Percutaneous epicardial ventricular tachycardia ablation after noncoronary cardiac surgery or pericarditis.

BACKGROUND: Patients with previous noncoronary cardiac surgery or pericarditis may require epicardial access to facilitate successful ventricular tachycardia (VT) ablation. Percutaneous pericardial access is known to be difficult in these patients owing to the presence of pericardial adhesions.
OBJECTIVE: To examine the success and safety of percutaneous pericardial access as well as the ability to map and ablate epicardial VT targets.
METHODS: We studied 10 consecutive patients with prior noncoronary cardiac surgery (8 patients) or prior pericarditis (2 patients) who required epicardial access for VT ablation.
RESULTS: Percutaneous pericardial access was achieved by experienced operators, and dense adhesions interfering with catheter mapping were encountered in all patients. Using blunt dissection with a deflected ablation catheter, adhesions were divided over the course of 19-125 minutes (mean 57±38 minutes; median 47 minutes). This dissection allowed for sufficient epicardial mapping in 9 of 10 (90%) patients. The clinical targeted VTs were rendered noninducible in 8 (80%) patients. One patient had 70 cm(3) of bleeding with the initial puncture. No other complications occurred. During a long-term follow-up of 24±27 months (median 13 months), 5 patients have remained VT-free.
CONCLUSIONS: Percutaneous pericardial access for epicardial VT ablation in patients with previous noncoronary cardiac surgery or pericarditis can usually be obtained. However, dense pericardial adhesions are often encountered and may limit the ability to map the entire epicardial space. Typically, appropriate targets can be reached and ablated by disrupting the adhesions with the ablation catheter and/or deflectable sheath, facilitating excellent long-term clinical outcome in half of the patients with no major complications.