Catheter Ablation -> Ventricular Arrhythmias -> Experimental methods D-AB08 - Ventricular Tachycardia Ablation: New Technology, Techniques and Insights (ID 30) Abstract

D-AB08-01 - Facilitated Epicardial Access By Means Of Intentional Coronary Vein Exit And Carbon Dioxide Insufflation During Ventricular Tachycardia Ablation: The Epi-Co2 Registry (ID 748)


Background: Access to the epicardial substrate is often required during scar-related ventricular tachycardia (VT) ablation, either as first approach or following a previous endocardial failure. Epicardial ablation is however far from being a widespread technique due to the intrinsic complications associated with it.
Using intentional coronary vein exit and carbon dioxide insufflation to facilitate subxiphoid epicardial access for VT ablation was demonstrated to be safe and feasible in our initial single-centre experience.
Objective: This multicentre registry aimed to demonstrate the reproducibility and safety of this technique.
Methods: A branch of the coronary sinus was selected using a diagnostic coronary catheter inside a steerable sheath. Intentional perforation by means of a high tip load angioplasty wire was then performed at the distal portion of the branch. A microcatheter was then passed over the wire into the pericardial space, allowing up to 200 ml of pericardial CO2 insufflation. This allowed direct visualization of the anterior pericardial space and facilitated subxiphoid puncture.
Results: From January 2016 to November 2019, 98 consecutive patients undergoing epicardial access by means of this technique in any of the 16 participant centres were included in the registry. 21 different practitioners performed at least 1 procedure as first operator.
Intentional coronary vein exit was achieved in all but 1 patient, whose coronary sinus did not communicate with the right atrium. Significant pericardial adhesions were confirmed in 2 patients with previous epicardial ablation and therefore CO2 was not insufflated.
Significant bleeding (greater than 80 cc) due to coronary vein exit occurred in 4 patients in whom the branch had been perforated too proximally (N 2) or had been previously heparinized (N 2). Protamine administration was required in one of the latter cases, whilst bleeding spontaneously stopped in the remaining cases. There were no other epicardial access complications.
Conclusion: This multicentre registry confirms the safety and reproducibility of coronary vein exit and carbon dioxide insufflation to facilitate subxiphoid pericardial access.