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(Circulation. 2003;108:1329.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

Percutaneous Pericardial Instrumentation for Endo-Epicardial Mapping of Previously Failed Ablations

Robert A. Schweikert, MD; Walid I. Saliba, MD; Gery Tomassoni, MD; Nassir F. Marrouche, MD; Christopher R. Cole, MD; Thomas J. Dresing, MD; Patrick J. Tchou, MD; Dianna Bash, RN; Salwa Beheiry, RN; Cathy Lam, MD; Logan Kanagaratnam, MD; Andrea Natale, MD

From the Cleveland Clinic Foundation (R.A.S., W.I.S., N.F.M., C.R.C., T.J.D., P.J.T., D.B., C.L., L.K., A.N.), Cleveland, Ohio, and Central Baptist Hospital (G.T., S.B.), Lexington, Ky.

Correspondence to Robert A. Schweikert, MD, Department of Cardiovascular Medicine/F15, Section of Electrophysiology and Pacing, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. E-mail Schweir{at}ccf.org

Received November 28, 2001; de novo received February 24, 2003; revision received June 27, 2003; accepted July 1, 2003.

Background— The epicardial location of an arrhythmia could be responsible for unsuccessful endocardial catheter ablation.

Methods and Results— In 48 patients referred after prior unsuccessful endocardial ablation, we considered percutaneous, subxiphoid instrumentation of the pericardial space for mapping and ablation. Thirty patients had ventricular tachycardia (VT), 6 patients had a right- and 4 had a left-sided accessory pathway (AP), 4 patients had inappropriate sinus tachycardia, and 4 patients had atrial arrhythmias. Of the 30 VTs, 24 (6 with ischemic cardiomyopathy, 3 with idiopathic cardiomyopathy, and 15 with normal hearts) appeared to originate from the epicardium. Seventeen (71%) of these 24 VTs were successfully ablated with epicardial lesions. The other 7 VTs had early epicardial sites that were inaccessible, predominantly because of interference from the left atrial appendage. Six of these were successfully ablated from the left coronary cusp. In 5 of the 10 patients with an AP, the earliest activation was recorded epicardially. Three of these were right atrial appendage–to–right ventricle APs, and epicardial ablation was successful. No significant complications were observed.

Conclusions— Failure of endocardial ablation could reflect the presence of an epicardial arrhythmia substrate. Epicardial instrumentation and ablation appeared feasible and safe and provided an alternative strategy for the treatment of patients with a variety of arrhythmias. This was particularly true for VT, including patients without structural heart disease.

Key Words: tachyarrhythmias • electrophysiology • catheter ablation • mapping • pericardium

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