Coronary Vein Exit and Carbon Dioxide Insufflation to Facilitate Subxiphoid Epicardial Access for Ventricular Mapping and Ablation: First Experience.

OBJECTIVES: This study assessed the feasibility of intentional coronary venous perforation and exit with subsequent pericardial carbon dioxide (CO2) insufflation as a novel method for assisting subxiphoid pericardial puncture in the setting of epicardial mapping and ablation for ventricular tachycardia. The technique required that coronary venous perforation would not lead to significant bleeding.
BACKGROUND: Widespread adoption of first-line endoepicardial ventricular tachycardia ablation has not been taken up because of the risk of lacerating coronary vessels and puncturing the right ventricle with direct subxiphoid puncture.
METHODS: A lateral branch of the coronary sinus was subselected using a diagnostic JR4 coronary catheter inside a steerable sheath, via femoral access, and a distal branch then perforated intentionally using a high tip load 0.014-inch angioplasty wire. Either a microcatheter or over-the-wire balloon was then passed over this into the pericardial space, allowing up to 150 ml of pericardial CO2 insufflation, which allowed direct visualization of subxiphoid anterior pericardial access using a microneedle technique.
RESULTS: Intentional coronary vein exit was achieved in all 12 patients. In 1 patient, this confirmed widespread pericardial adhesions and therefore only endocardial VT ablation was undertaken. The other patients underwent successful pericardial CO2 insufflation and subxiphoid access allowing epicardial ventricular mapping and ablation. The immediate pericardial aspirate was dry or contained serous fluid in all but 1 patient.
CONCLUSIONS: We report the first human transcoronary vein exit procedure. Coronary vein exit and subsequent percutaneous subxiphoid anterior access using a microneedle puncture after CO2 pericardial insufflation can be achieved reliably and safely.