Epicardial Interventions in Electrophysiology, An Issue of Cardiac Electrophysiology Clinics , livre ebook

Cardiac Electrophysiology Clinics
Epicardial Interventions in Electrophysiology
Kalyanam Shivkumar, MD, PhD, FHRS
UCLA Cardiac Arrhythmia Center & EP Programs, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, A2-237 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
Noel G. Boyle, MD, PhD, FHRS
Cardiac Electrophysiology Labs, UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, A2-237 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
CONSULTING EDITORS Ranjan K. Thakur, MD, MPH, FHRS Andrea Natale, MD, FACC, FHRS
ISSN  1877-9182
Volume 2 • Number 1 • March 2010

Contents
Cover
Forthcoming Issues
Foreword
Preface
Anatomy of the Pericardial Space and Mediastinum: Relevance to Epicardial Mapping and Ablation
The Pericardial Space: Obtaining Access and an Approach to Fluoroscopic Anatomy
Electrocardiographic Recognition of Epicardial Arrhythmias
How to Learn Epicardial Intervention Techniques in Electrophysiology
Energy Sources for Ablation in the Pericardial Space
Epicardial Ablation of Ventricular Tachycardia in Chagas Heart Disease
Epicardial Ablation of Ischemic Ventricular Tachycardia
Epicardial Ablation of Idiopathic Ventricular Tachycardia
Epicardial Ablation of VT in Patients with Nonischemic LV Cardiomyopathy
Epicardial Ablation of Supraventricular Tachycardia
Epicardial Catheter Ablation of Atrial Fibrillation
Remote Navigation and Electroanatomic Mapping in the Pericardial Space
Recognition and Prevention of Complications During Epicardial Ablation
Future Developments in Nonsurgical Epicardial Therapies
Index
Cardiac Electrophysiology Clinics , Vol. 2, No. 1, March 2010
ISSN: 1877-9182
doi: 10.1016/S1877-9182(09)00061-6

Forthcoming Issues
Cardiac Electrophysiology Clinics , Vol. 2, No. 1, March 2010
ISSN: 1877-9182
doi: 10.1016/j.ccep.2009.11.015

Foreword

Ranjan K. Thakur, MD, MPH, FHRS
Thoracic and Cardiovascular Institute, 405 West Greenlawn, Suite 400, Michigan State University, Lansing, MI 48910, USA
E-mail address: Thakur@msu.edu
E-mail address: Andrea.natale@stdavids.com

Andrea Natale, MD, FACC, FHRS ,
Texas Cardiac Arrhythmia Institute, Center for Atrial Fibrillation at St David’s Medical Center, 1015 East 32nd Street, Suite 516, Austin, TX 78705, USA
E-mail address: Thakur@msu.edu
E-mail address: Andrea.natale@stdavids.com
Ranjan K. Thakur, MD, MPH, FHRS Consulting Editor

Andrea Natale, MD, FACC, FHRS Consulting Editor

We are pleased to introduce the second issue of Cardiac Electrophysiology Clinics . This publication was launched with the idea of providing comprehensive reviews on topics of interest to the clinical electrophysiology community. We set out to recruit eminent electrophysiologists who have expertise on a particular topic and have them assemble a table of contents and suitable contributors from all over the world to illuminate the issue at hand.
We are delighted that Dr Shivkumar and Dr Boyle have tackled epicardial interventions, which is becoming an ever more important approach for electrophysiologic interventions. They have done exactly what we had hoped for.
Most practicing electrophysiologists do not perform epicardial interventions because “the pericardial space has long evoked a sense of trepidation.” The situation is not unlike transseptal catheterization a decade ago. When ablation for atrial fibrillation came along, electrophysiologists learned to perform transseptal puncture, and tools were developed subsequently (eg, intracardiac echocardiograpy, radiofrequency needle) so that we could do it safely, minimizing complications. The same will occur with pericardial access and interventions. As Dr Mittal has outlined in his article, this is a technique that can be learned and one can “get on the curve.”
Catheter ablation for ventricular tachycardia has had limited success. In the last 5 years we have learned, however, that a significant number of these patients have epicardial circuits, and thus the success rate of catheter ablation can be enhanced by epicardial mapping and ablation. Epicardial access may also prove useful in the future if left ventricular epicardial pacing (to achieve biventricular pacing) can be achieved without a thoracotomy.
We have enjoyed reading the reviews and learning from our colleagues. We are convinced that the readership will find this issue educational and feel sanguine that any interventional electrophysiologist can master this technique.
Cardiac Electrophysiology Clinics , Vol. 2, No. 1, March 2010
ISSN: 1877-9182
doi: 10.1016/j.ccep.2009.12.001

Preface

Kalyanam Shivkumar, MD, PhD, FHRS
UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, A2-237 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095
E-mail address: kshivkumar@mednet.ucla.edu
E-mail address: nboyle@mednet.ucla.edu

Noel G. Boyle, MD, PhD, FHRS ,
UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, A2-237 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095
E-mail address: kshivkumar@mednet.ucla.edu
E-mail address: nboyle@mednet.ucla.edu
Kalyanam Shivkumar, MD, PhD, FHRS Guest Editor

Noel G. Boyle, MD, PhD, FHRS Guest Editor

The pericardial space has long evoked a sense of trepidation for many cardiologists. Commonly associated with the pathologic pericardial effusion, it was rarely approached except when necessary to drain a chronic pericardial effusion or in the emergent setting of tamponade. The pioneering work of Sosa and colleagues, first reported in 1996 and described in the article by Drs Scanavacca and Sosa, opened up this new frontier to interventional cardiac electrophysiology and ablation.
This issue of Cardiac Electrophysiology Clinics focuses on the pericardial space, presents reviews from many leaders in the field of clinical cardiac electrophysiology, and outlines the latest advances in this area. Drs Ernst and Ho first present the anatomy of the pericardial space with its rediscovery in the setting of epicardial mapping and ablation, and Drs Syed, Asirvatham, and colleagues describe how a better understanding of the anatomy of the pericardial space and of radiology makes for safer access to pericardial space.
Drs Michowitz and Belhassen describe the electrocardiogram (EKG) recognition of epicardial arrhythmias, an important step in patient selection for the epicardial approach. Drs Garikipati, Paruchuri, and Mittal discuss how to learn the technique and how to set up a program for epicardial ablation. Drs Ghia and Haines provide a comprehensive description of the energy sources available for ablation with the epicardial approach.
Drs Scanavacca and Sosa describe their pioneering work in the field with the development of epicardial ventricular tachycardia (VT) ablation for the problem of VT in Chagas disease patients. Drs Tedrow and Stevenson discuss the epicardial ablation of scar-related VT, Drs Green and Wilber describe the method applied to idiopathic VT patients, and Drs Hutchinson and Marchlinski review the role of epicardial ablation in the setting of nonischemic cardiomyopathy–related VT. Dr Schweikert describes the application of the epicardial approach to supraventricular tachycardias, and Drs Buch, Nakahara and colleagues describe the potential for epicardial ablation of atrial fibrillation and important methods for protecting collateral structures.
The application of advances in remote navigation to epicardial ablation is discussed by Drs Burkhardt, Natale and associates, while Drs Yamada and Kay examine the important issue of procedure-related complications and how to prevent them. Drs Stanton, Friedman and coworkers conclude with a look at future prospects in the field.
The next decade will likely see major advances in the epicardial approach and wider use of the technique in ways analogous to how the first endocardial ablation procedure led to a revolution in the treatment of cardiac arrhythmias. These advances will come together with a new appreciation for the anatomy and physiology of the pericardial space and the development of new tools and therapeutics to make this procedure simpler and safer.
Cardiac Electrophysiology Clinics , Vol. 2, No. 1, March 2010
ISSN: 1877-9182
doi: 10.1016/j.ccep.2009.11.003

Anatomy of the Pericardial Space and Mediastinum: Relevance to Epicardial Mapping and Ablation

Sabine Ernst, MD, FESC a , b , Damian Sanchez-Quintana, MD, PhD c , Siew Yen Ho, PhD, FRCPath d , e , *
a Cardiology Department, Royal Brompton and Harefield Hospital, Sydney Street, London SW3 6NP, UK
b National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK
c Departamento de Anatomía Humana, Facultad de Medicina, University of Extremadura, UEX, E-06071 Badajoz, Spain
d Cardiac Morphology Unit, Imperial College London, London SW3 6LY, UK
e Cardiac Morphology Unit, Royal Brompton and Harefield Hospital, Sydney Street, London SW3 6NP, UK
* Corresponding author. Cardiac Morphology Unit, Royal Brompton and Harefield Hospital, Sydney Street, London SW3 6NP, UK.
E-mail address: yen.ho@imperial.ac.uk

Abstract
The pericardial space is a fairly new portal for interventional cardiac electrophysiologists to access the heart and requires an understanding of its anatomic peculiarities to maneuver safely around the ep