Anterior pericardial access to facilitate electrophysiology study and catheter ablation of ventricular arrhythmias: A single tertiary center experience

Abstract

Introduction Epicardial ablation is becoming an important part of management in patients with ventricular tachycardia (VT). Posterior epicardial access via the Sosa or needle-in-needle (NIN) approach for epicardial VT ablation is considered to be the method of choice for most electrophysiologists. Anterior epicardial access as an alternative technique has recently been proposed, but there are limited data about its safety, efficacy, and the rate of immediate complications. In this study, we report our experience with anterior epicardial access between 2009 and 2016. Methods Between 2009 and June 2016, 100 consecutive patients underwent epicardial VT ablation using an anterior approach. The success rate, epicardial bleeding, and other complications related to the epicardial access in these patients were compared to the previously reported rate of complications in patients whom epicardial access was performed using the NIN or Sosa techniques. Results Anterior epicardial access was obtained successfully in 100% of patients in the first attempt. The success rate of the anterior approach was comparable with the reported success rate of the NIN technique (100% vs. 100%, P value not significant) but better than the Sosa technique (100% vs. 94%, P = 0.012). None of the patients in the anterior approach series suffered from significant pericardial bleeding (defined as greater than 80 mL of blood loss), RV puncture/damage, or need for an emergent cardiac surgery. Conclusion An anterior epicardial approach is feasible and appears to have an acceptable safety profile in comparison with other epicardial approaches.

Epicardial access complications during electrophysiology procedures

“…The needle can be introduced from the epigastrium to the pericardial space using two approaches: anterior and posterior. In a prospective consecutive series of 100 patients using the anterior approach, success rate of anterior approach was noted to be significantly higher than historical controls using the posterior approach (100% vs. 94%, p = .012), 12 with zero complication rate. Prior series of patients undergoing EA with a posterior approach have reported hemopericardium requiring drainage in 7%–8.9% of cases and <1% of coronary injury 13 .…”

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

“…Nonetheless, the most common complication in our patient cohort was pericardial bleeding and consecutive tamponade. Interestingly, a previous study by Keramati et al reported about no pericardial bleeding complications (> 80 ml blood) after LAO guided and anterior-oriented puncture and no emergent cardiac surgery or procedure-related mortality [ 13 ]. Even though we observed pericardial bleeding in 4 patients (4.9%) in the anterior epicardial group, we also did not experience any need for emergent cardiac surgery or procedure-related mortality.…”

“…To avoid collateral damages, a fluoroscopically guided access using a left anterior oblique (LAO) 90° projection to obtain an anterior access to the pericardial space has been implemented at different institutions, delineating an acceptable safety profile and achievement of complete and detailed mapping of both ventricles [ 13 , 14 ]. The procedural safety and characteristics have not been analyzed systematically so far.…”

Damage to the left internal mammary artery during anterior epicardial access for ventricular tachycardia ablation

“…A conventional inferior pericardial puncture has been safely used, but still contains a limited risk of right ventricle and liver trauma. 7 , 8 Few complications so far have been described. 6 Since the runoff of the LIMA is more anterior, an anterior puncture in general may contain a higher risk of LIMA perforation.…”