epicardial ablation: another route to be arrhythmia free john r onufer md fhrs

Epicardial Ablation: Another route to be arrhythmia free

John R Onufer MD FHRS

Epicardial Ablation

Scar related Ventricular tachycardia Accessory pathways Atrial fibrillation Idiopathic Ventricular tachycardia

Outflow tract Non ischemic cm Sarcoid Chagas ARVD

Afib Hybrid lesion set

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).



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


Scar Map of VT

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.



A, Location of 2 puncture sites (black arrows) within the left hepatic lobe in an image obtained during laparotomy.



A, Left anterior oblique view of right coronary angiography.



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.



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).



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.

Thank you

Right ventricular (RV) angiogram reveals contrast entering a crypt (arrow pointing to structure encircled) extending inferiorly below the RV wall.



Epicardial VT Morphology

epicardial ablation: another route to be arrhythmia free john r onufer md fhrs

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