Author + information
- Received April 18, 2018
- Accepted April 26, 2018
- Published online August 20, 2018.
- Ameesh Isath, MBBSa,∗,
- Anas Abudan Al-Masry, MBBSa,∗,
- Alan Sugrue, MBBCha,
- Vaibhav R. Vaidya, MBBSa,
- Deepak Padmanabhan, MBBSa,
- Paul A. Friedman, MDa and
- Samuel J. Asirvatham, MDa,b,∗ ()
- aDivision of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
- bDepartment of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
- ↵∗Address for correspondence:
Dr. Samuel J. Asirvatham, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Southwest, Rochester, Minnesota 55905.
Percutaneous epicardial access is increasingly used for atrial and ventricular arrhythmia ablation and left atrial appendage ligation (1–4). Although electrophysiologists frequently perform a subxiphoid puncture for epicardial access; access to certain structures, such as the left atrial appendage and the transverse sinus, may be improved with lateral epicardial access. Additionally, lateral access may enable optimal left ventricular epicardial lead placement. Clinically, lateral access is generally avoided due to potential risk of lung injury and/or pneumothorax. We propose an alternative novel approach to subxiphoid epicardial access using a lateral vantage point. Lateral access from a parasternal puncture site can be achieved safely if the lungs and pleura are displaced, such as in the presence of a pericardial effusion. We sought to mimic this effect by using a novel prototype device, comprising an inflatable balloon sheath, which can push aside the lung, and provide a window for safe lateral access (Figure 1A).
In canine models (N = 3), standard subxiphoid percutaneous epicardial access was used to deploy the balloon device. The balloon was inflated with contrast, providing a landmark for lateral access. Under fluoroscopic guidance, a needle was introduced laterally in a left intercostal space, and advanced toward the balloon. The needle was maneuvered until an indentation was visible on the balloon (Figure 1B). The needle was advanced to puncture the balloon (Online Video 1). A guidewire was passed through the needle into the device window (Figure 1C). A sheath was placed over the wire, to complete the lateral epicardial access (Figure 1D).
There were no acute complications observed, in particular no pericardial bleeding, cardiac perforation, or lung injury (Figure 1E). Although this approach necessitates a traditional subxiphoid epicardial access for balloon placement, based upon these preliminary findings, a lateral epicardial approach seems feasible and appears to have an acceptable safety profile.
↵∗ Drs. Isath and Al-Masry contributed equally to this work and are joint first authors.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received April 18, 2018.
- Accepted April 26, 2018.
- 2018 American College of Cardiology Foundation
- Bartus K.,
- Han F.T.,
- Bednarek J.,
- et al.
- Sacher F.,
- Roberts-Thomson K.,
- Maury P.,
- et al.
- Swale M.,
- Mikell S.,
- Gard J.,
- Munger T.M.,
- Asirvatham S.J.,
- Friedman P.A.