Epicardial mapping and ablation for ventricular arrhythmias in experienced center without onsite cardiac surgery: A feasibility report

Objective: Epicardial access is sometimes required to effectively treat ventricular arrhythmias, but it can be associated with increased risk of procedural complications needing surgical intervention. The present study aimed to evaluate the feasibility and safety of epicardial mapping/ablation in experienced center without onsite cardiac surgery. Methods: Patients who had drug-refractory, recurrent ventricular arrhythmias were scheduled for catheter ablation. All surgeons had at least fifty pericardial puncture experiences. Epicardial puncture and perioperative anticoagulation were carried out based on institutional protocol. Phrenic nerve was mapped by 3-D mapping system. Coronary anatomy was delineated by coronary angiography. Results:  A total of 44 patients (63.3 years, male 86.4%) received epicardial access. Of them 7 (15.9%) were scheduled for PVC ablation, 37 (84.1%) for VT ablation (ICM: 25%, NICM: 59.1%). Mean LVEF was 41.3%. Acute ablation success rate was 35 (79.5%). Procedural adverse events included: pericardial effusion occurred in 3 (6.8%) patients who all well treated with pericardial drainage; and pericardial tamponade in 1 (2.3%) patient requiring transfer to surgical intervention. No death, stroke, phrenic nerves palsy, or coronary artery injury were observed. Median hospitalization was 4 (3-6) days. Univariable analysis and ROC curve showed that patients’ age was a significant predictor of epicardial procedural complication (area under curve (AUC): 0.813, P=0.041). Conclusions:  Guided by a tailored procedural protocol, the majority of the epicardial access related complications can be treated conservatively without needing onsite surgery. Older age is a risk factor associated with epicardial access related complications.