Successful percutaneous epicardial access in challenging scenarios

Background This case-series highlights strategies used for successful epicardial access in challenging cases. Percutaneous epicardial access has become a valuable tool for mapping and ablating arrhythmias. However, this technique can be especially difficult in certain circumstances and is frequently avoided. Methods All cases of epicardial access for ablation from our institution were reviewed searching for exceptionally difficult cases in patients with complex pericardial and thoracic anatomy. The successful strategies are characterized in this report. Results Among 144 patients who underwent an epicardial ablation procedure between January 2004 and June 2013, four required unconventional approaches for epicardial access for ventricular tachycardia ablation. Two patients (one with previous cardiac surgery and one with prior pericardial effusion) had substantial fibrous pericardial adhesions with no virtual pericardial space and required adhesiolysis. One patient, status postpartial colectomy, underwent computed tomography-guided intercostal epicardial access due to the presence of bowel throughout the subdiaphragmatic space in the upper abdomen. The fourth patient had partial congenital absence of the pericardium and underwent epicardial access through the creation of a subxiphoid window. All epicardial accesses were successful and performed without major complication. Conclusions With precise procedural planning and cardiac imaging, percutaneous epicardial access is feasible even in patients with significant anatomical challenges.