Author + information
- Simon Claridge, LLB, MBBS∗ (, )
- Theodore Velissaris, MRCS,
- Waqas Ullah, MBBS, PhD and
- Arthur Yue, MBBS, PhD
- ↵∗Address for correspondence:
Dr. Simon Claridge, Department of Cardiology, University Hospital Southampton, Tremona Road, Southampton, Hampshire NA SO16 6YD, United Kingdom.
An 81-year-old gentleman with idiopathic nonischemic dilated cardiomyopathy was admitted for endocardial and epicardial ablation of sustained ventricular tachycardia and fibrillation that had resulted in frequent recurrent implantable cardioverter-defibrillator shocks despite amiodarone therapy. Endocardial voltage mapping demonstrated an absence of endocardial scar and pace mapping suggested an epicardial exit for the poorly tolerated ventricular tachycardia.
Prior to subxiphoid puncture of the pericardium, anteroposterior fluoroscopy demonstrated an epigastric hollow viscous riding up superiorly. Lateral fluoroscopy confirmed a raised anterior diaphragmatic margin above a loop of transverse colon that was located immediately subjacent to the xiphisternum with obliteration of the Larrey space. The procedure was abandoned due to concern of accidental puncture of the bowel. (Figure 1, Online Video 1).
Epicardial access was achieved at a later date by complete surgical removal of the xiphisternum. This allowed safe and unrestricted access to the epicardial space by overriding the raised muscular diaphragm (Online Video 1). An Agilis sheath (St. Jude, Sylmar, California) was then inserted directly into the epicardial space and mapping and ablation performed.
The wound was closed surgically and an intravenous dose of 1,500 mg cefuroxime infused as prophylaxis against infection. At 3 months, the wound had healed well with no complications or discomfort and the patient was free of sustained ventricular tachycardia at 11-month follow-up.
A minimally invasive surgical approach to achieve epicardial access has been described in patients with pericardial adhesions from previous cardiac surgery; however, this approach still requires a direct route of access percutaneously without anatomical obstruction (1). A recent study highlighted that abdominal complications can occur as a result of epicardial access and our case potentially demonstrates a straightforward approach to both assess bowel location and the need for surgical intervention (2). We advocate the use of fluoroscopy in the lateral projection prior to pericardiocentesis and epicardial electrophysiological procedures to ensure a safe subxiphoid approach.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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- Received February 15, 2018.
- Accepted February 22, 2018.