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;3:274279
Copyright © American Heart Association
Left, Venogram of the great cardiac vein (GCV).
Baman T S et al. Circ Arrhythm Electrophysiol 2010;3:274279
Copyright © American Heart Association
Table 2 Steps taken preprocedurally and intraprocedurally
during a case of epicardial access
Preprocedural Decide on the likelihood/need for epicardial
access
1. Obtain a history of prior cardiac surgery,
pericarditis, or pericardial instrumentation
2. Ensure normal coagulation parameters
3. Have surface or preferably intracardiac
echocardiography available
4. Obtain a typed blood sample
5. Ensure access to a cardiac surgical team on
short notice
6. Intraprocedural Obtain baseline imaging of the pericardial
space before obtaining epicardial access
7. Routine double wiring of the pericardial
space
8. Use of soft tipped sheaths/do not leave
sheath tip exposed
9. Periodic survey of pericardial space by ICE
10 Periodic drainage of the intrapericardial
sheath, with or without use of pig-tail
catheter
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 4041
 20-25W average)
Sagittal section of a cadaveric specimen.
Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4:882888
Copyright © American Heart Association
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) puncture
2. 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;4:882888
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;4:882888
Copyright © American Heart Association
A, Left anterior oblique view of right coronary angiography.
Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4:882888
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;4:882888
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;3:274279
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.
Thank you
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;4:882888
Copyright © American Heart Association
Epicardial VT Morphology