From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN.
Circ Arrhythm Electrophysiol. 2015 Feb;8(1):94-101. doi: 10.1161/CIRCEP.114.002349. Epub 2015 Jan 9.
Prior cardiac surgery, especially the presence of coronary artery bypass grafts, is thought to preclude percutaneous epicardial access (EpiAcc) and, therefore, mapping and ablation. We evaluated the feasibility and safety of EpiAcc in patients with a prior cardiac operation.
We retrospectively analyzed all patients who underwent EpiAcc for ablation for ventricular tachycardia or symptomatic premature ventricular complexes between 2004 and 2013 at Mayo Clinic, Rochester, MN. Of 162 patients who underwent EpiAcc, 18 had prior cardiac surgery (median age, 64 years, all men). This included 10 coronary artery bypass grafts, 2 epicardial implantable cardioverter defibrillator placement, 5 valve surgery, 2 septal myectomy, 1 aortic arch replacement, 1 myocardial bridge unroofing, and 1 myocardial perforation repair (3 patients had multiple procedures). Access was successful in 12 of 18; the inferior approach was used in 78%. Successful access was achieved in 6 of 10 patients with prior coronary artery bypass grafts. Adhesiolysis was required in 10 patients with the sheath, access wire, and pigtail or ablation catheter. Intraprocedural coronary angiography was performed in 8 patients. A total of 45 ventricular tachycardias/premature ventricular complexes were ablated. Thirteen patients underwent endocardial-only ablation, 2 had epicardial-only ablation, whereas 3 had endocardial-epicardial ablation. Ablation was deemed successful in 13 of 18 patients. Four patients had bleeding complications (pericardial effusion, pericardial hematoma, hemoperitoneum, and pericardial tamponade). In patients with coronary grafts, there was no evidence of acute graft disruption.
Percutaneous EpiAcc is feasible in patients with previous cardiac surgery, including coronary artery bypass grafts. However, adhesiolysis is frequently required. Although the risk of coronary graft injury is low, life-threatening complications may occur.
先前的心脏手术，特别是冠状动脉旁路移植术的存在，被认为会妨碍经皮心外膜入路（EpiAcc）的建立，从而影响到标测和消融。我们评估了既往心脏手术患者行 EpiAcc 的可行性和安全性。
我们回顾性分析了 2004 年至 2013 年期间在明尼苏达州罗切斯特市 Mayo 诊所接受 EpiAcc 消融治疗室性心动过速或有症状的室性期前收缩的所有患者。在接受 EpiAcc 的 162 名患者中，有 18 名患者有既往心脏手术史（中位年龄 64 岁，均为男性）。其中包括 10 例冠状动脉旁路移植术、2 例心外膜植入式心律转复除颤器植入术、5 例瓣膜手术、2 例室间隔心肌切除术、1 例主动脉弓置换术、1 例心肌桥开窗术和 1 例心肌穿孔修复术（3 例患者接受了多种手术）。18 例患者中 12 例成功建立了 EpiAcc，其中 78%采用了下腔静脉入路。10 例既往接受冠状动脉旁路移植术的患者中有 6 例成功建立了 EpiAcc。在 10 例患者中，需要松解粘连以推进鞘管、导丝、猪尾导管或消融导管。8 例患者术中进行了冠状动脉造影。共消融了 45 次室性心动过速/室性期前收缩。13 例患者仅行心内膜消融，2 例患者仅行心外膜消融，3 例患者行心内膜-心外膜消融。18 例患者中有 13 例消融成功。4 例患者出现出血并发症（心包积液、心包积血、腹腔积血和心包填塞）。在接受冠状动脉旁路移植术的患者中，没有证据表明急性移植物破裂。
经皮心外膜入路（EpiAcc）在既往有心脏手术史的患者中是可行的，包括冠状动脉旁路移植术。然而，常常需要松解粘连。尽管冠状动脉旁路移植术损伤的风险较低，但可能会发生危及生命的并发症。
