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Epicardial Ablation
Scar related Ventricular tachycardia Accessory pathways Atrial fibrillation Idiopathic Ventricular tachycardia
Outflow tract Non ischemic cm Sarcoid Chagas ARVD
ECG of a PVC originating in the epicardium.
Baman T S et al. Circ Arrhythm Electrophysiol 2010;3:274-279
Copyright © American Heart Association
Left, Venogram of the great cardiac vein (GCV).
Baman T S et al. Circ Arrhythm Electrophysiol 2010;3:274-279
Copyright © American Heart Association
Table 2 Steps taken preprocedurally and intraprocedurallyduring a case of epicardial accessPreprocedural Decide on the likelihood/need for epicardialaccess1. Obtain a history of prior cardiac surgery,pericarditis, or pericardial instrumentation2. Ensure normal coagulation parameters3. Have surface or preferably intracardiacechocardiography available4. Obtain a typed blood sample5. Ensure access to a cardiac surgical team onshort notice6. Intraprocedural Obtain baseline imaging of the pericardialspace before obtaining epicardial access7. Routine double wiring of the pericardialspace8. Use of soft tipped sheaths/do not leavesheath tip exposed9. Periodic survey of pericardial space by ICE10 Periodic drainage of the intrapericardialsheath, with or without use of pig-tailcatheter ICE Intracardiac echocardiography catheter.
Epicardial Access
18g 15cm Epidural spinal needle .032 wire
Contrast injection Minimize contrast or will obscure view
Echocardiographic monitoring Soft tip sheaths Double wiring the access site Keep sheath occupied with pig tail catheter
wire or ablation catheter as sheath can lacerate epicardial vessels or RV
Epicardial access
Left of xiphoid process Aim to mid clavicular line Push down on the skin to create
angle of entrance. Keep open end of needle away from
heart on entrance to pericardium
Epicardial Access
Lungs: the more posterior you advance the less likely to hit lungs
Diaphram/infradiaphragmatic vessels Liver: more lateral less risk of injury LIMA: begin 20-30 degrees then
angle deeper after past xiphoid towards cardiac silhouette 40 degrees lao
Epicardial access
Air in pericardium: evacuate as cannot cardiovert nor defibrilate.
Aspirate frequently Ablate: initally 15W irrigation 30 cc
temp 40-41 20-25W average)
Sagittal section of a cadaveric specimen.
Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4:882-888
Copyright © American Heart Association
Epicardial Fat vs Scar
Inferolateral less fat RV free wall and RVOT more fat. >3 mm fat cannot burn through 0-5 mm fat voltage can be similar to
normal myocardium. >5 mm will have low voltages and no capture at 10ma unipolar pacing.
Endo scar <1.5 mv/ Epi Scar <1 mv with wide split potentials and late potentials
Epicardial Access Complications
Hemopericardium/tamponade Hemoperitoneum Injury to epicardial vessel (artery or
vein) Phrenic nerve injury Hepatic injury
Early hemopericardium
1. Inadvertent right ventricular (RV) puncture2. Perforation of an epicardial vessel (artery/vein)3. Disruption of pre-existent pericardial adhesions
Intraoperative image of the surgically repaired laceration (arrow) to a large-caliber posterolateral branch of the coronary sinus.
Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4:882-888
Copyright © American Heart Association
A, Location of 2 puncture sites (black arrows) within the left hepatic lobe in an image obtained during laparotomy.
Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4:882-888
Copyright © American Heart Association
A, Left anterior oblique view of right coronary angiography.
Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4:882-888
Copyright © American Heart Association
Transverse view of an abdominal CT scan with contrast showing a large heterogeneous lesion in the left hepatic lobe (arrows), measuring 6×7×11 cm.
Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4:882-888
Copyright © American Heart Association
CT angiography of the anterior aspect of the heart illustrating the course of the great cardiac vein in relation to the left anterior descending coronary artery (LAD) and the left circumflex
coronary artery (Cx).
Baman T S et al. Circ Arrhythm Electrophysiol 2010;3:274-279
Copyright © American Heart Association
Post ablation
Leave Pigtail in place: delayed tamponade
Pericarditis: triamcinalone 2mg/kg into pericardium
Pain management
Summary
Epicardial ablation is feasible for arrthythmias
There are specific techniques and attention to procedural details that are necessary to avoid complications and optimize outcomes
Complications can be avoided and mitigated by a knowledge of the anatomy and the experience of others.
Right ventricular (RV) angiogram reveals contrast entering a crypt (arrow pointing to structure encircled) extending inferiorly below the RV wall.
Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4:882-888
Copyright © American Heart Association