issue of the journal, Izquierdo et al 11 searched in a different direction. What if the substrate, although partially endocardial, involves subepicardial or epicardial areas as well? What if our endocardial lesions are not deep or large enough to permanently damage the VT substrate and epicardial ablation improves clinical results? To explore on such a hypothesis, they performed both endocardial and epicardial mapping and eventual ablation in a consecutive series of 15 patients with post-MI VT undergoing their first ablation procedure (endo-epi group).These patients were compared with a relatively heterogeneous group of 35 patients, who underwent exclusively endocardial mapping and ablation (endo-only group) because the procedure was performed before a certain date (when they started the combined approach), because they had undergone cardiac surgery in the past precluding a percutaneous pericardial access, or because of physician preference (less experienced operators). However, both groups seemed to be comparable except for the higher incidence of previous cardiac surgery in the endo-only group, as expected. There were some complications related to the epicardial approach, and the acute results (rate of complete or partial success in VT suppression) were similar. However, clinical outcome was better in the endo-epi group, with a tendency toward a lower recurrence rate (46% in the endo-only group versus 20% in the endo-epi group) and a significantly lower incidence of a combined end point of hospital/emergency admission because of VT or need for reablation (40% in the endo-only group versus 7% in the endo-epi ...

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Epicardial ablation of ventricular tachycardia: An institutional experience of safety and efficacy

Cited by 138 publications

References 24 publications

Differences in Complication Rates Between Large Bore Needle and a Long Micropuncture Needle During Epicardial Access

Differences in Complication Rates Between Large Bore Needle and a Long Micropuncture Needle During Epicardial Access

Epicardial Ablation of Ventricular Tachycardia

Epicardial Ablation in Post–Myocardial Infarction Ventricular Tachycardia

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