Strategies for epicardial mapping and ablation of ventricular tachycardia

Catheter ablation for ventricular tachycardia (VT) is becoming an essential component of the successful management of patients with structural heart disease and refractory ventricular arrhythmias. Despite detailed mapping and ablation from the endocardium, nearly a third of VT circuits remain inaccessible. Pericardial access has improved our ability to address these resistant VTs. Adhesions after cardiac surgery can impede access, necessitating a direct surgical approach to the pericardial space. Potential risks include risk of injury to an epicardial coronary artery, the phrenic nerve, subdiaphragmatic vessels, and right ventricle. We describe the indications for and approach to catheter ablation of VT for the pericardial space.