Epicardial catheter ablation is an important cornerstone in the treatment of patients with ventricular arrhythmias (VA) with a constantly increasing number of cases worldwide. However, the incidence of major complications still remains high and data on safety, complications and aggravating factors are sparse. Pericardial access can be gained fluoroscopically either by an anterior-posterior oriented (AP) or left lateral (LL) oriented epicardial puncture. We retrospectively sought to assess the periprocedural safety of these two puncture techniques in a large patient cohort.
Methods
In 211 patients (61.4 ±15.6 years, 179 males; 84.8%) 271 procedures with epicardial access for ablation of VA were performed using an anterior-posterior oriented (AP) or left lateral (LL) oriented puncture. Puncture-related cardiac and non-cardiac complications as well as periprocedural events were systematically analyzed. Also, the incidence of adhesions has been evaluated during first and repeated procedures.
Results
A total of 34/271 (12.5%) major complications occurred and 23/271 (8.5%) were directly related to the epicardial puncture. The incidence of puncture-related major complications in the LL and AP group was 4/82 (4,9%) and 19/189 (10,1%), respectively. Cardiac tamponade was the most common major complication (15/271; 5.5%) and occurred in 11/189 (5.8%) in the AP-oriented group and in 4/82 (4.9%) in LL-oriented group. Collateral damages of adjacent structures like liver, colon, gastric vessels and coronary arteries occurred in 6/189(3.2%) patients and within the AP-oriented group only. Periprocedural mortality was 1.1% (2/189) in this group. Adhesions were documented in 19/211 (9%) patients during the 1st procedure and in 47.1 % if patients had 2 or more epicardial procedures.
Conclusion
Subxyphoid epicardial access for catheter ablation bears a high risk of puncture-related complications. An left lateral oriented epicardial puncture technique may reduce the incidence of cardiac tamponades and collateral damages. In cases of repeated epicardial access adhesions increase significantly and may lead to ablation failure.
Puncture-related complications
|
Total
puncture-related complications – |
4/82 (4.9%) |
|
Pericardial tamponade |
4 (4.9%) |
|
Intrahospital death |
0 (0%) |
|
Total
puncture-related complications – |
19/189 (10.1%) |
|
Pericardial tamponade |
11 (4.1%) |
|
Abdominal organ puncture |
5 (1.6%) |
|
Myocardial infarction |
1 (0.4%) |
|
Pneumopericard |
1 (0.4%) |
|
Pneumothorax |
1 (0.4%) |
|
Intrahospital death |
2 (0.7%) |
A and B: AP oriented (inferior) puncture. Fluoroscopy projection in AP. White arrows in B illustrates the contrast media within the pericardial space. C and D: LL oriented (anterior) puncture. Fluoroscopy projection in LAO 90°. Yellow dotted points illustrate thesilhouette of the heart. Red dotted points the triangle between sternum, abdominal organs and heart. With permission of the Institute of Pathology, Asklepios Hospital St. George. LL= Left lateral view, AP= Anterior posterior view, LAO=Left anterior oblique.
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