Author + information
- Received August 19, 2019
- Revision received October 22, 2019
- Accepted October 25, 2019
- Published online January 20, 2020.
- aMercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California
- bCenter for Arrhythmia Care, Pritzker School of Medicine, University of Chicago Medicine, Chicago, Illinois
- cCardiac Arrhythmia Service, Hospital SOS Cardio, Florianopolis, SC, Brazil
- ↵∗Address for correspondence:
Dr. André d’Avila, Cardiac Arrhythmia Service, Instituto de Pesquisa em Arritmia Cardiaca, Hospital Cardiologico, Florianopolis, Santa Caterina 88030-000, Brazil.
• The critical anatomic substrate in certain patients with cardiac arrhythmias, particularly those with ventricular tachycardia, may occur in the intramural or subepicardial myocardium.
• Successful elimination of these substrates invariably requires epicardial mapping and ablation.
• Despite great similarities between epicardial and endocardial catheter mapping and/or ablation, there are fundamental differences that may significantly affect the biophysics of mapping and ablation within the pericardial space.
• Knowledge of the regional anatomy and potential risk factors for complications are key to mitigating the risk of adverse events.
Since their introduction >2 decades ago, percutaneous catheter-based epicardial mapping and ablation have become widely adopted by cardiac electrophysiologists around the world. Although epicardial mapping has been used for catheter ablation of a wide variety of cardiac arrhythmias, its most common use is for ablation of intramural and subepicardial substrates that give rise to ventricular tachycardia, particularly in patients with nonischemic cardiomyopathy. As such, the subxiphoid percutaneous epicardial approach has emerged as an important adjunct, and, in some cases, is the preferred strategy in this regard. This review discusses the rationale and indications for epicardial catheter mapping and/or ablation. This paper also reviews the prevalence of epicardial arrhythmias and their electrocardiographic criteria. In addition, it examines the anatomy of the pericardium and commonly used epicardial access techniques, as well as the optimal methodologies for epicardial mapping and ablation and the impact of epicardial fat. Finally, this review discusses the potential of the various complications associated with the percutaneous epicardial approach, in addition to patient-specific risk factors, and potential strategies to mitigate the risk of complications.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The 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 August 19, 2019.
- Revision received October 22, 2019.
- Accepted October 25, 2019.
- 2020 American College of Cardiology Foundation
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