Author + information
- Received September 1, 2016
- Revision received September 20, 2016
- Accepted October 6, 2016
- Published online March 8, 2017.
- Koji Fukuzawa, MD, PhDa,b,∗ (, )
- Shumpei Mori, MD, PhDb,
- Kunihiko Kiuchi, MD, PhDa,b,
- Tatsuya Nishii, MD, PhDc and
- Ken-ichi Hirata, MD, PhDa,b
- aSection of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- bDivision of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- cDepartment of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
- ↵∗Reprint requests and correspondence:
Dr. Koji Fukuzawa, Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuoh-Ku, Kobe 650-0017, Japan.
A middle-aged man with cardiac sarcoidosis underwent pericardiocentesis with the anterior approach for ablation of an epicardial ventricular tachycardia. The cutaneous entry point was determined by cardiac ultrasound imaging to obtain a window where liver injury could be avoided. An 18-G Tuohy needle was advanced subcutaneously with a very shallow angle (<15°) under fluoroscopic guidance (anterior-posterior/straight-lateral views). Once the needle came in contact with the bone or any lower costal cartilages, the needle was advanced just posterior to that and then advanced to the pericardium. After injecting a small amount of contrast media to confirm layering within the pericardial space, a guidewire was advanced (Figure 1A).
An arrhythmogenic substrate causing ventricular tachycardia was detected on the left ventricular epicardial surface (Figure 1B, yellow dotted line). The local potentials there were delayed from the QRS complex (Figure 1C, red circle), and ablation there abolished all the ventricular tachycardias. The epicardial sheath was exchanged for a drainage tube to monitor any bleeding.
Volume-rendered images reconstructed from plain computed tomography after the procedure clearly demonstrated the course of the drainage tube, corresponding with the needle course, and its relation to the surrounding organs (Figures 1D to 1F, Online Video 1, the tube is traced as a light green line). The percutaneous puncture point (Figures 1D and 1E, yellow arrows) was 1.5 cm inferior and 2.5 cm lateral to the lower end of the left side of the bifurcated xiphoid process (Figure 1D, dotted line). The tube travelled subcutaneously and penetrated the rectus abdominis. It then travelled just posterior to the lower costal cartilage without penetrating the diaphragm (Figures 1E and 1F, red arrowheads). It then entered the pericardial space. These images demonstrated that the tube did not travel through the abdominal cavity. We could intuitively recognize why we could prevent abdominal complications with the anterior approach.
For a supplemental video, please see the online version of this article.
The Section of Arrhythmia is supported by an endowment from Medtronic JAPAN and St. Jude Medical JAPAN.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 1, 2016.
- Revision received September 20, 2016.
- Accepted October 6, 2016.
- 2016 American College of Cardiology Foundation