Published Online
on September 2, 2003

A more recent version of this article appeared on September 16, 2003

This Article Full Text (PDF) All Versions of this Article: 108/11/1329    most recent 01.CIR.0000087407.53326.31v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schweikert, R. A. Articles by Natale, A. Search for Related Content PubMed PubMed Citation Articles by Schweikert, R. A. Articles by Natale, A. Pubmed/NCBI databases Medline Plus Health Information Arrhythmia Related Collections Ablation/ICD/surgery

Submitted on November 28, 2001
Revised on June 27, 2003
Accepted on July 1, 2003

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, and 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.

^* To whom correspondence should be addressed. E-mail: Schweir{at}ccf.org.

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

This article has been cited by other articles:

				O. Cano, M. Hutchinson, D. Lin, F. Garcia, E. Zado, R. Bala, M. Riley, J. Cooper, S. Dixit, E. Gerstenfeld, et al. Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy. J. Am. Coll. Cardiol., August 25, 2009; 54(9): 799 - 808. [Abstract] [Full Text] [PDF]

				E. M. Aliot, W. G. Stevenson, J. M. Almendral-Garrote, F. Bogun, C. H. Calkins, E. Delacretaz, P. D. Bella, G. Hindricks, P. Jais, M. E. Josephson, et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA) Europace, June 1, 2009; 11(6): 771 - 817. [Full Text] [PDF]

				T. Ota, A. Degani, D. Schwartzman, B. Zubiate, J. McGarvey, H. Choset, and M. A. Zenati A Highly Articulated Robotic Surgical System for Minimally Invasive Surgery Ann. Thorac. Surg., April 1, 2009; 87(4): 1253 - 1256. [Abstract] [Full Text] [PDF]

				J.#x.;n. Farré, H. J.J. Wellens, J.#x. M. Rubio, and J. Benezet CHAPTER 28 Supraventricular Tachycardias ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]

				M. A. Zenati, A. Shalaby, G. Eisenman, J. Nosbisch, J. McGarvey, and T. Ota Epicardial Left Ventricular Mapping Using Subxiphoid Video Pericardioscopy Ann. Thorac. Surg., December 1, 2007; 84(6): 2106 - 2107. [Abstract] [Full Text] [PDF]

				H. Nakagawa and W. M. Jackman Catheter Ablation of Paroxysmal Supraventricular Tachycardia Circulation, November 20, 2007; 116(21): 2465 - 2478. [Full Text] [PDF]

				J. D. Burkhardt and B. L. Wilkoff Interventional Electrophysiology and Cardiac Resynchronization Therapy: Delivering Electrical Therapies for Heart Failure Circulation, April 24, 2007; 115(16): 2208 - 2220. [Abstract] [Full Text] [PDF]

				I. Ho, A. d'Avila, J. Ruskin, and M. Mansour Percutaneous Epicardial Mapping and Ablation of a Posteroseptal Accessory Pathway Circulation, April 24, 2007; 115(16): e418 - e421. [Full Text] [PDF]

				R. Vatasescu, T. Shalganov, A. Kardos, K. Jalabadze, D. Paprika, M. Gyorgy, and T. Szili-Torok Right diaphragmatic paralysis following endocardial cryothermal ablation of inappropriate sinus tachycardia Europace, October 1, 2006; 8(10): 904 - 906. [Abstract] [Full Text] [PDF]

				D. V. Daniels, Y.-Y. Lu, J. B. Morton, P. A. Santucci, J. G. Akar, A. Green, and D. J. Wilber Idiopathic Epicardial Left Ventricular Tachycardia Originating Remote From the Sinus of Valsalva: Electrophysiological Characteristics, Catheter Ablation, and Identification From the 12-Lead Electrocardiogram Circulation, April 4, 2006; 113(13): 1659 - 1666. [Abstract] [Full Text] [PDF]

				H. Tada, S. Ito, S. Naito, K. Kurosaki, S. Kubota, A. Sugiyasu, T. Tsuchiya, K. Miyaji, M. Yamada, Y. Kutsumi, et al. Idiopathic ventricular arrhythmia arising from the mitral annulus: A distinct subgroup of idiopathic ventricular arrhythmias J. Am. Coll. Cardiol., March 15, 2005; 45(6): 877 - 886. [Abstract] [Full Text] [PDF]

				H. Tanner, G. Hindricks, P. Schirdewahn, R. Kobza, A. Dorszewski, C. Piorkowski, J.-H. Gerds-Li, and H. Kottkamp Outflow tract tachycardia with R/S transition in lead V3: Six different anatomic approaches for successful ablation J. Am. Coll. Cardiol., February 1, 2005; 45(3): 418 - 423. [Abstract] [Full Text] [PDF]

				D. P. Zipes The year in electrophysiology J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1306 - 1314. [Full Text] [PDF]