Percutaneous Epicardial Approach Research Articles

In-hospital mortality following catheter ablation procedures in Germany: insights from the VARY project

Abstract Background The number of catheter ablation (CA) procedures has increased significantly over the last decade. 102,737 CA have been performed in Germany in 2021. Although CA of different types of arrhythmias is generally considered to be safe, serious complications, including in-hospital death, may occur. There is a paucity of real-world national healthcare data in Germany. Aim To investigate the overall in-hospital mortality in patients undergoing any type of CA procedure in Germany and to identify variables associated with in-hospital mortality. Methods According to the German law German hospitals are obliged to provide a dataset including case data, diagnosis based on the ICD-10-GM, operational and procedural codes to the Institute for hospital remuneration system (InEK) every year. The VARY project aims at analyzing and monitoring these data to report the real world scenario on patients undergoing CA in Germany. As of now, 22 German centers were contacted by the Institute for Myocardial Infarction Research (IHF). Their Data between 2019 and 2023 provided from seven of those centers were used for this analysis. Datasets from ten centers are pending. Five centers were not able to provide their data. The project is supported by the German Heart Foundation. Results A total 21,028 patients underwent inpatient CA. 49 patients (69.4% males) died in-hospital following a CA procedure resulting in an overall in-hospital mortality rate of 0.23%. A percutaneous epicardial ablation approach was used in 6.1% of the patients who died (Group A) compared to 0.3% in the surviving patients (Group B). Radiofrequency ablation was used in 83.7% vs. 72.6%, cryoablation in 10.2% vs 27.1%. Patients who died were older compared to those who survived (mean age: 66.7 ± 14.6 vs. 62.0 ± 14.4 years, p <0.01) and had more comorbidities such as diabetes (19/49 (38.8.%) vs. 2274/20,979 (10.8%), p <0,01), chronic obstructive pulmonary disease (5/49 (10.2%) vs. 555/20,979 (2.6%), p < 0,01) and heart failure (39/49 (79.6%) vs. 5116/20,979 (24.4%), p <0.01). There was no difference with regards to gender between the two groups. The most common arrhythmia in both groups was atrial fibrillation with 67.3% and 75.3% (p < 0.01). Cardiac arrest was observed in 44.9% of patients in group A compared to only 0.3% in group B. The median hospital stay was longer in group A (19.0 (IQR 8.0; 42.0) vs. 2.0 (IQR 1.0; 3.0), p < 0.01). 46/49 (93.9%) patients who died were treated on an intensive care unit for a median time of 13.5 days (IQR 3.8; 33.8) compared to 1272/20,979 (6.1%) (p < 0.01) in group B. A cardiac implantable electronic device implantation or revision was performed in 18.4% patients in group A (4 defibrillator implantations, 2 pacemaker implantations, 5 revisions) compared to 2.9% in group B (survivors). Conclusion Inpatient catheter ablation procedures in Germany are associated with a very low in-hospital mortality comparable to data reported from the US.

Characteristics and outcomes of ventricular tachycardia and premature ventricular contractions ablation in patients with prior mitral valve surgery.

Data regarding ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation following mitral valve surgery (MVS) is limited. Catheter ablation (CA) can be challenging given perivalvular substrate in the setting of mitral annuloplasty or prosthetic valves. To investigate the characteristics, safety, and outcomes of radiofrequency CA in patients with prior MVS and ventricular arrhythmias (VA). We identified consecutive patients with prior MVS who underwent CA for VT or PVC between January 2013 and December 2018. We investigated the mechanism of arrhythmia, ablation approach, peri-operative complications, and outcomes. In our cohort, 31 patients (77% men, mean age 62.3 ± 10.8 years, left ventricular ejection fraction 39.2 ± 13.9%) with prior MVS underwent CA (16 VT; 15 PVC). Access to the left ventricle was via transseptal approach in 17 patients, and a retrograde aortic approach was used in 13 patients. A combined transseptal and retrograde aortic approach was used in one patient, and a percutaneous epicardial approach was combined with trans-septal approach in one patient. Heterogenous scar regions were present in 94% of VT patients and scar-related reentry was the dominant mechanism of VT. Forty-seven percent of PVC patients had abnormal substrate at the site targeted for ablation. Clinical VA substrates involved the peri-mitral area in six patients with VT and five patients with PVC ablation. No procedure-related complications were reported. The overall recurrence-free rate at 1-year was 72.2%; 67% in the VT group and 78% in the PVC group. No arrhythmia-related death was documented on long-term follow-up. CA of VAs can be performed safely and effectively in patients with MVS.

Percutaneous epicardial approach for LAA ligation

The left atrial appendage (LAA) is believed to be a source for thrombus formation and an ancillary structure involved in the initiation and maintenance of atrial fibrillation (AF). LAA ligation has been proposed as adjunctive therapy for the treatment of AF. This study will determine the feasibility of a percutaneous epicardial approach for LAA ligation. The pericardium of 5 dogs was accessed via percutaneous subxyphoid approach. A 20F epicardial cannula was inserted into the pericardial space and contrast-injected to visualize the LAA. Under fluoroscopic guidance, a suction cup catheter was inserted and attached to the LAA. A 12F snare device was inserted over the vacuum cup to ligate the LAA. The closure of the LAA was verified with LA angiography, in the first 2 dogs, and ICE in all 5 animals. All animals were sacrificed for post hoc assessment of LAA closure. All 5 dogs underwent successful epicardial suture ligation of the LAA. In the first 2 dogs, LA angiography demonstrated complete closure of the LAA. All dogs underwent gross examination of the LAA. Post hoc assessment was notable for a small well-circumscribed hematoma on the LAA, consistent with point of suction cup attachment, as well as complete closure of the entire LAA. No laceration or perforation was noted on the LAA. Exclusion of the LAA via a novel percutaneous epicardial-only approach was successful without complications. This demonstrates the feasibility of this technique in an animal model, and may provide an effective approach for epicardial-only LAA exclusion in humans.

Epicardial Ablation Complications.

The percutaneous epicardial approach has become an adjunctive tool for electrophysiologists to treat disparate cardiac arrhythmias, including accessory pathways, atrial tachycardia, and particularly ventricular tachycardia. This novel technique prompted a strong impulse to perform epicardial access as an alternative strategy for pacing and defibrillation, left atrial appendage exclusion, heart failure with preserved ejection fraction, and genetically engineered tissue delivery. However, because of the incremental risk of major complications compared with stand-alone endocardial ablation, it is still practiced in a limited number of highly experienced centers across the world.

Perioperative Imaging to Guide Epicardial Mapping and Ablation.

Accessing the epicardial space without a sternotomy or a surgical pericardial window to treat ventricular arrhythmias in Chagas disease became a medical necessity in South America. Since the introduction of the dry percutaneous epicardial access approach, epicardial access has been standard procedure for management of ventricular arrhythmias in ischemic and nonischemic cardiomyopathies and atrioventricular accessory pathways after failed conventional endocardial ablation. Understanding the epicardial space and neighboring structures has become an important subject of teachings in electrophysiology. The evolution of complex ablation procedures to treat atrial and ventricular arrhythmias and device interventions to prevent cardioembolic stroke requires thorough understanding of pericardial anatomy.

Percutaneous Epicardial Approach toCatheterAblation of CardiacArrhythmias.

Since their introduction >2 decades ago, percutaneous catheter-based epicardial mapping and ablation have become widely adopted by cardiac electrophysiologists around the world. Although epicardial mapping has been used for catheter ablation of a wide variety of cardiac arrhythmias, its most common use is for ablation of intramural and subepicardial substrates that give rise to ventricular tachycardia, particularly in patients with nonischemic cardiomyopathy. As such, the subxiphoid percutaneous epicardial approach has emerged as an important adjunct, and, in some cases, is the preferred strategy in this regard. This review discusses the rationale and indications for epicardial catheter mapping and/or ablation. This paper also reviews the prevalence of epicardial arrhythmias and their electrocardiographic criteria. In addition, it examines the anatomy of the pericardium and commonly used epicardial access techniques, as well as the optimal methodologies for epicardial mapping and ablation and the impact of epicardial fat. Finally, this review discusses the potential of the various complications associated with the percutaneous epicardial approach, in addition to patient-specific risk factors, and potential strategies to mitigate the risk of complications.

Epicardial approach for cardiac electrophysiology procedures.

Since its introduction over two decades ago, percutaneous epicardial procedures have become well-adopted by cardiac electrophysiologists, most commonly for catheter ablation of cardiac arrhythmias as well as left atrial appendage closure. The percutaneous epicardial approach has also been utilized for cardiac pacing and drug delivery. But still, its most common usage is for the treatment of intramural and subepicardial substrates that give rise to ventricular tachycardia, particularly in patients with nonischemic cardiomyopathy. In fact, subxiphoid, percutaneous epicardial mapping and ablation have emerged as an important adjunct and in some cases the preferred strategy for characterizing and treating certain types of ventricular arrhythmias. Herein, we will review the indications and rationale for various epicardial procedures. Additionally, we will explore the anatomy of the pericardium as well as the frequently-used epicardial access techniques. We will further examine the optimal approaches and methodologies for epicardial mapping and ablation and the impact of epicardial fat. We will also discuss the epicardial technique for left atrial appendage closure for the purpose of embolic stroke risk reduction. Finally, we will consider the potential for various complications in the setting of epicardial procedures along with their risk factors and discuss strategies to mitigate such adverse events.

Feasibility of percutaneous epicardial mapping and ablation for refractory atrial fibrillation: Insights into substrate and lesion transmurality

Recurrences of atrial fibrillation (AF) after ablation have been attributed to conduction gaps and nontransmural ablation lesions. The purpose of this study was to assess the feasibility of adjunctive percutaneous mapping of the epicardial regions of the left atrium to characterize the transmural extent of substrate and ablation lesions. Between 2014 and 2018, combined epicardial and endocardial mapping of AF was performed in 18 patients via an inferior subxiphoid percutaneous approach (16 with previously failed ablation procedures and 2 patients with long-standing persistent AF) at 2 centers. Epicardial substrate mapping was compared with endocardial mapping to assess transmural uniformity. Of 18 patients, 4 (22%) demonstrated nontransmural atrial low-voltage regions with relative epicardial sparing in the left atrial posterior wall. Transmural isolation of the posterior wall was achieved after an endocardial "box" lesion set in 6/9 (67%), guided by epicardial voltage data, while epicardial and endocardial dissociation during AF was observed in 1 patient. In 3 patients, epicardial capture along the endocardial pulmonary vein lesion set despite endocardial capture loss and bidirectional block was observed. Two cases of mitral flutter were terminated from the epicardium. A balloon was positioned in the pericardial space in 6 patients for esophageal protection during ablation. A percutaneous epicardial approach for mapping and ablation of the left atrium is feasible in the electrophysiology laboratory during endocardial catheter ablation for AF and may be useful as an adjunctive approach in refractory cases. High-density epicardial mapping can provide direct evidence of nonuniform lesion and substrate transmurality of the human left atrium before and after ablation.

Percutaneous epicardial approach for ventricular tachycardia ablation in patients with structural heart disease – case series presentation form University Hospital Centre Split

Epikardna VT ablacija je vrlo invazivna procedura, no kada se radi u centrima s kardiokirurskom podrskom i velikim volumenom ablacijskih procedura, nudi mogucnost sigurnog izvođenja i daje sansu ostvariti kontrolu nad aritmijama koje ugrožavaju ne samo kvalitetu, vec i život ovih pacijenata.

First Simultaneous Endocardial and Epicardial Mapping of a Ventricular Tachycardia in an ARVD/C Patient

A 73-year-old patient with an arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) was referred for ventricular tachycardia (VT) ablation. The procedure was performed with a combined endocardial and percutaneous epicardial approach, using the CARTO3 mapping system. After the clinical

Percutaneous Catheter Ablation of Epicardial Accessory Pathways

Radiofrequency (RF) catheter ablation is the treatment of choice in patients with accessory pathways (APs) and Wolff-Parkinson-White syndrome. Endocardial catheter ablation has limitations, including the inability to map and ablate intramural or subepicardial APs. Some of these difficulties can be overcome using an epicardial approach performed through the epicardial venous system or by percutaneous catheterisation of the pericardial space. When a suspected left inferior or infero-paraseptal AP is refractory to ablation or no early activation is found at the endocardium, a transvenous approach via the coronary sinus is warranted because such epicardial pathways can be in close proximity to the coronary venous system. Associated congenital abnormalities, such as right atrial appendage, right ventricle diverticulum, coronary sinus diverticulum and absence of coronary sinus ostium, may also hamper a successful outcome. Percutaneous epicardial subxiphoid approach should be considered when endocardial or transvenous mapping and ablation fails. Epicardial mapping may be successful. It can guide and enhance the effectiveness of endocardial ablation. The finding of no epicardial early activation leads to a more persistent new endocardial attempt. When both endocardial and epicardial ablation are unsuccessful, open-chest surgery is the only option to eliminate the AP.

Percutaneous Catheter Ablation of Epicardial Accessory Pathways

Radiofrequency (RF) catheter ablation is the treatment of choice in patients with accessory pathways (APs) and Wolff–Parkinson–White syndrome. Endocardial catheter ablation has limitations, including the inability to map and ablate intramural or subepicardial APs. Some of these difficulties can be overcome using an epicardial approach performed through the epicardial venous system or by percutaneous catheterisation of the pericardial space. When a suspected left inferior or infero-paraseptal AP is refractory to ablation or no early activation is found at the endocardium, a transvenous approach via the coronary sinus is warranted because such epicardial pathways can be in close proximity to the coronary venous system. Associated congenital abnormalities, such as right atrial appendage, right ventricle diverticulum, coronary sinus diverticulum and absence of coronary sinus ostium, may also hamper a successful outcome. Percutaneous epicardial subxiphoid approach should be considered when endocardial or transvenous mapping and ablation fails. Epicardial mapping may be successful. It can guide and enhance the effectiveness of endocardial ablation. The finding of no epicardial early activation leads to a more persistent new endocardial attempt. When both endocardial and epicardial ablation are unsuccessful, open-chest surgery is the only option to eliminate the AP.

Lariat-Small Step or Giant Leap?

When Neil Armstrong spoke these now-famous words as he stepped off Apollo 11’s lunar excursion module and onto the moon on July 21, 1969, it was both a small physical step, like the many steps each of us takes every day, and a giant figurative leap formankind to walkonanotherworld for the first time. Similarly, the approval processes for medical devicessubject to reviewintheUnitedStates throughtheUSFood andDrugAdministration (FDA) can be characterized asmany “small steps” via the simple premarket notification, or 510(k) process, and relatively few “giant leaps” via the rigorous and expensive premarket approval (PMA) process. Overwhelmingly,most reviewablemedical devices are evaluated and approved by the far less-stringent 510(k) process because they represent either Class I (low risk) or Class II devices (intermediate risk, such as electrocardiographymachines).1 NewClass III devices (high risk, such as cardiac pacemakers) require approval through themuchmore stringent PMAprocess, which requires formal evaluation of safety and efficacy, often in the form of expensive randomized trials.2 If a Class III devices is “substantially equivalent” in function and use to an already approved device, submission of supplementary materials to an existing PMAmay suffice. As a practicing cardiac electrophysiologist, I am thankful that we have both the 510(k) and PMA processes for approving themyriadmedical devices I use every day in the process of providing heart rhythm care. And yet, when I consider the tools that I used inperforming invasive procedures thisweek, manyof themareClass II and III devices, and all of themwere approved by either the 510(k) process or by PMA supplement. The defibrillator I most recently implanted, for example, is many generations of capacitor and battery technology, processing power, and programming features beyond the original implantable defibrillators that underwent evaluation through the full PMA process years ago. Without these processes, manufacturers would be forced either to stifle innovation or to conduct new randomized trials for eachminor iteration, which would clearly be expensive, unwieldy, and in most cases, unnecessary. In this issue of JAMA Internal Medicine, Chatterjee and colleagues3 evaluate the safetyof theLariat suturedeliverydevicewith a systematic reviewof the literature and an analysis of events reported to the FDAManufacturer andUser Facility Device Experience (MAUDE) database. This device was approvedbyFDAasaClass IIdevicedescribed in theoriginal 2006 application under the 510(k) process as having the intended useof “sutureplacement andknot tying for use in surgical applicationswheresoft tissue [sic] arebeingapproximatedand/or ligated”with predicates of loop surgical ligationdevices used in abdominal surgery via laparoscopic tools and in endoscopic saphenousveinharvesting.4Approvalby theFDAof this 510(k) applicationwasbasedprimarily on the concept that the device represented an intermediate-risk product for the iterative “small step”of suture ligationof tissue similar toprior devices. Chatterjee and colleagues,3 however, found that the entire published literature andall the events reported toMAUDE were in associationwithuseof theLariat for left atrial appendageocclusion.3TheLariatprocedure involves transseptal catheterizationof the left atrial appendagevia the femoralveinwith a catheter that includes amagnetic tip. Simultaneously, a second catheter with a magnetic tip is placed in the epicardial space via a percutaneous epicardial access approach. The 2 catheters (endocardial and epicardial) are magnetically opposedwith the tip of the left atrial appendage between them, creating a rail over which the Lariat passes to the base of the appendage. The loop is then closed to ligate the left atrial appendageat its base.While thecompany’spatent5mentions the intendeduseof leftatrialappendageocclusion, theirFDA510(k) application does not.4 Occlusion of the left atrial appendage is, indeed, an intriguing potential target for stroke risk reduction in atrial fibrillation.Atrial fibrillationaffectsmillions in this country, and risk of stroke associatedwith atrial fibrillation (muchofwhich is due to left atrial appendage thrombus) is a very real problemthathashistoricallybeenaddressedwithwarfarinorother anticoagulant therapy in patients at risk. Oral anticoagulant therapy is burdensome and associated with bleeding risk, so aprocedural alternative (if safe andeffective)wouldbe attractive in at least some patients. Appendage ligation at the time of cardiac surgery is performed based on this plausible benefit, but I amnotawareof randomizeddatademonstrating that the practice reduces stroke risk.6 Other devices, such as the Watchmandevice (BostonScientificCorp)7 andAmplatzerCardiac Plug (AGA Medical Corp)8 are undergoing evaluation as newClass III devices for the intendeduse of stroke risk reduction by left atrial appendage occlusion, but unlike the Lariat procedure, which results in external loop ligation of the appendage at its base, the Watchman and Amplatzer procedures involve implantation of a self-expanding nitinol and polyethylene terephthalate or polyester device inside the appendage. Via the PMA process, the FDA considered the Watchman device after very promising results from the PROTECTAF(WatchmanLeftAtrialAppendageSystemforEmbolic PROTECTion in Patients With Atrial Fibrillation) trial,7 which demonstrated that the efficacy of the Watchman was not inferior to warfarin for the prevention of stroke in patients at high risk. The agency’s approval of the device, however, was delayed after subsequent follow-up data from the PREVAIL (Prospective Randomized Evaluation of theWatchmanLAAClosureDevice inPatientsWithAtrialFibrillationVerRelated article page 1104 Research Original Investigation Safety of Left Atrial Appendage ExclusionWith the Lariat Device

Accessory atrioventricular pathways refractory to catheter ablation: role of percutaneous epicardial approach.

Epicardial mapping and ablation of accessory pathways through a subxiphoid approach can be an alternative when endocardial or epicardial transvenous mapping has failed. We reviewed acute and long-term follow-up of 21 patients (14 males) referred for percutaneous epicardial accessory pathway ablation. There was a median of 2 previous failed procedures. All patients were highly symptomatic, 8 had atrial fibrillation (3 with cardiac arrest) and 13 had frequent symptomatic episodes of atrioventricular reentrant tachycardia. Six patients (28.5%) had a successful epicardial ablation. Five patients (23.8%) underwent a successful repeated endocardial mapping, and ablation after epicardial mapping yielded no early activation site. Epicardial mapping was helpful in guiding endocardial ablation in 2 patients (9.5%), showing that the earliest activation was simultaneous at the epicardium and endocardium. Four patients (19%) underwent successful open-chest surgery after failing epicardial/endocardial ablation. Two patients (9.5%) remained controlled under antiarrhythmic drugs after unsuccessful endocardial/epicardial ablation. Two patients had a coronary sinus diverticulum and one a right atrium to right ventricle diverticulum. Three patients acquired postablation coronary sinus stenosis. There was no major complication related to pericardial access. Percutaneous epicardial approach is an alternative when conventional endocardial or transvenous epicardial ablation fails in the elimination of the accessory pathway. A new attempt by endocardial approach was successful in a significant number of patients. Open-chest surgery may be required in symptomatic cases refractory to endocardial-epicardial approach.

Abstract 8428: Percutaneous Intrapericardial Echocardiographic Imaging with CMUT Based Imaging Catheters: First In Vivo Results

Background: The standard approach for the catheter ablation of arrhythmias and the accompanying guidance of intracardiac echocardiography (ICE) is performed from the endocardial aspect of the heart. This approach may now also include percutaneous epicardial mapping which has been developed and utilized in several electrophysiology (EP) laboratories. Previous research using percutaneous pericardial procedures has been safely and effectively applied to a range of supraventricular arrhythmia substrates. Methods: Our family of ICE devices now includes a new 9F forward-looking catheter which is constructed with a silicon based capacitive micromachined ultrasonic transducer (CMUT) technology. Several CMUT ML catheters have been tested in 3 porcine experiments. The percutaneous epicardial approach was tested with successful imaging of heart chambers from the oblique sinus of the pericardial space. Results: This micro-linear (ML) catheter provides high-resolution, real-time, 2D ultrasound images at 14 MHz, and is capable of both electrical mapping and electroanatomical guidance. Although the 24 element array aperture is small (1.6 mm), the imaging depth of penetration is considerable (> 3 cm). A thin metalized cap can be placed over the array for performing radiofrequency ablation without distorting imaging. Conclusions: This silicon based technology has the unique prospect of enhancing both miniaturization and multiple modalities of operation.

Non-Surgical Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation

Non-Surgical Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation. The most feared complication associated with atrial fibrillation (AF) is stroke, the risk of which increases with advanced age. Because of its complex anatomy and diminished blood flow during AF, the left atrial appendage (LAA) has been a common site of left atrial thrombi and presumed source of thromboembolism. Systemic anticoagulation to treat what may be largely a localized phenomenon is associated with significant complications. Newer anticoagulation agents hold great promise in facilitating dosing and eliminating drug and food interactions, but do not eliminate bleeding risk. These challenges have led to interest in mechanical exclusion of the LAA as a means of preventing thromboembolism in AF. Although surgery permits greater visualization and management of complications, the potential morbidity has limited adoption in often-frail elderly patients. In this paper, we review the current state of percutaneous left atrial exclusion for stroke prevention in AF, and the strengths and limitations of each of these strategies. The nonsurgical approaches to excluding the LAA from the central circulation can be divided into 3 broad categories: transseptally placed devices, percutaneous epicardial approach, and hybrid approaches. The availability of several approaches will allow physician selection of the optimal approach for a given patient based on clinical, physiological, and anatomical considerations. LAA exclusion stands to become an increasingly attractive option for patients with nonvalvular AF because it can be offered to elderly AF patients, and eliminates the long-term cumulative bleeding risks and adherence challenge of anticoagulants.

Management of hemopericardium related to percutaneous epicardial access, mapping, and ablation

Percutaneous epicardial access (Figs. 1A and 1B) has gained wide acceptance as an interventional technique to access the pericardial space. Since its initial description 1 Sosa E. Scanavacca M. D'Avila A. Pilleggi E. A new technique to perform epicardial mapping in the electrophysiology laboratory. J Cardiovasc Electrophysiol. 1996; 7: 531-536 Crossref PubMed Scopus (645) Google Scholar in targeting epicardial circuits of ventricular tachycardia (VT) in patients with Chagasic cardiomyopathy, percutaneous epicardial access and ablation has come to play an important role in interventional electrophysiology. This technique has been recognized as a vital addition to catheter ablation of certain cardiac arrhythmias and for the delivery of newer investigational devices such as epicardial suture ligation of the left atrial appendage. Thus, the utilization of the percutaneous epicardial approach is set to likely increase.

Left atrial appendage as a target for reducing strokes: Justifiable rationale? Safe and effective approaches?

u t b One of every six strokes occurs in patients with atrial fibrillation (AF). Among the patients in whom a left atrial thrombus is found, 90% are located in the left atrial appendage (LAA). Given the morbidity and disability associated ith stroke, various targets to decrease this dreaded comlication have been identified. AF itself appeared intuitively to be a viable target; however, ntiarrhythmic drugs, even when effective in reducing AF, ave not been shown to reduce stroke risk. To date, anticoaglation remains the mainstay for managing stroke risk with AF. arfarin decreases the likelihood of stroke by 60% to 70% ompared with no antithrombotic therapy and 30% to 40% ompared with aspirin. Significant limitations with warfarin se, including hemorrhagic stroke, prevalence of subtherapeutic anticoagulation, narrow therapeutic window, need for close monitoring, and various diet and drug interactions, greatly limit the actual utility of this proven therapy. The severity of the disease (stroke) combined with the lack of safe and effective therapies has understandably led to the development of novel therapies, including a variety of surgical and percutaneous approaches that target the LAA. In this issue of Heart Rhythm, Bartus et al report the first human experince of a percutaneous epicardial LAA ligation technique sing the LARIAT snare device (SentreHEART Inc., Palo lto, CA, USA). This technique involves a combined endoardial and percutaneous subxiphoid epicardial magnet-tipped ire-guided approach and snaring of the LAA at the ostium. hree screening computerized tomography (CT) scans were erformed to assess the appropriateness of the appendage anatmy and transesophageal echocardiography (TEE) with conrast fluoroscopy used to assess effective closure. Ten of 11 atients (9 with percutaneous epicardial access and 2 with imultaneous open surgical mitral valve replacement) had sucessful acute ligation. Follow-up was available at 60 days in 6 f these patients, and 4 of these had persistent closure. In order

Percutaneous epicardial ablation reverses ventricular tachycardia mediated cardiomyopathy

We report on the case of an 18-year-old girl with asymptomatic incessant ventricular tachycardia. Initial attempts at endocardial ablation failed and she was monitored until her cardiac function deteriorated. A percutaneous epicardial approach with electroanatomical mapping was then used which successfully terminated the tachycardia. Left ventricular size and function subsequently returned to normal. This case demonstrates that percutaneous epicardial ablation of ventricular tachycardia is safe and feasible in young patients and highlights the importance of recognising this at an early stage.

Percutaneous epicardial mapping during ablation of difficult accessory pathways as an alternative to cardiac surgery

Objectives The aim of this study was to define the role of percutaneous epicardial mapping for the ablation of previous failed ablation of accessory pathways. Background Cardiac surgery is the only curative option for failed radiofrequency (RF) catheter ablation of accessory pathway (AP)-mediated tachycardias. We investigated a combined percutaneous epicardial and endocardial approach for failed AP ablations. Methods We present our experience in a series of 6 cases (7 APs) with previous failed attempts at catheter ablation (median 2 attempts, range 1–4) and persistent symptomatic tachycardias. Endocardial mapping of the APs was performed using conventional techniques. Sites with local electrograms suggestive of AP location were selected. When initial endocardial mapping was not successful for ablation of the pathway, percutaneous transthoracic pericardial puncture was performed via a subxiphoid approach, and an ablation catheter was positioned at the epicardial aspect of the putative AP location for epicardial-endocardial electrogram comparison. Endocardial RF energy was applied to locations considered appropriate. Epicardial RF applications were delivered when endocardial applications failed. Coronary arteriography was performed to assess the proximity of coronary arteries to the ablation catheter. Results APs were located in the right free wall (4 patients, 5 APs) and the right (1 patient) and left (1 patient) posteroseptal regions. In all patients, epicardial mapping assisted in identifying successful ablation sites. In 3 patients, the earliest atrial activation during orthodromic tachycardia was present in an epicardial electrogram. Successful AP ablation was achieved with an epicardial RF application in 2 patients, either alone or with simultaneous endocardial-epicardial delivery. In the remaining 4 patients, APs were successfully ablated endocardially after epicardial mapping. These patients represent 18% of all cases referred to our institution for ablation of previously failed accessory pathways (6/32 patients). Conclusions A combined endocardial-epicardial approach to mapping and RF ablation can facilitate successful endocardial ablation in most cases. In selected cases, APs can be ablated by epicardial delivery of RF. Epicardial mapping is an effective alternative to cardiac surgery for patients in whom prior attempts at AP ablation have failed.