Accessory Atrioventricular Pathways Refractory to Catheter Ablation Role of Percutaneous Epicardial Approach

作者：Scanavacca Mauricio Ibrahim^*; Sternick Eduardo Back; Pisani Cristiano; Lara Sissy; Hardy Carina; d'Avila Andre; Correa Frederico Soares; Darrieux Francisco; Hachul Denise; Marcial Miguel Barbero; Sosa Eduardo A

来源：Circulation-Arrhythmia and Electrophysiology, 2015, 8(1): 128-U196.

DOI：10.1161/CIRCEP.114.002373

• arrhythmias, cardiac
• cardiac surgical procedures
• catheter ablation
• electrophysiology
• epicardial mapping
• Wolff-Parkinson-White syndrome

Background-Epicardial mapping and ablation of accessory pathways through a subxiphoid approach can be an alternative when endocardial or epicardial transvenous mapping has failed.
Methods and Results-We reviewed acute and long-term follow-up of 21 patients (14 males) referred for percutaneous epicardial accessory pathway ablation. There was a median of 2 previous failed procedures. All patients were highly symptomatic, 8 had atrial fibrillation (3 with cardiac arrest) and 13 had frequent symptomatic episodes of atrioventricular reentrant tachycardia. Six patients (28.5%) had a successful epicardial ablation. Five patients (23.8%) underwent a successful repeated endocardial mapping, and ablation after epicardial mapping yielded no early activation site. Epicardial mapping was helpful in guiding endocardial ablation in 2 patients (9.5%), showing that the earliest activation was simultaneous at the epicardium and endocardium. Four patients (19%) underwent successful open-chest surgery after failing epicardial/endocardial ablation. Two patients (9.5%) remained controlled under antiarrhythmic drugs after unsuccessful endocardial/epicardial ablation. Two patients had a coronary sinus diverticulum and one a right atrium to right ventricle diverticulum. Three patients acquired postablation coronary sinus stenosis. There was no major complication related to pericardial access.
Conclusions-Percutaneous epicardial approach is an alternative when conventional endocardial or transvenous epicardial ablation fails in the elimination of the accessory pathway. A new attempt by endocardial approach was successful in a significant number of patients. Open-chest surgery may be required in symptomatic cases refractory to endocardial-epicardial approach.

• 出版日期2015-2