Percutaneous pericardial instrumentation for endo-epicardial mapping of previously failed ablations

• Published in: Circulation (New York, N.Y.) Vol. 108; no. 11; pp. 1329 - 1335
• Main Authors: SCHWEIKERT, Robert A, SALIBA, Walid I, KANAGARATNAM, Logan, NATALE, Andrea, TOMASSONI, Gery, MARROUCHE, Nassir F, COLE, Christopher R, DRESING, Thomas J, TCHOU, Patrick J, BASH, Dianna, BEHEIRY, Salwa, LAM, Cathy
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 16.09.2003; American Heart Association, Inc
• Subjects: Adolescent; Adult; Aged; Arrhythmias, Cardiac - diagnosis; Arrhythmias, Cardiac - surgery; Atrial Fibrillation - surgery; Biological and medical sciences; Body Surface Potential Mapping - instrumentation; Cardiac dysrhythmias; Cardiology. Vascular system; Catheter Ablation; Endocardium; Female; Follow-Up Studies; Heart; Humans; Male; Medical sciences; Middle Aged; Pericardium; Tachycardia, Sinus - surgery; Tachycardia, Ventricular - surgery; Treatment Failure; Treatment Outcome; Human; mapping; Prognosis; Arrhythmia; pericardium; Instrumentation therapy; Electrophysiology; Endocardium; Epicardium; Cardiovascular disease; catheter ablation; Ablation; Excitability disorder; Percutaneous route; Treatment; Heart mapping; Heart disease; Accessory bundle; Paroxysmal ventricular tachycardia; tachyarrhythmias
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/01.CIR.0000087407.53326.31

The epicardial location of an arrhythmia could be responsible for unsuccessful endocardial catheter ablation. In 48 patients referred after prior unsuccessful endocardial ablation, we considered percutaneous, subxiphoid instrumentation of the pericardial space for mapping and ablation. Thirty patients had ventricular tachycardia (VT), 6 patients had a right- and 4 had a left-sided accessory pathway (AP), 4 patients had inappropriate sinus tachycardia, and 4 patients had atrial arrhythmias. Of the 30 VTs, 24 (6 with ischemic cardiomyopathy, 3 with idiopathic cardiomyopathy, and 15 with normal hearts) appeared to originate from the epicardium. Seventeen (71%) of these 24 VTs were successfully ablated with epicardial lesions. The other 7 VTs had early epicardial sites that were inaccessible, predominantly because of interference from the left atrial appendage. Six of these were successfully ablated from the left coronary cusp. In 5 of the 10 patients with an AP, the earliest activation was recorded epicardially. Three of these were right atrial appendage-to-right ventricle APs, and epicardial ablation was successful. No significant complications were observed. Failure of endocardial ablation could reflect the presence of an epicardial arrhythmia substrate. Epicardial instrumentation and ablation appeared feasible and safe and provided an alternative strategy for the treatment of patients with a variety of arrhythmias. This was particularly true for VT, including patients without structural heart disease.