Abstract 1128 Safety and efficacy of epicardial access for VT ablation: a single-center experience

Background:

Epicardial ablation has become an integral part of the treatment of ventricular tachycardias (VT). This study reports the safety of epicardial access as well as the efficacy of epicardial ablation of structural heart disease in a tertiary single-centre experience.

Methods:

Between January 2016 and February 2022 consecutive patients undergoing an epicardial puncture for VT ablation were included. Different puncture techniques were analysed and occurrence of epicardial access-related complications as well as the safety of low ionic 0.45% saline (half-normal saline [HNS]) and nonionic 5% dextrose in water (D5W) compared to standard 0.9% normal saline investigated. VT recurrence rates, rehospitalizations as well as mortality rates during a mean follow-up of 37 ± 23 months were reported.

Results:

197 patients undergoing a total of 239 procedures were included (59.8 ± 15.3 years, 86% males). Of them 154 patients (78%) suffered from non-ischemic cardiomyopathies with a mean LVEF of 37 ± 14. Anterior-oriented epicardial access was aimed for in all cases and was successful in 217 (91%) of all procedures, whereas in 19 cases (8%) an inferior oriented access and in 3 procedures (1%) a surgical access was obtained due to severe adhesions or anatomical requirements. HNS/D5W was used in 145 cases, normal saline in 94 procedures. Epicardial puncture-related complications occurred in 18 (8%) of all procedures with pericardial bleeding in 9, pericardial tamponade in 1, pneumothorax in 5, pneumopericardium in 1 and abdominal puncture in 2 cases. Presence of adhesions could be identified as the only independent predictor of epicardial access-related complications. The clinical VT could be eliminated in 80% and 74% of all patients were rendered non-inducible at the end of the procedure with no differences between irrigation fluid groups. During follow-up 48% of all patients were free from VTs (irrespective of irrigation management) and 17% of all patients died due to cardiovascular causes. Independent predictors of VT recurrence were presence of electrical storm and the number of VTs inducible, whereas increasing age, adhesions, worse LVEF and length of ICU stay were independent predictors of subsequent mortality.

Conclusions:

In this large single-centre experience pericardial access and ablation was safe and feasible. Long-term VT recurrence rates as well as mortality were high advocating for a highly experienced, interdisciplinary approach. Usage of HNS/D5W was safe, but not associated with higher short or long-term VT-freedom.

Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w
Safety and efficacy of epicardial access for VT ablation: a single-center experience
J. Müller¹, K. Nentwich², A. Berkovitz², P. Halbfaß³, E. Ene⁴, K. Sonne², I. Chakarov⁴, S. Barth⁵, T. Schupp⁶, M. Behnes⁶, T. Deneke²
¹Herz- und Gefäß-Klinik Campus Bad Neustadt, Bad Neustadt a. d. Saale; ²Klinik für Kardiologie II / Interventionelle Elektrophysiologie, RHÖN-KLINIKUM AG Campus Bad Neustadt, Bad Neustadt a. d. Saale; ³Klinik für Kardiologie, Klinikum Oldenburg AöR, Oldenburg; ⁴Kardiologie, RHÖN-KLINIKUM AG Campus Bad Neustadt, Bad Neustadt a. d. Saale; ⁵Klinik für Kardiologie I - Interventionelle Kardiologie und kardiale Bildgebung, RHÖN-KLINIKUM AG Campus Bad Neustadt, Bad Neustadt a. d. Saale; ⁶I. Medizinische Klinik, Universitätsklinikum Mannheim, Mannheim;
Background: Epicardial ablation has become an integral part of the treatment of ventricular tachycardias (VT). This study reports the safety of epicardial access as well as the efficacy of epicardial ablation of structural heart disease in a tertiary single-centre experience. Methods: Between January 2016 and February 2022 consecutive patients undergoing an epicardial puncture for VT ablation were included. Different puncture techniques were analysed and occurrence of epicardial access-related complications as well as the safety of low ionic 0.45% saline (half-normal saline [HNS]) and nonionic 5% dextrose in water (D5W) compared to standard 0.9% normal saline investigated. VT recurrence rates, rehospitalizations as well as mortality rates during a mean follow-up of 37 ± 23 months were reported. Results: 197 patients undergoing a total of 239 procedures were included (59.8 ± 15.3 years, 86% males). Of them 154 patients (78%) suffered from non-ischemic cardiomyopathies with a mean LVEF of 37 ± 14. Anterior-oriented epicardial access was aimed for in all cases and was successful in 217 (91%) of all procedures, whereas in 19 cases (8%) an inferior oriented access and in 3 procedures (1%) a surgical access was obtained due to severe adhesions or anatomical requirements. HNS/D5W was used in 145 cases, normal saline in 94 procedures. Epicardial puncture-related complications occurred in 18 (8%) of all procedures with pericardial bleeding in 9, pericardial tamponade in 1, pneumothorax in 5, pneumopericardium in 1 and abdominal puncture in 2 cases. Presence of adhesions could be identified as the only independent predictor of epicardial access-related complications. The clinical VT could be eliminated in 80% and 74% of all patients were rendered non-inducible at the end of the procedure with no differences between irrigation fluid groups. During follow-up 48% of all patients were free from VTs (irrespective of irrigation management) and 17% of all patients died due to cardiovascular causes. Independent predictors of VT recurrence were presence of electrical storm and the number of VTs inducible, whereas increasing age, adhesions, worse LVEF and length of ICU stay were independent predictors of subsequent mortality. Conclusions: In this large single-centre experience pericardial access and ablation was safe and feasible. Long-term VT recurrence rates as well as mortality were high advocating for a highly experienced, interdisciplinary approach. Usage of HNS/D5W was safe, but not associated with higher short or long-term VT-freedom.
https://dgk.org/kongress_programme/jt2023/aV977.html