Repeat Percutaneous Epicardial Mapping and Ablation of Ventricular Tachycardia: Safety and Outcome

Abstract

Epicardial mapping and ablation of ventricular tachycardia (VT) has been increasingly performed. Occasionally additional ablation is necessary, requiring repeat percutaneous access to the pericardial space. We studied 30 consecutive patients who required a repeat epicardial procedure. We specifically examined the success and safety of repeat percutaneous pericardial access as well as the ability to map and ablate epicardial VT targets. Percutaneous pericardial access at a median of 110 days after the last procedure was successful in all 30 patients. Significant adhesions interfering with catheter mapping were encountered in 7 patients (23%); 6 had received intrapericardial triamcinolone acetate (IPTA) with prior procedures. Using blunt dissection with a deflected ablation catheter and a steerable sheath, adhesions were divided allowing for complete catheter mapping in 5 patients with areas of dense adherence compartmentalizing the pericardium in 1 patient and precluding ablation over previously targeted ablation site in the second. Targeted VT noninducibility was achieved in 27 (90%) patients including 7 patients with adhesions. No direct complications related to pericardial access or adhesions disruption occurred. One periprocedural death occurred from refractory cardiogenic shock in patient with LV ejection fraction of 10%. Another patient developed asymptomatic positive Haemophilus influenzae pericardial fluid cultures identified at second procedure, which was successfully treated. Repeat access can be obtained after prior epicardial ablation. Adhesions from prior procedures may limit mapping, but can usually be disrupted mechanically and allow for ablation of recurrent VT. IPTA may not completely prevent adhesions.