Cardiac Electrophysiology Program, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA.
J Cardiovasc Electrophysiol. 2012 Jul;23(7):744-9. doi: 10.1111/j.1540-8167.2011.02286.x. Epub 2012 Feb 21.
Epicardial mapping and ablation of ventricular tachycardia (VT) has been increasingly performed. Occasionally additional ablation is necessary, requiring repeat percutaneous access to the pericardial space.
We studied 30 consecutive patients who required a repeat epicardial procedure. We specifically examined the success and safety of repeat percutaneous pericardial access as well as the ability to map and ablate epicardial VT targets. Percutaneous pericardial access at a median of 110 days after the last procedure was successful in all 30 patients. Significant adhesions interfering with catheter mapping were encountered in 7 patients (23%); 6 had received intrapericardial triamcinolone acetate (IPTA) with prior procedures. Using blunt dissection with a deflected ablation catheter and a steerable sheath, adhesions were divided allowing for complete catheter mapping in 5 patients with areas of dense adherence compartmentalizing the pericardium in 1 patient and precluding ablation over previously targeted ablation site in the second. Targeted VT noninducibility was achieved in 27 (90%) patients including 7 patients with adhesions. No direct complications related to pericardial access or adhesions disruption occurred. One periprocedural death occurred from refractory cardiogenic shock in patient with LV ejection fraction of 10%. Another patient developed asymptomatic positive Haemophilus influenzae pericardial fluid cultures identified at second procedure, which was successfully treated.
Repeat access can be obtained after prior epicardial ablation. Adhesions from prior procedures may limit mapping, but can usually be disrupted mechanically and allow for ablation of recurrent VT. IPTA may not completely prevent adhesions.
心外膜标测和消融心室性心动过速（VT）的技术已经越来越成熟。偶尔需要额外的消融，这需要再次经皮进入心包腔。
我们研究了 30 例需要重复心外膜手术的连续患者。我们专门研究了重复经皮心包腔穿刺的成功率和安全性，以及在心外膜标测和消融 VT 靶点方面的能力。在最后一次手术 110 天后，所有 30 例患者均成功进行了经皮心包穿刺。7 例（23%）患者存在影响导管标测的明显粘连，其中 6 例患者既往在心包腔内注射过曲安奈德（IPTA）。使用偏转消融导管和可转向护套钝性分离，可使 5 例患者的粘连松解，使心包完全可进行导管标测，而 1 例患者因心包致密粘连将心包分隔，第 2 例患者因先前的消融部位存在粘连而无法进行消融。27 例（90%）患者达到了 VT 靶点的非诱发性，其中 7 例患者存在粘连。心包介入或粘连松解无直接并发症发生。1 例患者因 LV 射血分数为 10%的难治性心源性休克而在围手术期死亡。另 1 例患者在第二次手术时发现无症状的流感嗜血杆菌心包液培养阳性，经成功治疗。
在先前的心外膜消融后可以再次进行心外膜穿刺。既往手术引起的粘连可能会限制标测，但通常可以通过机械方法破坏粘连，并允许消融复发性 VT。IPTA 可能不能完全预防粘连。
