Left-lateral thoracotomy for catheter ablation of scar-related ventricular tachycardia in patients with inaccessible pericardial access

Peng-Pai Zhang,Michael Schmoeckel,Francesco Santoro,Shibu Mathew,Feifan Ouyang,Johannes Riedl,Andreas Rillig,Thomas Fink,Christian-Hendrik Heeger,Bruno Reissmann,Andreas Metzner,Karl-Heinz Kuck,Tilman Maurer,Christine Lemeš,Yinghao Huang

doi:10.1007/s00392-020-01670-5

Abstract

ObjectivesWe aimed to describe the feasibility of a surgical left thoracotomy for catheter ablation of scar-related ventricular tachycardia (VT) in patients with inaccessible pericardial access.BackgroundPericardial adhesion due to prior cardiac surgery or previous epicardial ablation procedures limits epicardial access in patients with drug-refractory VT originated from the epicardium.MethodsSix patients who underwent a surgical left lateral thoracotomy epicardial access for catheter ablation of VT after failed subxiphoid percutaneous epicardial access were reviewed. Patients’ baseline characteristics and procedural characteristics including epicardial access, mapping, and ablation were described. Epicardial access was successfully obtained in all patients by a surgical left lateral thoracotomy.ResultsThe reasons of pericardial adhesion were prior cardiac surgery (n = 3, 50%) and previous epicardial ablation procedures (n = 3, 50%). Epicardial mapping of the lateral and inferior left ventricle was acquired, and a total of 15 different VTs originated from those regions were abolished. Unless one patient with ST elevation myocardial infarction due to periprocedural occlusion of the posterior descending artery no further complications occurred. All patients were discharged 10.2 ± 4 days after the procedure. VT recurred in 1 patient (17%) and was controlled with oral amiodarone therapy during follow-up (median follow-up: 479 days).ConclusionsA surgical left lateral thoracotomy is feasible and safe for selected patients. This approach provides epicardial ablation in patients with VT located at the infero-lateral left ventricle and pericardial adhesions due to previous cardiac surgery or previous ablation procedures.Graphic abstract

Highlights

Percutaneous catheter ablation is a well-established therapy for recurrent ventricular tachycardia (VT) [1, 2]
The purpose of this study was to describe a surgical left lateral thoracotomy to access the pericardial space for epicardial mapping and ablation in patients with scar-related VT located at the infero-lateral left ventricle (LV) and failed percutaneous epicardial access
Previous epicardial mapping and ablation was performed in three patients (#1, #3, and #6)

Summary

Introduction

Percutaneous catheter ablation is a well-established therapy for recurrent ventricular tachycardia (VT) [1, 2]. Epicardial mapping and ablation are necessary in 15–30% of patients when endocardial mapping techniques failed [6]. The percutaneous subxiphoid puncture technique is the most common approach to access the pericardium as first described by Sosa et al [7]. In patients with pericardial adhesions, due to prior cardiac surgery or previous epicardial catheter ablation, the percutaneous subxiphoid puncture approach may be not successful or cause severe complications [8]. The purpose of this study was to describe a surgical left lateral thoracotomy to access the pericardial space for epicardial mapping and ablation in patients with scar-related VT located at the infero-lateral left ventricle (LV) and failed percutaneous epicardial access

Objectives

Results

Discussion

Conclusion