Epicardial Radiofrequency Ablation Failure During Ablation Procedures for Ventricular Arrhythmias

Abstract

Procedures were performed under conscious sedation or general anesthesia. Programmed ventricular stimulation with ≤3 extrastimuli © 2015 American Heart Association, Inc. Original ArticleBackground-Radiofrequency ablation (RFA) from the epicardial space for ventricular arrhythmias is limited or impossible in some cases. Reasons for epicardial ablation failure and the effect on outcome have not been systematically analyzed. Methods and Results-We assessed reasons for epicardial RFA failure relative to the anatomic target area and the type of heart disease and assessed the effect of failed epicardial RFA on outcome after ablation procedures for ventricular arrhythmias in a large single-center cohort. Epicardial access was attempted during 309 ablation procedures in 277 patients and was achieved in 291 procedures (94%). Unlimited ablation in an identified target region could be performed in 181 cases (59%), limited ablation was possible in 22 cases (7%), and epicardial ablation was deemed not feasible in 88 cases (28%).Reasons for failed or limited ablation were unsuccessful epicardial access (6%), failure to identify an epicardial target (15%), proximity to a coronary artery (13%), proximity to the phrenic nerve (6%), and complications (<1%). Epicardial RFA was impeded in the majority of cases targeting the left ventricular summit region. Acute complications occurred in 9%. The risk for acute ablation failure was 8.3× higher (4.5-15.0; P<0.001) after no or limited epicardial RFA compared with unlimited RFA, and patients with unlimited epicardial RFA had better recurrence-free survival rates (P<0.001). Conclusions-Epicardial RFA for ventricular arrhythmias is often limited even when pericardial access is successful.Variability of success is dependent on the target area, and the presence of factors limiting ablation is associated with worse outcomes.

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

“…Since then, the epicardial mapping and ablation are becoming increasingly important in the catheter ablation of VT in both ischemic and nonischemic cardiomyopathies . While success rates for epicardial ablation have improved outcomes, the associated complication rates continue to range between 4% and 10%, including significant pericardial bleeding, inadvertent right ventricular (RV) puncture, and emergent cardiac surgery.…”

“…In the 1990s, Sosa et al described the cardiomyopathies. [3][4][5][6][7][8] While success rates for epicardial ablation have improved outcomes, 3 the associated complication rates continue to range between 4% and 10%, 3,9 including significant pericardial bleeding, inadvertent right ventricular (RV) puncture, and emergent cardiac surgery.…”

Retrograde Coronary Venous Ethanol Infusion for Ablation of Refractory Ventricular Tachycardia

“…PVC/VT originating from the LV summit remain particularly challenging since they combine both an intramural origin and inaccessibility to epicardial approaches. 11 Proximity to coronary vessels is another factor that limits local application of radiofrequency 8, 10 . Surgical cryoablation or TCEA have been reported.…”

“…This is particularly true for VT originating from the LV summit, where an intramural origin, proximity to coronary vessels and inaccessibility to the epicardial approach limit radiofrequency ablation success. 11 …”

Ablation of ischemic ventricular tachycardia

“…Epicardial ablation has become an essential component of ablation strategies, especially for ventricular tachycardia because of nonischemic cardiomyopathies, although proximity of major coronary vessels or the phrenic nerve to critical sites may preclude adequate ablation [39]. In ischemic heart disease, epicardial ablation is usually performed after failed endocardial ablation.…”