Department of Electrophysiology, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK.
Europace. 2013 Feb;15(2):284-9. doi: 10.1093/europace/eus258. Epub 2012 Sep 21.
In patients undergoing epicardial catheter ablation of ventricular tachycardia (VT), current guidelines recommend obtaining pericardial access prior to heparinization to minimize bleeding complications. Consequently, access is obtained before endocardial mapping (leading to unnecessary punctures) or during an additional procedure. We present our experience of obtaining pericardial access during the index procedure in heparinized patients.
Patients undergoing catheter ablation of VT in whom pericardial access was performed after heparinization were included. Clinical and procedural data and complications were recorded. Electrocardiograms (ECGs) were analysed for published criteria suggesting an epicardial ablation target and compared with patients (matched for substrate) undergoing successful endocardial ablation. Seventeen patients (13 males, age 58 ± 16 years, 8 (47%) ischaemic) were evaluated. Pericardial access was achieved in 16 (94%), including 2 patients with prior epicardial ablation. The mean activated clotting time was 273 ± 36 s. No bleeding complications occurred. In three patients, inadvertent puncture of the right ventricle caused no adverse consequences. An epicardial ablation target was found in nine of which three (33%) had ECG criteria, suggesting an epicardial circuit. In comparison 5 of 17 patients undergoing successful endocardial ablation had at least one ECG criterion suggesting an epicardial ablation target.
Obtaining pericardial access for epicardial catheter ablation for VT appears to be safe in heparinized patients. Electrocardiogram criteria suggesting an epicardial ablation target lack the sensitivity and specificity accurately to predict which patients might need epicardial ablation. Performing pericardial access in heparinized patients therefore may reduce unnecessary punctures and reduce the number of additional procedures in some patients.
在接受心外膜导管消融治疗室性心动过速（VT）的患者中，目前的指南建议在肝素化之前获得心包腔入路，以最大程度地减少出血并发症。因此，入路是在心内膜标测之前（导致不必要的穿刺）或在附加程序期间获得的。我们介绍了在肝素化患者中在行索引程序时获得心包腔入路的经验。
纳入了在肝素化后进行心包腔穿刺的接受 VT 导管消融治疗的患者。记录了临床和程序数据以及并发症。分析心电图（ECG）以确定是否存在提示心外膜消融靶点的发表标准，并与接受成功的心内膜消融的患者（匹配基质）进行比较。共评估了 17 例患者（13 例男性，年龄 58±16 岁，8 例（47%）为缺血性）。16 例（94%）患者获得了心包腔入路，其中 2 例患者曾进行过心外膜消融。平均激活凝血时间为 273±36 秒。无出血并发症发生。在 3 例患者中，右心室的无意穿刺没有造成不良后果。在 9 例患者中发现了心外膜消融靶点，其中 3 例（33%）有心电图标准，提示有心外膜环。相比之下，17 例接受成功的心内膜消融的患者中有 5 例至少有 1 个心电图标准提示需要心外膜消融靶点。
在心包内肝素化患者中进行心包腔穿刺以进行 VT 的心外膜导管消融似乎是安全的。提示心外膜消融靶点的心电图标准缺乏敏感性和特异性，无法准确预测哪些患者可能需要心外膜消融。因此，在肝素化患者中进行心包腔入路可能会减少不必要的穿刺，并在某些患者中减少附加程序的数量。
