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Epicardial Mapping and Ablation of Cardiac Arrhythmias

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Cardiac Arrhythmias

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Abstract

Epicardial mapping and ablation of cardiac arrhythmias has been an important development in interventional electrophysiology. The fibrous and serous pericardia are separated by a space that permits introduction of a guide wire using a subxiphoid percutaneous approach. There are two major sinuses in the pericardial space. A sheath advanced over the guide wire provides a mean to introduce one or more catheters or probes to perform mapping and ablation epicardially. Atrial arrhythmias that require epicardial mapping and ablation include unusual types of atrial tachycardia or accessory pathways. In patients with atrial fibrillation or atypical atrial flutter, epicardial mapping and ablation may be required to obtain isolation or elimination of atrial substrate. In patients with ischemic heart disease and left ventricular dysfunction, as well as in patients with dilated cardiomyopathy, or with infiltrative or unusual forms of heart disease, ventricular tachycardia may originate epicardially or require epicardial mapping prior to performing endocardial ablation. There are numerous considerations requiring safety and management of patients undergoing epicardial mapping and ablation. Newer surgical and hybrid procedures, from the collaboration of electrophysiology and surgery, may also provide new approaches to performing interventional electrophysiology procedures that may require epicardial mapping and ablation.

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References

  1. Sealy WC, Gallagher JJ, Wallace AG. The surgical treatment of Wolff-Parkinson-White syndrome: evolution of improved methods for identification and interruption of the Kent bundle. Ann Thorac Surg. 1976;22:443.

    Article  CAS  PubMed  Google Scholar 

  2. Guiraudon GM, Klein GJ, Gulamhusein S, Jones DL, Yee R, Perkins DG, Jarvis E. Sureical reDair of Wolff-Parkinson-White syndrome: a new closed-heart technique. Ann Thorac Surg. 1984;37:67.

    Article  CAS  PubMed  Google Scholar 

  3. Jackman WM, Wang X, Friday KJ, Roman CA, Moulton KP, Beckman KJ, McClelland JH, Twidale N, Hazlitt A, Pior MI, Margolis D, Calame JD, Overholt ED, Lazarra R. Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome) by radiofrequency current. N Engl J Med. 1991;324:1605–11.

    Article  CAS  PubMed  Google Scholar 

  4. Lemery R, Talajic M, Roy D, Coutu B, Lavoie L, Lavallee E, Cartier R. Success, safety, and late electrophysiological outcome of low-energy direct-current ablation in patients with the Wolff-Parkinson-White syndrome. Circulation. 1992;85:957–62.

    Article  CAS  PubMed  Google Scholar 

  5. Yamane T, Jais P, Shah DC, Hocini M, Peng JT, Deisenhofer I, Clementy J, Haissaguerre M. Efficacy and safety of an irrigated-tip catheter for the ablation of accessory pathways resistant to conventional radiofrequency ablation. Circulation. 2000;102:2565–8.

    Article  CAS  PubMed  Google Scholar 

  6. Sosa E, Scanavacca M, d’Avila A, Pilleggi F. A new technique to perform epicardial mapping in the electrophysical laboratory. J Cardiovasc Electrophyisol. 1996;7:537–8.

    Article  Google Scholar 

  7. McAlpine WA. Heart and coronary arteries: an anatomical atlas for clinical diagnosis, radiological investigation, and surgical treatment. Berlin/New York: Springer; 1975.

    Book  Google Scholar 

  8. D’Avila A, Scanacca M, Sosa E, Ruskin JE, Reddy VY. Pericardial anatomy for the interventional electrophysiologist. J Cardiovasc Electrophysiol. 2003;14:422–30.

    Article  PubMed  Google Scholar 

  9. Lemery R, Birnie D, Tang A, Green M, Gollob M, Hendry M, Lau E. Normal atrial activation and voltage during sinus rhythm in the human heart. J Cardiovasc Electrophysiol. 2007;18:402–8.

    Article  PubMed  Google Scholar 

  10. Nazarian S, Kantsevoy SV, Zviman MM, Matsen FA, Calkins H, Berger RD, Halperin HR. Feasibility of endoscopic guidance for nonsurgical transthoracic atrial and ventricular epicardial ablation. Heart Rhythm. 2008;5(8):1115–9.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Nagashima K, Watanabe I, Okumura Y, Ohkubo K, Kofune M, Ohya T, Kasamaki Y, Hirayama A. Efficacy and feasibility of pericardial endoscopy by subcutaneous approach. Europace. 2011;13:1501–3.

    Article  PubMed  Google Scholar 

  12. Buch E, Nakahara S, Shivkumar K. Intra-pericardial balloon retraction of the left atrium. A novel method to prevent esophageal injury during catheter ablation. Heart Rhythm. 2008;5(10):1473–5.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Nakahara S, Ramirez R, Buch E, Michowitz Y, Vaseshi M, de Diego C, Boyle N, Mahajan A, Shivkumar K. Intrapericardial balloon placement for prevention of collateral injury during catheter ablation of the left atrium in a porcine model. Heart Rhythm. 2010;7:81–7.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Soejima K, Couper G, Coopr JM, Sapp JL, Epstein LM, Stevenson WG. Subxiphoid surgical approach for epicardial catheter-based mapping and ablation in patients with prior cardiac surgery or difficult pericardial access. Circulation. 2004;110:1197–201.

    Article  PubMed  Google Scholar 

  15. Verner RL, Waxman S, Lovett EG, Moreno R. Transatrial access to the normal pericardial space: an approach for diagnostic sampling, pericardiocentesis, and therapeutic interventions. Circulation. 1998;98(21):2331–3.

    Article  Google Scholar 

  16. Scanavacca M, Vanancio A, Pisani C, Lara S, Hachul D, Darrieux F, Hardy C, Paola E, Aiello V, Mhapatra S, Sosa E. Percutaneous transatrial access to the pericardial space for epicardial mapping and ablation. Circ Arrhytm Electrophysiol. 2011;4:331–6.

    Article  Google Scholar 

  17. Durrer D, Van Dam RT, Freud GE, Janse MJ, Meijler FL, Arzbaecher C. Total excitation of the isolated human heart. Circulation. 1970;41:899–912.

    Article  CAS  PubMed  Google Scholar 

  18. Puech P, Esclavissat M, Sodi-Pollares D, Cisneros F. Normal auricular activation in the dog’s heart. Am Heart J. 1954;47:174–91.

    Article  CAS  PubMed  Google Scholar 

  19. Lemery R, Guiraudon G, Veinot JP. Anatomic description of Bachmann’s bundle and its relation to the atrial septum. Am J Cardiol. 2003;91:1482–5.

    Article  PubMed  Google Scholar 

  20. Schweikert RA, Saliba WI, Tomassoni G, Marrouche NF, Cole CR, Dressing TJ, Tchou PJ, Bash D, Beheiry S, Lam C, Kanagarathan L, Natale A. Percutaneous pericardial instrumentation for endo-epicardial mapping of previously failed ablations. Circulation. 2003;108(11):1329–35.

    Article  PubMed  Google Scholar 

  21. Valderrabano M, Cessario DA, Ji S, Shannon K, Weiner I, Swerdlow CD, Oral H, Morady F, Shivkumar K. Percutaneous epicardial mapping during ablation of difficult accessory pathways as an alternative to cardiac surgery. Heart Rhythm. 2004;1(3):311–6.

    Article  PubMed  Google Scholar 

  22. Ho I, D’Avila A, Ruskins J, Mansour M. Images in cardiovascular medicine. Percutaneous epicardial mapping and ablation of a posteroseptal accessory pathway. Circulation. 2007;115:e418–21.

    Article  PubMed  Google Scholar 

  23. de Paloa AAV, Leite LR, Mesas CE. Nonsurgical transthoracic epicardial ablation for the treatment of a resistant posteroseptal accessory pathway. Pacing Clin Electrophysiol. 2004;27:259–61.

    Article  Google Scholar 

  24. Lam C, Schweikert R, Kanagaratnam L, Natale A. Radiofrequency ablation of a right atrial appendage-ventricular accessory pathway by transcutaneous epicardial instrumentation. J Cardiovasc Electrophysiol. 2000;11:1170–3.

    Article  CAS  PubMed  Google Scholar 

  25. Phillips KP, Natale A, Sterba R, Saliba WI, Burkhardt JD, Wazni O, Liberman L, Schweikert RA. Percutaneous pericardial instrumentation for catheter ablation of focal atrial tachycardias arising from the left atrial appendage. J Cardiovasc Electrophysiol. 2008;19:430–3.

    Article  PubMed  Google Scholar 

  26. Armour JA, Murphy DA, Yuan BX, Macdonald S, Hopkins DA. Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anat Rec. 1997;247(2):289–98.

    Article  CAS  PubMed  Google Scholar 

  27. Scherlag BJ, Nakagawa H, Jackman WM, Yamanashi WS, Patterson E, Po S, Lazzara R. Electrical stimulation to identify neural elements on the heart: their role in atrial fibrillation. J Interv Card Electrophysiol. 2005;13 Suppl 1:37–42.

    Article  PubMed  Google Scholar 

  28. Lemery R, Birnie D, Tang SL, Green M, Gollob M. Feasibility study of endocardial mapping of ganglionated plexuses during catheter ablation of atrial fibrillation. Heart Rhythm. 2006;3:387–96.

    Article  PubMed  Google Scholar 

  29. Scanavacca M, Pisani CF, Hachul D, Lara S, Hardy C, Darrieux F, Trombetta I, Negrao CE, Sosa E. Selective atrial vagal denervation guided by evoked vagal reflex to treat patients with paroxysmal atrial fibrillation. Circulation. 2006;114:876–85.

    Article  PubMed  Google Scholar 

  30. Lemery R. How to perform ablation of the parasympathetic ganglia of the left atrium. Heart Rhythm. 2006;3(10):1237–9.

    Article  PubMed  Google Scholar 

  31. Scherlag BJ, Po S. The intrinsic cardiac nervous system and atrial fibrillation. Curr Opin Cardiol. 2006;21(1):51–4.

    Article  PubMed  Google Scholar 

  32. Pokushalov E, Romanov A, Shugayev P, Artymenko S, Shirokova N, Turov A, Katritsis DG. Selective ganglionated plexi ablation for paroxysmal atrial fibrillation. Heart Rhythm. 2009;6(9):1257–64.

    Article  PubMed  Google Scholar 

  33. Pokushalov E, Romanov A, Artyomenko S, Shirokva N, Turov A, Karaskov S, Katritsis D, Po SS. Ganglionated plexi ablation directed by high-frequency stimulation and complex fractionated atrial electrograms for paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2012;35:776–84.

    Article  PubMed  Google Scholar 

  34. Lemery R. Autonomics and ablation of paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2012;35:773–5.

    Article  PubMed  Google Scholar 

  35. Doshi RN, Wu TJ, Yashima M, Kim YH, Ong JJ, Cao JM, Hwang C, Yashar P, Fishbein MC, Karagueuzian HS, Chen PS. Relation between ligament of Marshall and adrenergic atrial tachyarrhythmia. Circulation. 1999;100:876–83.

    Article  CAS  PubMed  Google Scholar 

  36. Hwang C, Wu TJ, Doshi RN, Peter CT, Chen PS. Vein of Marshall cannulation for the analysis of electrical activity in patients with focal atrial fibrillation. Circulation. 2000;101:1503–5.

    Article  CAS  PubMed  Google Scholar 

  37. Valderrabano M, Liu X, Sasaridis C, Sidhu J, Little S, Khoury DS. Ethanol infusion in the vein of Marshall: adjunctive effects during ablation of atrial fibrillation. Heart Rhythm. 2009;6:1552–8.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Reddy VY, Neuzil P, Ruskin JN. Extra-ostial pulmonary venous isolation: use of epicardial ablation to eliminate a point of conduction breakthrough. J Cardiovasc Electrophysiol. 2003;14(6):663–6.

    Article  CAS  PubMed  Google Scholar 

  39. Pak HN, Hwang C, Lim HE, Kim JS, Kim YH. Hybrid epicardial and endocardial ablation of persistent or permanent atrial fibrillation: a new approach to difficult cases. J Cardiovasc Electrophysiol. 2007;18(9):917–23.

    Article  PubMed  Google Scholar 

  40. Reddy V, Neuzil P, d’Avila A, JN R. Isolating the posterior left atrium and pulmonary veins with a “box” lesion set: use of epicardial ablation to complete electrical isolation. J Cardiovasc Electrophysiol. 2008;19(3):326–9.

    Article  PubMed  Google Scholar 

  41. Shivkumar K. Percutaneous epicardial ablation of atrial fibrillation. Heart Rhythm. 2008;5:152–4.

    Article  PubMed  Google Scholar 

  42. Krul SPJ, Driessen AHG, van Boven WJ, Linnebank AC, Geuzebroek GSC, Jackman WM, Wilde AAM, de Bakker JMT, de Groot JR. Thoracoscopic video-assisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions: first results of a hybrid surgical-electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol. 2011;4:262–70.

    Article  PubMed  Google Scholar 

  43. Scanavacca M, Sosa E. Epicardial ablation of ventricular tachycardia in Chagas heart disease. Cardiac Electrophysiol Clin. 2010;2:55–67.

    Article  Google Scholar 

  44. Sosa E, Scanavacca M, d’Avila A, Oliveira F, Ramires JAF. Nonsurgical transthoracic epicardial ablation to treat recurrent ventricular tachycardia occurring late after myocardial infarction. J Am Coll Cardiol. 2000;35(6):1442–9.

    Article  CAS  PubMed  Google Scholar 

  45. Brugada J, Berruezo A, Cuesta A, Osca J, Chueca E, Fosch X, Waynar L, Mont L. Nonsurgical transthoracic epicardial radiofrequency ablation: an alternative in incessant ventricular tachycardia. J Am Coll Cardiol. 2003;41(11):2036–43.

    Article  PubMed  Google Scholar 

  46. Soejima E, Stevenson WG, Sapp JL, Selwyn AP, Couper G, Epstein LM. Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy: the importance of low-voltage scars. J Am Coll Cardiol. 2004;43:1834–42.

    Article  PubMed  Google Scholar 

  47. Cano O, Hutchinson M, Lin D, Garcia F, Zado E, Bala R, Riley M, Cooper J, Dixit S, Gerstenfeld E, Callans D, Marchlinski FE. Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular non-ischemic cardiomyopathy. J Am Coll Cardiol. 2009;54(9):799–808.

    Article  PubMed  Google Scholar 

  48. Farcia FC, Bazan V, Zado ES, Ren JF, Marchlinksi FE. Epicardial substrate and outcome with epicardial ablation of ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Circulation. 2009;120:366–75.

    Article  Google Scholar 

  49. Berruezo A, Fernandez-Armenta J, Mont L, Zeliko H, Andreu D, Herczku C, Boussy T, Tolosana JM, Arbelo E, Brugada J. Combined endocardial and epicardial ablation in arrhythmogenic right ventricular dysplasia incorporating scar dechanneling technique. Circ Arrhythm Electrophysiol. 2012;5:111–21.

    Article  PubMed  Google Scholar 

  50. Daniels DV, Lu YY, Morton JB, Santucci P, Akar JG, Green AI, Wilber DJ. Idiopathic epicardial left ventricular tachycardia originating remote from the sinus of valsalva electrophysiological characteristics, catheter ablation, and identification from the 12-lead electrocardiogram. Circulation. 2006;113:1659–66.

    Article  PubMed  Google Scholar 

  51. Berruezo A, Mont L, Nava S, Cheuca E, Bartholomay E, Brugada J. Electrocardiographic recognition of the epicardial origin of ventricular tachycardias. Circulation. 2004;109:1842–7.

    Article  PubMed  Google Scholar 

  52. Bazan V, Gertsenfeld E, Garcia F, Bala R, Rivas N, Dixit S, Zado E, Callans D, Marchlinski E. Site-specific twelve-lead ECG features to identify an epicardial origin for left ventricular tachycardia in the absence of myocardial infarction. Heart Rhythm. 2007;4:1403–10.

    Article  PubMed  Google Scholar 

  53. Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Della Bella P, Hindricks G, Jails P, Josephson MF, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D. EHRA/ESC/HRS/ACC/AHA expert consensus on catheter ablation of ventricular arrhythmias. Heart Rhythm. 2009;6:886–933.

    Article  PubMed  Google Scholar 

  54. Sacher F, Roberts-Thomson K, Maury P, Tedro U, Nault I, Steven D, Hocini M, Koplan B, Lerpux L, Derval N, Seiler J, Wright MJ, Epstein L, Haissaguerre M, Jais P, Stevenson WG. Epicardial ventricular tachycardia ablation of multicenter safety study. J Am Coll Cardiol. 2010;55:2366–72.

    Article  PubMed  Google Scholar 

  55. d’Avila A, Houghtaling C, Gutierrez P, Vragovic O, Ruskin JN, Josephson ME, Reddy VY. Catheter ablation of ventricular epicardial tissue. A comparison of standard and cooled-tip radiofrequency energy. Circulation. 2004;109:2363–9.

    Article  PubMed  Google Scholar 

  56. d’Avila A, Gutierrez P, Scanavacca M, Reddy V, Lustgarten BDL, Sosa E, Ramires JA. Effects of radiofrequency pulses delivered in the vicinity of the coronary arteries: implication for nonsurgical transthoracic epicardial catheter ablation to treat ventricular tachycardia. Pacing Clin Electrophysiol. 2002;25:1488–95.

    Article  PubMed  Google Scholar 

  57. Buch E, Vaseghi M, Cesario DA, Shivkumar K. A novel method for preventing phrenic nerve injury during catheter ablation. Heart Rhythm. 2007;4:95–8.

    Article  PubMed Central  PubMed  Google Scholar 

  58. Di Biase L, Burkhardt JD, Pelargonio G, Dello Russo A, Casella M, Santarelli P, Horton R, Sanchez J, Gallinghouse JG, Al-Ahmad A, Wang P, Cummings JE, Schweikert RA, Natale A. Prevention of phrenic nerve injury during epicardial ablation: comparison of methods for separating the phrenic nerve from the epicardial surface. Heart Rhythm. 2009;6:957–61.

    Article  PubMed  Google Scholar 

  59. Sanchez-Quintana D, Cabrera JA, Climent V, Murillo M, Cabrera JA. Anatomic evaluation of the left phrenic nerve relevant to epicardial and endocardial catheter ablation: implications for phrenic nerve injury. Heart Rhythm. 2009;6:764–8.

    Article  PubMed  Google Scholar 

  60. Tung R, Nakahara S, Ramirez R, Lai C, Fishbein MC, Shivkumar K. Distinguishing epicardial fat from scar: analysis of electrograms using high-density electroanatomic mapping in a novel porcine infarct model. Heart Rhythm. 2010;7:389–95.

    Article  PubMed Central  PubMed  Google Scholar 

  61. Koruth J, Aryana A, Dukkipati S, Pak HN, Kim YH, Sosa EA, Scanavacca M, Mahapatra S, Ailawadi G, Reddy V, d’Avila A. Unusual complications of percutaneous epicardial access and epicardial mapping and ablation of cardiac arrhythmias. Circ Arrhythm Electrophysiol. 2011;4:882–8.

    Article  PubMed  Google Scholar 

  62. Hsieh CH, Ross DL. Case of coronary perforation with epicardial access for ablation of ventricular tachycardia. Heart Rhythm. 2011;8:318–21.

    Article  PubMed  Google Scholar 

  63. D’Avila A, Neuzil P, Thaigalingam A, Gutierrez P, Aleong R, Ruskin J, Reddy V. Experimental efficacy of pericardial instillation of anti-inflammatory agents during percutaneous epicardial catheter ablation to prevent postprocedure pericarditis. J Cardiovasc Electrophysiol. 2007;18:1178–83.

    Article  PubMed  Google Scholar 

  64. Di Biase L, Santangeli P, Astudillo V, Conti S, Mohanty P, Sanchez J, Horton R, Thomas B, Burkhardt JD, Natale A. Endo-epicardial ablation of ventricular arrhythmias in the left ventricle with the Remote Magnetic Navigation System and the 3.5-mm open irrigated magnetic catheter: results from a large single-center case–control series. Heart Rhythm. 2010;7:1029–35.

    Article  PubMed  Google Scholar 

  65. Gersak B, Pernat A, Robic B, Sinkovec M. Prospective long-term outcomes after atrial fibrillation treatment using the convergent epicardial and endocardial ablation procedure. J Cardiovasc Electrophysiol. 2012;23(10):1059–66. doi:10.1111/j.1540-8167.2012.02355.x.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, K1Y-4W7, Canada

    Robert Lemery MD

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  1. Robert Lemery MD
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Correspondence to Robert Lemery MD .

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Editors and Affiliations

  1. Department of Cardiology, Center Hospitalier Coutances, Coutances, France

    Ambrose S. Kibos

  2. Department of Internal Medicine Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

    Bradley P. Knight

  3. Division of Cardiology, McGill University Health Center, Montreal, Québec, Canada

    Vidal Essebag

  4. Department of Cardiology, Miami Children's Hospital, Miami, Florida, USA

    Steven B. Fishberger

  5. School of Biology, Chemistry and Health, Manchester Metropolitan University, Manchester, United Kingdom

    Mark Slevin

  6. “Acad. Vasile Candea” Emergency Clinical Center for Cardiovascular Diseases, “Carol Davila” University of Medicine and Pharmacy, “Titu Maiorescu” University Faculty of Medicine,, Bucharest, Romania

    Ion C. Țintoiu

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Lemery, R. (2014). Epicardial Mapping and Ablation of Cardiac Arrhythmias. In: Kibos, A., Knight, B., Essebag, V., Fishberger, S., Slevin, M., Țintoiu, I. (eds) Cardiac Arrhythmias. Springer, London. https://doi.org/10.1007/978-1-4471-5316-0_42

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