Epicardial access for VT ablation: analysis of two different puncture techniques, incidence of adhesions and complication management

Abstract

Introduction Pericardial access for ablation of ventricular arrhythmias (VA) can be gained either by an anterior-oriented or inferior-oriented epicardial puncture under fluoroscopical guidance. We retrospectively sought to assess the safety of these two puncture techniques and the incidence of epicardial adhesions and introduce our algorithm for management of pericardial tamponade. Methods and results In 211 patients (61.4 ± 15.6 years, 179 males; 84.8%) 271 epicardial ablation procedures of VA were performed using either an anterior-or inferior-oriented approach for epicardial access. Puncture-related complications were systematically analyzed. Furthermore, the incidence of adhesions was evaluated during first and repeated procedures. A total of 34/271 (12.5%) major complications occurred and 23/271 (8.5%) were directly related to epicardial puncture. The incidence of puncture-related major complications in the anterior and inferior group was 4/82 (4.9%) and 19/189 (10.1%), respectively. Pericardial tamponade was the most common major complication (15/271; 5.5%). Collateral damages of adjacent structures such as liver, colon, gastric vessels and coronary arteries occurred in 6/189 (3.2%) patients and only within the inferior epicardial access group. Adhesions were documented in 19/211 (9%) patients during the first procedure and in 47.1% if patients had 2 or more procedures involving epicardial access. Conclusion Anterior-oriented epicardial puncture shows an observed association to a reduced incidence of pericardial tamponades and overall puncture-related complications in epicardial ablation of VA. In cases of repeated epicardial access adhesions increase significantly and may lead to ablation failure.

Road-Map to Epicardial Approach for Catheter Ablation of Ventricular Tachycardia in Structural Heart Disease: Results From a 10-Year Tertiary-Center Experience

“…39 Recently, a trend toward higher complication rate with percutaneous inferior approach as compared with the anterior one has been described (10.1% versus 4.9%). 40 In our experience of inferior-only oriented punctures, the rate of epicardial-related complications was very low as compared with previously reported data (3.6% versus 10.1%), on a considerable larger number of procedures (575 versus 189). Starting from 2014, tools and approaches were routinely implemented in the need to treat substrates, minimizing the risks of damaging epicardial structures, like CA e PN.…”

Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology

“…The posterior access route has a higher incidence of complications as the abdominal space is punctured. 186 Liver haemorrhage or damage may result from inadvertent puncture, especially in the case of right heart failure.…”

Can Early Ablation of Ventricular Tachycardia Improve Survival?

“…Epicardial ablation by accessing the pericardial space is more often required in this population and has been associated with a 5 to 12% risk of major complications, usually pericardial bleeding. 12 In PARTITA, 22% of patients had nonischemic dilated cardiomyopathy, and the majority had ischemic heart disease. Although epicardial ablation was allowed, none was performed.…”