Epicardial Ablation of Ventricular Tachycardia

Abstract

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.

Management of Arrhythmias in Heart Failure

“…It is common to induce multiple morphologies of VT in this patient group and endocardial ablation alone is less successful [ 91 ]. Mapping and ablating epicardial sits increase the success in this patient group, but the optimal timing of epicardial ablation is yet to be determined [ 92 ].…”

Near‐field impedance accurately distinguishes among pericardial, intracavitary, and anterior mediastinal position

“…Large pericardial effusion and consequent tamponade, the most feared complications, can be catastrophic if not emergently treated with catheter drainage or surgical repair. In a recent study by Tung et al., 8.8% of patients had major complications, including epicardial bleeding from RV puncture. In a multicenter trial of epicardial VT ablation reported by Sacher et al., the inadvertent RV puncture rate was reported to range between 4.5% and 17% at the participating centers; most of these incidents involved <80 mL of intrapericardial bleeding and had no serious consequences.…”

Confirming pericardial access by using impedance measurements from a micropuncture needle

“…A study in which 163 patients underwent pericardial access for either mapping or ventricular ablation noted a complication rate of 11% and an increase in fluoroscopy time compared with endocardial ablation alone 12 . Although pericardial effusion is the primary complication associated with pericardial access, other complications, such as liver injury, vascular injury, pleural effusion, and abdominal wall hematoma, can occur 5,13 . These complications can be attributed to inadvertently contacting vessels or organs on or around the heart and to subsequently inserting a large sheath.…”