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Romero J, Patel K, Lakkireddy D, Alviz I, Velasco A, Rodriguez D, Karpenos J, Zhang XD, Natale A, Di Biase L. Epicardial access complications during electrophysiology procedures. J Cardiovasc Electrophysiol 2021; 32:1985-1994. [PMID: 33993576 DOI: 10.1111/jce.15101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/12/2021] [Accepted: 04/14/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Percutaneous epicardial access (EA) was first described more than two decades ago. Since its initial introduction, indications for its utilization in the field of electrophysiology have expanded dramatically. DISCUSSION Epicardial mapping and ablation in patients with ventricular tachycardia is routinely performed in tertiary electrophysiology centers around the world. Although limited by lack of randomized controlled trials, epicardial ablation for atrial fibrillation has been suggested as a conjunctive strategy in patients who have failed an initial endocardial catheter ablation attempt, and it is necessary for placement of some left atrial appendage occlusion devices as well. An accurate understanding of the cardiac anatomy is crucial to avoid complications such as inadvertent right ventricular puncture, injury to the coronary arteries, abdominal viscera, phrenic nerves, and esophagus during both EA and catheter ablation. CONCLUSION The aim of this review is to provide a comprehensive overview of the cardiac anatomy, technical aspects to optimize the safety of epicardial puncture, recognize and avoid potential complications.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kavisha Patel
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.,Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA.,Kansas City Heart Rhythm Institute at HCA Midwest Health, Overland Park, Kansas, USA
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute at HCA Midwest Health, Overland Park, Kansas, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel Rodriguez
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.,Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA.,Kansas City Heart Rhythm Institute at HCA Midwest Health, Overland Park, Kansas, USA
| | - Joseph Karpenos
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Xiao-Dong Zhang
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Narasimhan B, Turagam MK, Garg J, Della Rocca DG, Gopinathannair R, Biase LD, Romero J, Mohanty S, Natale A, Lakkireddy D. Role of immunosuppressive therapy in the management refractory postprocedural pericarditis. J Cardiovasc Electrophysiol 2021; 32:2165-2170. [PMID: 33942420 DOI: 10.1111/jce.15069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/26/2021] [Accepted: 04/17/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of a novel immunosuppressive regimen-combination Methotrexate/Prednisone (cMtx/P)-in the management of severe refractory rPPP. METHODS In this multicenter, nonrandomized, retrospective, observational study, 408 consecutive patients diagnosed with persistent rPPP between 2017 and 19 were included. Patients with refractory symptoms despite 3 months of conventional therapy were initiated on a 4-week regimen of oral steroids. Persistence of symptoms at this point, that is, rPPP (n = 25; catheter based = 18, open surgical = 7) prompted therapy with Methotrexate (7.5-15 mg weekly) with folate supplementation along with low dose prednisone (5 mg PO) for a further 3 months. Patients were followed for a total of 11.3 ± 1.8 months. RESULTS Treatment refractory rPPP occurred in 6.1% of the study population prompting immunosuppressive therapy with cMtx/P. All patients demonstrated complete symptom resolution following 3 months of treatment with an 85% decline in clinically significant pericardial effusions. One patient developed recurrent pericarditis during the 11-month follow-up. Therapy was well tolerated with no significant drug related adverse effects. CONCLUSION cMtx/P therapy is a safe and effective adjunct in the management of rPPP refractory to standard therapy.
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Affiliation(s)
- Bharat Narasimhan
- St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohit K Turagam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jalaj Garg
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | | | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
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Killu AM, Asirvatham SJ. Percutaneous pericardial access for electrophysiological studies in patients with prior cardiac surgery: approach and understanding the risks. Expert Rev Cardiovasc Ther 2018; 17:143-150. [DOI: 10.1080/14779072.2019.1561276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Ammar M. Killu
- Department of Cardiovascular Disease, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Samuel J. Asirvatham
- Department of Cardiovascular Disease, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
- Department of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
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Killu AM, Sugrue A, Munger TM, Hodge DO, Mulpuru SK, McLeod CJ, Packer DL, Asirvatham SJ, Friedman PA. Impact of sedation vs. general anaesthesia on percutaneous epicardial access safety and procedural outcomes. Europace 2018; 20:329-336. [PMID: 28339558 DOI: 10.1093/europace/euw313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 09/06/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Patient movement while under moderate/deep sedation may complicate percutaneous epicardial access (EpiAcc), mapping and ablation. We sought to compare procedural outcomes in patients undergoing EpiAcc under sedation vs. general anaesthesia (GA) for ablation. Methods and results Patients undergoing EpiAcc between January 2004 and July 2014 were included. Safety, procedural, and clinical outcomes were compared between patients undergoing EpiAcc under sedation or GA for ventricular tachycardia or premature ventricular complex ablation. Between January 2004 and July 2014, 170 patients underwent EpiAcc (mean age, 53.2 ± 15.8 years; average ejection fraction, 44.3 ± 15.3%). The majority (122 [72%] patients) were male. GA was used in 69 (40.6%). There was no difference in route of access (more often anterior, 53.0%) or the rate of successful access (96% overall) between groups. Similarly, the site of ablation (endocardial vs. epicardial vs. combined endocardial/epicardial) was similar between groups. Complications were equally seen between groups-the most frequent event/complication was pericardial effusion, occurring in 10.6% of patients. Finally, procedural and clinical success rates between GA and sedation groups were comparable (93 vs. 91% and 44 vs. 51%, respectively, P > 0.05). Conclusions Choice of anaesthesia for EpiAcc does not appear to significantly affect safety and procedural or clinical outcomes. For patients in whom anaesthesia may pose increased risk, it is reasonable to obtain epicardial access under sedation.
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Affiliation(s)
- Ammar M Killu
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Alan Sugrue
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Thomas M Munger
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Siva K Mulpuru
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Christopher J McLeod
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Douglas L Packer
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul A Friedman
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Case Report and Review of Management of Penetrating Trauma and Cardiac Pericarditis. J Trauma Nurs 2017; 24:174-181. [PMID: 28486324 DOI: 10.1097/jtn.0000000000000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute pericarditis is the most common form of pericardial disease worldwide and it has many potential etiologies. This case study examines a patient admitted for multiple gunshot wounds who developed acute pericarditis postpericardial drain removal. The initial penetrating abdominal trauma, along with facial injuries and a suspected myocardial infarction, led to confusion in which the initial etiology of pericarditis was missed, creating a delay in overall patient care and extended length of stay.
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Strategies for phrenic nerve preservation during ablation of inappropriate sinus tachycardia. Heart Rhythm 2016; 13:1238-1245. [PMID: 26804567 DOI: 10.1016/j.hrthm.2016.01.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Radiofrequency (RF) ablation can alleviate drug-refractory inappropriate sinus tachycardia (IST). However, phrenic nerve (PN) injury and other complications limit its use. OBJECTIVE The purpose of this study was to characterize the maneuvers used to avoid PN injury and the long-term clinical outcomes. METHODS The study consisted of a retrospective analysis of consecutive patients who underwent ablation for IST. RESULTS RF ablation was performed on 13 consecutive female patients with drug-refractory IST. Eleven patients exhibited PN capture at desired ablation sites. In 1 patient, PN capture was not continuous throughout the respiratory cycle and ventilation holding sufficed to avoid PN injury. In 10 patients, pericardial access (PA) and balloon insertion was required. Initially (n = 4) a posterior PA was used, which was replaced by an anterior PA in the subsequent 6 cases. PA to optimal balloon positioning time was significantly lower in anterior vs posterior PA (16.3 ± 6 minutes vs 58 ± 21.3 minutes, P = .01), as was fluoroscopy time (15.66 ± 16.72 min vs 35.9 ± 1.8 min, P = .03). RF ablation successfully reduced sinus rate to <90 bpm in 13 of 13 patients. Procedure times and total RF times were not significantly different in anterior vs posterior PA. Major complications occurred in 2 patients, including unremitting pericardial bleeding requiring open-chested repair in 1 patient and sinus pauses mandating pacemaker implantation in the other patient. Long-term symptom control after follow-up of 811 ± 42 days was successful in 84.6%. CONCLUSION Ventilation holding and/or pericardial balloon insertion are frequently warranted in IST ablation. Anterior PA appears to facilitate the procedure over posterior PA.
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