Percutaneous Epicardial Interventions: A Guide for Cardiac Electrophysiologists

Cover
Title Page
Copyright
Dedication
Contents
Foreword
Preface
Contributors
Abbreviations
Video Legends
Chapter 1: Epicardial Interventions in Electrophysiology: Historical Perspectives
	INTRODUCTION
	ARRHYTHMIA INTERVENTIONS AND RF ABLATION: THE EARLY YEARS
	THE CHAGAS DISEASE CHALLENGE
	DEVELOPING THE NONSURGICAL EPICARDIALMAPPING TECHNIQUES
	EXPANDING THE PROCEDURE
	REFERENCES
Chapter 2: Epicardial Anatomy
	INTRODUCTION
	PERICARDIAL SAC
	PERICARDIAL SINUSES
	PERICARDIAL RECESSES
	PERICARDIAL AND EPICARDIAL FAT
	PERICARDIAL NERVE SUPPLY
	PERICARDIAL ANOMALIES
	CONCLUSION
	REFERENCES
Chapter 3: Inferior and Anterior Approaches Using a Tuohy Needle
	INTRODUCTION
	ACCESSING THE PERICARDIUM
	SUBXIPHOID APPROACH
	INFERIOR PUNCTURE
	ANTERIOR PUNCTURE
	CONCLUSION
	REFERENCES
Chapter 4: Micropuncture Needle for Epicardial Access
	INTRODUCTION
	RATIONALE FOR MICROPUNCTURE ACCESS
	TECHNIQUE OF NEEDLE-IN-NEEDLE MICROPUNCTURE EPICARDIAL ACCESS
	OUTCOMES OF THE NEEDLE-IN-NEEDLE APPROACH
	FUTURE DIRECTIONS
	REFERENCES
Chapter 5: Pressure Sensor Needle for Epicardial Access
	INTRODUCTION
	NEEDLE DESCRIPTION
	CLINICAL DATA: EFFICACY AND SAFETY
	REFERENCES
Chapter 6: Different Fluoroscopic Approaches for Epicardial Access
	INTRODUCTION
	FLUOROSCOPIC ASSESSMENT AND COMPLICATIONS
	FLUOROSCOPIC SETTINGS
	FLUOROSCOPIC ANGLES
	EPICARDIAL ACCESS IN OUR INSTITUTION
	CONCLUSION
	REFERENCES
Chapter 7: Epicardial Access for Left Atrial Appendage Occlusion: Techniques and Challenges
	INTRODUCTION
	ANATOMICAL CONSIDERATIONS ANDPREPROCEDURAL PLANNING
	PERICARDIAL ACCESS TECHNIQUE
	POTENTIAL CHALLENGES
	POTENTIAL COMPLICATIONS
	PREVENTION OF COMPLICATIONS
	CONCLUSION
	REFERENCES
Chapter 8: Epicardial Access in Anticoagulated Patients
	INTRODUCTION
	EPICARDIAL ACCESS ON ANTICOAGULATION
	CONCLUSION
	REFERENCES
Chapter 9: Epicardial Ablation After Prior Open-Chest Surgery or Percutaneous Epicardial Procedures
	INTRODUCTION
	LIMITED EPICARDIAL MAPPING FROM THE CORONARY VENOUS SYSTEM
	PERCUTANEOUS ACCESS WITH LIMITED EPICARDIAL MAPPING
	MICROPUNCTURE ACCESS
	PREPROCEDURAL IMAGING
	COMPLICATIONS
	CONCLUSION
	REFERENCES
Chapter 10: Surgical Window for Epicardial Ablation
	INTRODUCTION
	PREPROCEDURAL PLANNING
	CREATION OF THE SURGICAL WINDOW
	KEY CONSIDERATIONS FOR EPICARDIAL ABLATION USING A SURGICAL WINDOW
	COMPLICATIONS
	CONCLUSION
	REFERENCES
Chapter 11: Totally Endoscopic Robotic Epicardial Surgical Ablation (TERESA) Procedure to Treat Arrhythmias from the Left Ventriular Summit
	INTRODUCTION
	RATIONALE
	PRIOR SURGICAL APPROACHES
	SURGICAL SETUP
	MAPPING AND ABLATION
	POSTPROCEDURAL MANAGEMENT
	CONCLUSION
	REFERENCES
Chapter 12: Beyond Ablation: Other Potential Roles for Epicardial Access
	INTRODUCTION
	PERICARDIOSCOPY TO ENHANCE ARRHYTHMIAMANAGEMENT
	INTRAPERICARDIAL DRUG DELIVERY
	STRUCTURAL INTERVENTIONS
	AUTONOMIC INTERVENTIONS
	EPICARDIAL LEAD PLACEMENT
	CONCLUSION
	REFERENCES
Chapter 13: Effect of Fat on Electrogram Interpretation
	INTRODUCTION
	EPICARDIAL FAT
	DIFFERENTIATING FAT FROM SCAR
	EFFECT ON ABLATION OUTCOMES
	CONCLUSION
	REFERENCES
Chapter 14: Magnetic Resonance Imaging: Role and Limitations
	INTRODUCTION
	CARDIAC MAGNETIC RESONANCE METHODS
	SPECTRUM OF CARDIAC MRI FINDINGS IN PATIENTS WITH SUBEPICARDIAL SCARS
	CARDIAC MRI FOR THE PLANNING AND GUIDANCE OF EPICARDIAL ABLATION PROCEDURES
	CHALLENGES OF AN EPICARDIAL ACCESS
	CARDIAC MRI-BASED SUBSTRATE MAPPING TO GUIDE ABLATION PROCEDURES
	CARDIAC MRI LIMITATIONS
	CONCLUSION
	REFERENCES
Chapter 15: Intracardiac Echocardiography: Identification of Substrate and Role in Ablation
	INTRODUCTION
	AVAILABLE ICE SYSTEMS
	STANDARD ECHOCARDIOGRAPHIC VIEWS
	GUIDANCE OF PERCUTANEOUS EPICARDIAL ACCESS
	USE OF ICE FOR IDENTIFICATION OF EPICARDIAL SUBSTRATE
	MONITORING OF CATHETER POSITION AND LESION FORMATION
	INTEGRATION WITH ELECTROANATOMIC MAPPING SYSTEMS
	DETECTION AND PREVENTION OF COMPLICATIONS
	REFERENCES
Chapter 16: Unipolar Identification of Scar: The Basics
	INTRODUCTION
	ENDOCARDIAL UNIPOLAR MAPPING TO  IDENTIFY THE EPICARDIAL VT ANATOMIC SUBSTRATE
	CONCLUSIONS
	REFERENCES
Chapter 17: Effect of Transmural Scar & Hypertrophy on Identifying Epicardial Substrate with Unipolar Endocardial Recording
	INTRODUCTION
	TYPES OF SCAR: PRESENCE, EXTENT, AND TRANSMURALITY
	DIAGNOSTIC UTILITY OF UNIPOLAR VOLTAGE MAPPING
	PROGNOSTIC UTILITY OF UNIPOLAR VOLTAGE MAPPING
	EFFECT OF HYPERTROPHY ON UNIPOLAR VOLTAGES
	UNIPOLAR ELECTROGRAMS AND INTRAMURAL SEPTAL SUBSTRATE MAPPING
	CONCLUSION
	REFERENCES
Chapter 18: Compartmentalization of the Endocardium Versus the Epicardium
	INTRODUCTION
	POTENTIAL FOR EPICARDIAL COMPARTMENTALIZATION DURING SCAR-RELATED VT
	NORMAL EPICARDIAL ACTIVATION SEQUENCE RELATIVE TO ENDOCARDIUM
	POTENTIAL FOR COMPARTMENTALIZED EPICARDIAL SINUS RHYTHM ACTIVATION
	IMPLICATIONS FOR EPICARDIAL VT IN ARVC
	FUTURE DIRECTIONS
	CONCLUSIONS
	REFERENCES
Chapter 19: Electrocardiographic Criteria to Identify Epicardial Idiopathic Ventricular Tachycardia
	INTRODUCTION
	VENTRICULAR TACHYCARDIA LOCALIZING CLUES
	THE LEFT VENTRICULAR SUMMIT
	CARDIAC CRUX
	CONCLUSION
	REFERENCES
Chapter 20: Nonischemic Ventricular Tachycardia
	INTRODUCTION
	ECG CRITERIA SUGGESTING AN EPICARDIAL VT ORIGIN IN LV NONISCHEMIC CARDIOMYOPATHY
	ECG CRITERIA SUGGESTING AN EPICARDIAL VT ORIGIN IN RV CARDIOMYOPATHY
	PROSPECTIVE VALIDATION OF INTERVAL AND MORPHOLOGICAL CRITERIA
	CONCLUSION
	REFERENCES
Chapter 21: Ischemic Ventricular Tachycardia: Limitations of the Electrocardiogram
	INTRODUCTION
	RELATION BETWEEN EXITS AND REENTRY CIRCUITS IN INFARCT-RELATED VT
	ECG CANNOT ALWAYS DISTINGUISH EPICARDIAL FROM ENDOCARDIAL VTS
	UTILITY OF ECG
	CONCLUSION
	REFERENCES
Chapter 22: Sinus Rhythm Clues to Presence of Epicardial Substrate
	INTRODUCTION
	CONCLUSION
	REFERENCES
Chapter 23: Depolarization Abnormalities in Arrhythmogenic Right Ventricular Cardiomyopathy
	INTRODUCTION
	PATHOPHYSIOLOGY OF DEPOLARIZATION CHANGES IN ARVC
	DEPOLARIZATION ABNORMALITIES IN ARVC
	DEPOLARIZATION ABNORMALITIES AND RISK STRATIFICATION IN ARVC
	CONCLUSION
	REFERENCES
Chapter 24: Endocardial and Epicardial Anatomic Correlates of Repolarization Abnormalities in Arrhythmogenic Right Ventricular Dysplasia
	INTRODUCTION
	SURFACE ECG REPOLARIZATION ABNORMALITIES AND ELECTROANATOMIC SUBSTRATE
	ANALYSIS OF VENTRICULAR REPOLARIZATIONUSING DIRECT UNIPOLAR ENDOCARDIAL AND EPICARDIAL RECORDINGS
	REFERENCES
Chapter 25: Endocardial and Epicardial Anatomic Correlates of Electrocardiographic Depolarization Abnormalities in Nonischemic Cardiomyopathy
	INTRODUCTION
	COMMON ECG FINDINGS IN NONISCHEMIC DILATED CARDIOMYOPATHY
	ECG CORRELATES OF ELECTROANATOMIC ABNORMALITIES
	CONCLUSION
	REFERENCES
Chapter 26: Epicardial Anatomic Correlates of Electrocardiographic Abnormalities in Brugada Syndrome
	INTRODUCTION
	BRUGADA SYNDROME HISTORICAL PRECEDENTS
	THE DISCOVERY OF THE BRUGADA SUBSTRATE
	EPICARDIAL BRUGADA SUBSTRATE DRIVING ELECTROMECHANICAL CHANGES
	A NOVEL 3D MULTIMODALITY APPROACH
	ELECTROANATOMIC MAPPING
	RV MECHANICAL IMAGING
	AJMALINE PROVOCATION TO UNMASK EPICARDIAL BRUGADA SUBSTRATES
	EPICARDIAL ABLATION OF BRUGADA SUBSTRATE
	THE ROLE OF BRUGADA SUBSTRATE IN PATHOPHYSIOLOGY AND OUTCOME OF BRS
	CONCLUSION
	REFERENCES
	VIDEO LEGENDS
Chapter 27: Multielectrode Epicardial Mapping
	INTRODUCTION
	HISTORICAL PERSPECTIVES
	SUGGESTED WORKFLOW
	REFERENCES
Chapter 28: Ablation of Epicardial Substrate and Ventricular Tachycardia Through Endocardial Ablation
	INTRODUCTION
	ABLATION STRATEGY
	RESULTS OF EPI-LAVA ELIMINATION THROUGH ENDOCARDIAL ABLATION
	UNDERLYING STRUCTURAL HEART DISEASE
	CONCLUSION
	REFERENCES
Chapter 29: Surgical Epicardial Ablation
	INTRODUCTION
	INDICATIONS FOR SURGICAL EPICARDIAL ABLATION
	MAPPING AND ABLATION IN THE OPERATING ROOM
	ABLATION ENERGY SOURCES FOR SURGICAL ABLATION
	ENDPOINTS OF SURGICAL ABLATION
	SURGICAL VT ABLATION FOR NONISCHEMIC CARDIOMYOPATHY: THE PENN EXPERIENCE
	CONCLUSION
	REFERENCES
	VIDEO LEGENDS
Chapter 30: Epicardial Ablation of Sustained Ventricular Tachycardia in Patients with Chagas Heart Disease
	INTRODUCTION
	CARDIAC ARRHYTHMIAS AND SUDDEN DEATH IN CHRONIC CHAGAS HEART DISEASE
	IMAGING IN CHAGAS DISEASE
	TREATMENT OF VENTRICULAR TACHYCARDIA IN PATIENTS WITH CHAGAS HEART DISEASE
	RESULTS OF CHAGAS VT ABLATION
	REFERENCES
Chapter 31: Epicardial Ventricular Tachycardia Mapping and Ablation in Arrhythmogenic Right Ventricular Cardiomyopathy
	INTRODUCTION
	PATIENT SELECTION
	PROCEDURAL APPROACH: ENDOCARDIAL MAPPING AND ABLATION
	PROCEDURAL APPROACH: EPICARDIAL MAPPING AND ABLATION
	PROCEDURAL ENDPOINTS
	DISEASE PROGRESSION
	CONCLUSION
	REFERENCES
Chapter 32: Do We Need Epicardial Ablation in All Patients with Arrhythmogenic Right Ventricular Cardiomyopathy?
	INTRODUCTION
	ENDOCARDIAL ABLATION IN ARVC
	ENDOCARDIAL–EPICARDIAL ABLATION AFTER PREVIOUSLY FAILED ENDOCARDIAL PROCEDURE
	FIRST-LINE ENDOCARDIAL–EPICARDIAL ABLATION
	ENDOCARDIAL AND ADJUVANT EPICARDIAL SUBSTRATE ABLATION
	REFERENCES
Chapter 33: Hypertrophic Cardiomyopathy
	INTRODUCTION
	MECHANISMS OF VENTRICULAR ARRHYTHMIAS
	PREABLATION EVALUATION
	ABLATION PROCEDURE
	CLINICAL OUTCOMES
	POSTPROCEDURE MANAGEMENT
	CONCLUSION
	REFERENCES
Chapter 34: Ischemic Cardiomyopathy
	INTRODUCTION
	EPICARDIAL VT SUBSTRATE IN ISCHEMIC HEART DISEASE
	INDICATIONS TO EPICARDIAL APPROACH AND ABLATION: EVIDENCE FROM THE LITERATURE
	WHEN IS EPICARDIAL ABLATION REQUIRED? OUR EXPERIENCE
	SPECIFIC ISSUE OF EPICARDIAL ACCESS IN ISCHEMIC PATIENTS: PERFORMING EPICARDIAL APPROACH ON DUAL ANTIPLATELET THERAPY
	REFERENCES
Chapter 35: Sarcoidosis and Other Granulomatous Diseases
	INTRODUCTION
	CLINICAL AND ELECTROPHYSIOLOGIC CHARACTERISTICS OF VT IN GRANULOMATOUS MYOCARDITIS
	AUTHORS’ EXPERIENCE
	EPICARDIAL MAPPING AND ABLATION TECHNIQUE
	CONCLUSION
	REFERENCES
Chapter 36: Epicardial Catheter Ablation of Ventricular Tachycardia: A Meta-Analysis
	INTRODUCTION
	MATERIAL AND METHODS
	RESULTS
	DISCUSSION
	CONCLUSION
	REFERENCES
Chapter 37: Epicardial Mapping and Ablation of Premature Ventricular Complexes
	INTRODUCTION
	LEFT VENTRICULAR SUMMIT ANATOMY
	ELECTROCARDIOGRAPHIC CHARACTERISTICS
	MAPPING AND ABLATION
	CONCLUSION
	REFERENCES
Chapter 38: Percutaneous Catheter Ablation of Epicardial Accessory Pathways
	INTRODUCTION
	ACCESSORY PATHWAY ABLATION
	ENDOCARDIAL ABLATION
	INTRAVENOUS MAPPING AND ABLATION
	PERCUTANEOUS EPICARDIAL MAPPING AND ABLATION
	CLINICAL PERSPECTIVES
	REFERENCES
Chapter 39: Epicardial Fat
	INTRODUCTION
	EPICARDIAL FAT
	IMPACT ON EPICARDIAL ELECTROGRAM
	IMPACT ON IMPEDANCE
	IMPACT ON EPICARDIAL ABLATION
	NEURONAL MODULATION
	FAT NECROSIS
	CONCLUSION
	REFERENCES
Chapter 40: Impact of Irrigation Flow Rate and Intrapericardial Fluid
	INTRODUCTION
	IMPACT OF IRRIGATION FLOW RATES
	IMPACT OF IPF
	ALTERNATE IRRIGATION SOLUTIONS
	CONCLUSION
	REFERENCES
Chapter 41: Alternate Irrigation Solutions for Radiofrequency Ablation and Alternative Energy Sources
	INTRODUCTION
	STANDARD RF ABLATION EXTERNALLY COOLED WITH LOW-IONIC IRRIGANTS
	ALTERNATIVE ENERGY SOURCES FOR EPICARDIAL ABLATION
	CONCLUSION
	REFERENCES
Chapter 42: Risk Factors for Percutaneous Epicardial Access Complications and Strategies for Management
	INTRODUCTION
	RISK FACTORS FOR DAMAGE TO THE EXTRACARDIAC ORGANS
	RISK FACTORS FOR CARDIAC PUNCTURE AND TAMPONADE
	PRIOR CARDIAC SURGERY
	ADHESIONS DISCOVERED DURING PERCUTANEOUS EPICARDIAL ACCESS ATTEMPTS
	SURGICAL STRATEGIES WHEN PERCUTANEOUS EPICARDIAL ACCESS FAILS
	SUMMARY
	REFERENCES
	VIDEO LEGENDS
Chapter 43: Hemopericardium
	INTRODUCTION
	PREPROCEDURAL PLANNING AND EPICARDIAL ACCESS
	CLASSIFICATION OF HEMOPERICARDIUM
	MANAGEMENT OF HEMOPERICARDIUM
	CONCLUSION
	REFERENCES
Chapter 44: Intra-Abdominal Bleeding
	INTRODUCTION
	VASCULAR INJURY
	HEPATIC INJURY
	INTRA-ABDOMINAL BLEEDING
	MITIGATING RISK
	CONCLUSION
	REFERENCES
Chapter 45: Vascular and Phrenic Nerve Injury and Protection
	INTRODUCTION
	EPIDEMIOLOGY
	VASCULAR INJURY: PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS
	PHRENIC NERVE INJURY: PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS
	TECHNIQUES TO AVOID VASCULAR AND PHRENIC NERVE INJURY
	CONCLUSIONS
	REFERENCES
Chapter 46: Esophageal Injury: Recognition and Prevention
	INTRODUCTION
	PREVENTION METHODS
	CONCLUSION
	REFERENCES
Chapter 47: Unusual Complications
	INTRODUCTION
	VASCULAR INJURY
	MYOCARDIAL INJURY
	GUIDEWIRE DISLODGEMENT
	HEPATIC INJURY
	INTRA-ABDOMINAL HEMORRHAGE AND INJURY
	PHRENIC NERVE INJURY
	RIGHT VENTRICULAR PSEUDOANEURYSM
	CARDIO-ABDOMINAL FISTULA
	PLEURAL INJURY
	INCREASED DEFIBRILLATION THRESHOLD
	RECURRENT PERICARDITIS AND DELAYED PERICARDIAL EFFUSION
	CONSTRICTIVE PERICARDITIS
	CONCLUSION
	REFERENCES
Disclosures
Index