INTRODUCTION

The utility of subxiphoid epicardial access for catheter mapping and ablation of cardiac arrhythmias was not recognized until its introduction by Sosa et al.¹ over two decades ago, when these authors described its role in treating patients with Chagas-related ventricular tachycardia. Since then, the role for this technique has gradually expanded, and to date it has been utilized to guide epicardial left atrial appendage closure,² myocardial pacing,^3,4 drug delivery,^5,6 and protection of mediastinal collateral structures such as the esophagus and the phrenic nerve during catheter ablation.^7,8 However, this approach necessitates advancement of a needle percutaneously in juxtaposition to several extracardiac structures. While in general deemed safe, several studies have reported complication rates ranging between 5%–10%.^9–12 Postprocedure pericarditis and inadvertent right ventricular puncture represent the most common adverse events associated with this approach.¹³ However, other less frequent complications such as vascular, abdominal, pleural, and phrenic injuries can also ensure.^9–12 Among the uncommon adverse events, intra-abdominal bleeding remains particularly noteworthy as it has the potential to lead to major catastrophic sequelae. This complication may occur as a consequence of vascular injury (for instance, related to diaphragmatic vascular puncture) or organ injury (such as hepatic puncture). This chapter will provide an overview of various causes for intra-abdominal bleeding and ways to mitigate them.

VASCULAR INJURY

When attempting a percutaneous epicardial access, vascular injury may occur as a result of a puncture of (1) the diaphragmatic vessels, (2) the mediastinal vessels, or (3) the epicardial vessels. As discussed in earlier chapters, the diaphragm is a highly vascular organ, and therefore a diaphragmatic puncture during percutaneous epicardial access can result in significant bleeding complications. Such an event will typically only occur if an inferior (as opposed to an anterior) epicardial puncture approach has been undertaken.

During an epicardial puncture, the target is the space of Larrey, which is bounded by the sternum anteriorly, the pericardium posteriorly, and the dome of the diaphragm inferiorly (Figure 44.1). It is imperative that the needle be directed over, and never through, the diaphragm itself, irrespective of presence or absence of systemic anticoagulation. The diaphragm is a vascular organ that encompasses abundant veins and arteries. The aorta gives rise to the inferior phrenic arteries just below the aortic hiatus, which supplies the diaphragm and in turn gives rise to the suprarenal vessels to supply the adrenal glands.¹⁴ The arterial supply to the diaphragmatic costal margin is provided by the lower 5 intercostal and subcostal arteries, whereas the arterial supplies of the midportion of the diaphragm is provided by the phrenic arteries.¹⁵ These vessels anastomose to ensure ample blood supply to this structure. In addition, there are abundant veins within the diaphragm that follow their corresponding arteries along the inferior thoracic surface.¹⁴ As a result, a diaphragmatic puncture can sometimes lead to extensive hemorrhage within the abdominal cavity. Given the considerable size of this space, significant blood loss can sometimes occur intraprocedurally and go unnoticed, eventually culminating into hemodynamic collapse and compromise.

In rare instance, the liver may be punctured unintentionally during percutaneous epicardial access. Such a complication can solely occur during an inferior epicardial puncture, whereas as an anterior approach will typically evade both the diaphragm and the intra-abdominal organs. Though several different practices have been developed to avoid a diaphragmatic or intra-abdominal puncture, this dreadful complication can still occur in the setting of an inferior epicardial approach despite all efforts. Individuals with a smaller build and those with an enlarged or congested liver, such as patients with congestive heart failure, remain more vulnerable. There may be a wide range to the presentation of a hepatic puncture ranging from an intrahepatic subcapsular hematoma (Figure 44.2),¹⁶ to puncture of the left lobe of the liver (Figure 44.3),¹⁷ and even hepatic perforation (Figure 44.4) and/or laceration.¹⁶ As such, the clinical manifestations can vary accordingly. These may include epigastric pain,¹⁶ a mild-to-moderate drop in the hematocrit,^16,17 or profound bleeding, hypotension, and hemodynamic compromise requiring urgent laparotomy and surgical repair.^16,17 Consequently, this complication represents a significant and potentially life-threatening outcome that can be circumvented by taking the appropriate measures to avoid unintentional advancement of the epicardial access needle through the abdominal cavity as discussed in the previous chapters (such as validation of the needle’s path in the left lateral projection and performing the epicardial puncture in end-inspiration).

Figure 44.2 Intrahepatic subcapsular hematoma during epicardial puncture. Hepatic injury as a result of an unintended puncture during pericardial access may present as an intrahepatic subcapsular hematoma. Shown is a transverse view of an abdominal computed tomographic angiography scan showing a large heterogeneous lesion in the left lobe of the liver (red arrow), measuring 6 cm × 7 cm × 11 cm. The lesion had a thin layer surrounding it anteriorly and laterally, indenting the hepatic parenchyma posteriorly. The diagnosis of subcapsular hematoma was confirmed by ultrasonography. This was associated with a 4-unit drop in hemoglobin. Image was modified with permission from: Koruth et al., Circ Arrhythm Electrophysiol. 2011;4:882–888.

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