Epicardial catheter ablation for ventricular tachycardia in heparinized patients
Stephen P Page1, Edward R Duncan, Glyn Thomas
1Department of Electrophysiology, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK.
Insights
Obtaining pericardial access during ventricular tachycardia (VT) ablation in heparinized patients is safe and avoids unnecessary procedures. This approach reduces punctures and additional procedures for epicardial ablation of VT.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Current guidelines recommend pericardial access before heparinization for epicardial catheter ablation of ventricular tachycardia (VT).
- This timing can lead to unnecessary punctures or require additional procedures.
- This study explores an alternative approach for pericardial access in heparinized patients.
Purpose of the Study:
- To evaluate the safety and efficacy of obtaining pericardial access during the index procedure in heparinized patients undergoing epicardial catheter ablation for VT.
- To assess the incidence of complications associated with this approach.
- To compare the utility of electrocardiogram (ECG) criteria in predicting the need for epicardial ablation.
Main Methods:
- Retrospective analysis of 17 patients undergoing epicardial catheter ablation for VT with pericardial access post-heparinization.
- Data collected included clinical characteristics, procedural details, and complications.
- ECGs were analyzed for criteria suggesting epicardial ablation targets and compared with endocardial ablation patients.
Main Results:
- Pericardial access was successful in 94% of patients (16/17) despite therapeutic anticoagulation (mean activated clotting time 273 ± 36 s).
- No major bleeding complications occurred; three patients had transient right ventricular punctures without adverse events.
- ECG criteria suggestive of epicardial circuits had low sensitivity and specificity in predicting the need for epicardial ablation.
Conclusions:
- Obtaining pericardial access in heparinized patients for epicardial VT ablation is a safe strategy.
- This approach can potentially reduce unnecessary punctures and the need for additional procedures.
- Current ECG criteria are insufficient for accurately identifying patients who would benefit from epicardial ablation.
Aims:
In patients undergoing epicardial catheter ablation of ventricular tachycardia (VT), current guidelines recommend obtaining pericardial access prior to heparinization to minimize bleeding complications. Consequently, access is obtained before endocardial mapping (leading to unnecessary punctures) or during an additional procedure. We present our experience of obtaining pericardial access during the index procedure in heparinized patients.
Methods And Results:
Patients undergoing catheter ablation of VT in whom pericardial access was performed after heparinization were included. Clinical and procedural data and complications were recorded. Electrocardiograms (ECGs) were analysed for published criteria suggesting an epicardial ablation target and compared with patients (matched for substrate) undergoing successful endocardial ablation. Seventeen patients (13 males, age 58 ± 16 years, 8 (47%) ischaemic) were evaluated. Pericardial access was achieved in 16 (94%), including 2 patients with prior epicardial ablation. The mean activated clotting time was 273 ± 36 s. No bleeding complications occurred. In three patients, inadvertent puncture of the right ventricle caused no adverse consequences. An epicardial ablation target was found in nine of which three (33%) had ECG criteria, suggesting an epicardial circuit. In comparison 5 of 17 patients undergoing successful endocardial ablation had at least one ECG criterion suggesting an epicardial ablation target.
Conclusion:
Obtaining pericardial access for epicardial catheter ablation for VT appears to be safe in heparinized patients. Electrocardiogram criteria suggesting an epicardial ablation target lack the sensitivity and specificity accurately to predict which patients might need epicardial ablation. Performing pericardial access in heparinized patients therefore may reduce unnecessary punctures and reduce the number of additional procedures in some patients.
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