Accessory Atrioventricular Pathways Refractory to Catheter Ablation

Abstract

Background— Epicardial mapping and ablation of accessory pathways through a subxiphoid approach can be an alternative when endocardial or epicardial transvenous mapping has failed. Methods and Results— We reviewed acute and long-term follow-up of 21 patients (14 males) referred for percutaneous epicardial accessory pathway ablation. There was a median of 2 previous failed procedures. All patients were highly symptomatic, 8 had atrial fibrillation (3 with cardiac arrest) and 13 had frequent symptomatic episodes of atrioventricular reentrant tachycardia. Six patients (28.5%) had a successful epicardial ablation. Five patients (23.8%) underwent a successful repeated endocardial mapping, and ablation after epicardial mapping yielded no early activation site. Epicardial mapping was helpful in guiding endocardial ablation in 2 patients (9.5%), showing that the earliest activation was simultaneous at the epicardium and endocardium. Four patients (19%) underwent successful open-chest surgery after failing epicardial/endocardial ablation. Two patients (9.5%) remained controlled under antiarrhythmic drugs after unsuccessful endocardial/epicardial ablation. Two patients had a coronary sinus diverticulum and one a right atrium to right ventricle diverticulum. Three patients acquired postablation coronary sinus stenosis. There was no major complication related to pericardial access. Conclusions— Percutaneous epicardial approach is an alternative when conventional endocardial or transvenous epicardial ablation fails in the elimination of the accessory pathway. A new attempt by endocardial approach was successful in a significant number of patients. Open-chest surgery may be required in symptomatic cases refractory to endocardial–epicardial approach.

“Needle-in-needle” epicardial access: Preliminary observations with a modified technique for facilitating epicardial interventional procedures

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14]16 In arrhythmogenic RV dysplasia and idiopathic dilated cardiomyopathies, a high incidence of epicardial substrate for ventricular arrhythmias is appreciated such that a endocardial/epicardial strategy may be applied during the first procedure. 15,23 Previous multicenter studies of epicardial ablation have shown that major pericardial bleeding (480 mL) occurs in 3.7% to 10% of patients.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Significant pericardial bleeding (480 mL) is the most common complication of epicardial access, with a reported incidence ranging from 3.7% to 10% 6,11,12,17,18 and is usually due to inadvertent right ventricular (RV) puncture, which may be severe enough to require surgical repair. 6,11 Methods to improve safety are of interest.…”

Percutaneous Catheter Ablation of Epicardial Accessory Pathways

“…Its correct identification is possible if a thorough programmed electrical stimulation is carried out after the ablation attempt. 3,4,8,9 Percutaneous Catheter Ablation of Epicardial Accessory Pathways In 1992 Haïssaguerre et al reported the effectiveness and safety of radiofrequency catheter ablation of left lateral APs via the mid or distal CS when endocardial approaches are unsuccessful. 10 They had no significant complications, except a marked nonspecific pain during RF energy application.…”

“…There are some case reports and a few series of cases about using the epicardial percutaneous subxiphoid approach to map and ablate APs (see Table 1). 3…”

“…However, this is not the case when the AP distal end is closer to the epicardial surface or its atrial or ventricular insertion is located far from the atrioventricular groove, and a small subset of patients will fail ablation procedures using a conventional endocardial approach. 2,3…”