Assessment of pericardial adhesions by means of the EpiCO₂ technique: Brighton Adhesion Classification

Epicardial ablation complications are more frequent in patients with preexisting pericardial adhesions. As opposed to the dry puncture technique, the coronary vein exit and carbon dioxide (CO₂) insufflation (EpiCO₂) technique allows diagnosing pericardial adhesions before subxiphoid puncture.

This study aimed to evaluate the efficacy of the EpiCO₂ technique in diagnosing pericardial adhesions prior to subxiphoid puncture.

Following coronary vein exit, contrast was injected in the pericardial space, and adhesions classified using our novel Brighton Adhesion Classification (BAC) into BAC-0 (no adhesions), BAC-1 (dispersed adhesions), and BAC-2 (dense adhesions extending to the entire assessed area). CO₂ insufflation allowed subclassification of BAC-1 adhesions into BAC-1a (not preventing epicardial access or restricting catheter movement) and BAC-1b (either preventing epicardial access or significantly limiting catheter movement).

Intentional coronary vein exit (right atrial appendage exit in 1 case) was achieved in all 235 consecutive epicardial ablation procedures undertaken at our center. A diagnosis of BAC-0 was made in 219 cases (93.2%), BAC-1a in 9 cases (3.8%), BAC-1b in 2 cases (0.9%), and BAC-2 in 5 cases (2.1%). This led to not attempting subxiphoid puncture in 6 cases (2.6%) and abandoning epicardial mapping because of limited catheter movement in 1 case (0.4%). Access-related complications occurred in 7 cases (3%) only in the BAC-0 group.

The EpiCO₂ technique allows assessment of the presence of pericardial adhesions prior to attempting subxiphoid puncture for epicardial access, which may lead to a reduction in the procedural complications within this subset of patients.