Published Online
on August 30, 2004

A more recent version of this article appeared on September 7, 2004

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Submitted on December 30, 2003
Revised on April 29, 2004
Accepted on April 30, 2004

Subxiphoid Surgical Approach for Epicardial Catheter-Based Mapping and Ablation in Patients With Prior Cardiac Surgery or Difficult Pericardial Access

Kyoko Soejima MD^*, Gregory Couper MD, Joshua M. Cooper MD, John L. Sapp MD, Laurence M. Epstein MD, and William G. Stevenson MD

From the Cardiovascular Division (K.S., J.M.C., J.L.S., L.M.E., W.G.S.), Department of Internal Medicine, and Department of Thoracic Surgery (G.C.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass.

^* To whom correspondence should be addressed. E-mail: ksoejima{at}bics.bwh.harvard.edu.

Background--Percutaneous epicardial mapping and ablation are successful in some patients with ventricular epicardial reentry circuits but may be impossible when pericardial adhesions are present, such as from prior cardiac surgery. The purpose of this study was to evaluate the feasibility of direct surgical exposure of the pericardial space to allow catheter epicardial mapping and ablation in the electrophysiology laboratory when percutaneous access is not feasible.

Methods and Results--In 6 patients with prior cardiac surgery or failed percutaneous pericardial access, a subxiphoid pericardial window was attempted. In all 6 patients, manual lysis of adhesions exposed the epicardial surface of the heart through a small subxiphoid incision and allowed placement of an 8F sheath into the pericardial space under direct vision. Access to the diaphragmatic surface of the heart with ablation catheters was achieved in all patients, and catheter manipulation to the lateral and anterior walls was possible in 4 patients. Three-dimensional electroanatomic voltage maps revealed low-amplitude regions in the inferior or posterior left ventricular epicardium. A total of 16 ventricular tachycardias were induced, and 14 were abolished by radiofrequency ablation. Ablation was limited by intrapericardial defibrillator patches adherent to the likely target region in 2 patients. All patients had chest pain consistent with pericarditis early after the procedure that resolved within a few days. There were no other complications.

Conclusions--A direct surgical subxiphoid epicardial approach in the electrophysiology laboratory is feasible for patients with difficult pericardial access who require ablation of epicardial arrhythmia foci.

Key words: tachycardia • ablation • epicardium

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