Percutaneous epicardial ventricular tachycardia ablation after noncoronary cardiac surgery or pericarditis
Cory M Tschabrunn1, Haris M Haqqani, Joshua M Cooper
1Cardiac Electrophysiology Program, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
Insights
Percutaneous pericardial access for ventricular tachycardia (VT) ablation is feasible in patients with prior cardiac surgery or pericarditis. Dividing adhesions allows epicardial mapping and ablation, with good long-term outcomes in half of patients.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Surgery
Background:
- Epicardial access is crucial for ventricular tachycardia (VT) ablation in patients with prior noncoronary cardiac surgery or pericarditis.
- Pericardial adhesions in these patients present significant challenges to percutaneous pericardial access.
Purpose of the Study:
- To evaluate the success and safety of percutaneous pericardial access for VT ablation.
- To assess the feasibility of mapping and ablating epicardial VT targets in challenging patient populations.
Main Methods:
- A study of 10 consecutive patients with prior noncoronary cardiac surgery or pericarditis requiring epicardial access for VT ablation.
- Experienced operators used blunt dissection with a deflected ablation catheter to divide dense pericardial adhesions, enabling epicardial mapping.
Main Results:
- Percutaneous pericardial access was achieved in all patients, with adhesions successfully divided in 19-125 minutes.
- Epicardial mapping was sufficient in 90% of patients, and targeted VTs were rendered noninducible in 80%.
- Long-term follow-up showed 50% of patients remained VT-free, with no major complications reported besides initial puncture bleeding in one patient.
Conclusions:
- Percutaneous pericardial access for epicardial VT ablation is generally obtainable in patients with prior cardiac surgery or pericarditis.
- Dense adhesions frequently encountered require disruption for adequate epicardial mapping and ablation.
- This approach facilitates excellent long-term outcomes in approximately half of the patients without major complications.
Background:
Patients with previous noncoronary cardiac surgery or pericarditis may require epicardial access to facilitate successful ventricular tachycardia (VT) ablation. Percutaneous pericardial access is known to be difficult in these patients owing to the presence of pericardial adhesions.
Objective:
To examine the success and safety of percutaneous pericardial access as well as the ability to map and ablate epicardial VT targets.
Methods:
We studied 10 consecutive patients with prior noncoronary cardiac surgery (8 patients) or prior pericarditis (2 patients) who required epicardial access for VT ablation.
Results:
Percutaneous pericardial access was achieved by experienced operators, and dense adhesions interfering with catheter mapping were encountered in all patients. Using blunt dissection with a deflected ablation catheter, adhesions were divided over the course of 19-125 minutes (mean 57±38 minutes; median 47 minutes). This dissection allowed for sufficient epicardial mapping in 9 of 10 (90%) patients. The clinical targeted VTs were rendered noninducible in 8 (80%) patients. One patient had 70 cm(3) of bleeding with the initial puncture. No other complications occurred. During a long-term follow-up of 24±27 months (median 13 months), 5 patients have remained VT-free.
Conclusions:
Percutaneous pericardial access for epicardial VT ablation in patients with previous noncoronary cardiac surgery or pericarditis can usually be obtained. However, dense pericardial adhesions are often encountered and may limit the ability to map the entire epicardial space. Typically, appropriate targets can be reached and ablated by disrupting the adhesions with the ablation catheter and/or deflectable sheath, facilitating excellent long-term clinical outcome in half of the patients with no major complications.
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