Nonsurgical Transthoracic Epicardial Approach in Patients with Ventricular Tachycardia and Previous Cardiac Surgery

AbstractIntroduction: The subxyphoid pericardial mapping approach can be used to facilitate catheter ablation of postmyocardial-infarction ventricular tachycardia (post-MI VT), but the presence of dense adhesions is thought to preclude this approach in patients who have previously undergone open-chest cardiac surgery. Aims of the Study: This study reports the first use of a nonsurgical transthoracic epicardial approach in patients with scar-related VT and previous cardiac surgery. Methods: Five patients with a mean age of 67 ± 10 years, left ventricular ejection fraction (LVEF) of 40 ± 4.3%) and recurrent VT occurring 7 months to 10 years after cardiac surgery underwent combined endocardial and epicardial mapping and ablation during the same session. Because pericardial adhesions were anticipated to be denser in the anterior wall, the nonsurgical transthoracic epicardial puncture was directed to the inferior wall of the left ventricle. Failure to interrupt VT with radio frequency (RF) energy pulses delivered at the best endocardial or epicardial site prompted changing from one approach to the other. Results: During the epicardial puncture procedure, the contrast medium accumulated in the inferior wall instead of spreading around the cardiac silhouette. The pericardial sac could be entered in all patients, and mapping of the infero-lateral epicardial wall of the left ventricle was feasible. Fourteen VTs were induced, of which 8 could not be mapped because of poor hemodynamic tolerance. Three of the remaining 6 mappable VTs were eliminated by endocardial ablation, 2 required an epicardial RF pulse to be rendered noninducible, and 1 VT was not eliminated. No intra- or postprocedural complications were noted despite full heparinization. Conclusion: Nonsurgical transthoracic epicardial catheter mapping and ablation of epicardial VT related to the inferolateral left ventricular wall are feasible in patients who have previously undergone open- cardiac surgery.