INTRODUCTION

Percutaneous epicardial puncture and access are increasingly utilized for mapping and ablation of certain cardiac arrhythmias, left atrial appendage closure, and, rarely, even myocardial pacing. This approach necessitates advancement of a needle through and in juxtaposition to several extracardiac structures. The two most commonly reported techniques utilized by cardiac electrophysiologists include the subxiphoid approach¹ and the anterior parasternal approach.² The anterior parasternal approach is designed to access the anterior region of the pericardium through the left intercostal space. However, this is a less frequently practiced method due a higher propensity for adverse events. Thus, the preferred and most frequently employed method is the subxiphoid technique as reported by Sosa et al.³ While generally deemed safe, various studies have reported a complication rate ranging between 5–10%.^4–7

It should be emphasized that the vast majority of epicardial complications are due to epicardial access itself. Along these lines, a history of cardiac surgery and/or presence of pericardial adhesions serve as important risk factors for epicardial complications. Thus, patient selection, careful planning, and detailed knowledge of the underlying anatomy are key to preventing them. While the most common adverse events associated with epicardial puncture, mapping, and ablation consist of inadvertent right ventricular puncture and postprocedure pericarditis, both of these are typically self-limiting and without major sequelae. Nonetheless, several rare and distinct complications not otherwise encountered during an endocardial procedure may exclusively occur in the context of an epicardial procedure. Some of them may even be catastrophic or life-threatening. In this chapter, we will review in detail a variety of rare and unusual adverse events that may ensue from percutaneous epicardial puncture and catheter mapping and ablation as well as means to mitigate them.

VASCULAR INJURY

During a percutaneous epicardial procedure vascular injury may involve (1) the phrenic vessels during an inferior epicardial puncture with the needle traversing through the diaphragm, (2) the mediastinal vessels, or (3) the epicardial vessel as a consequence of a direct puncture using the epicardial needle, poor catheter/sheath management or manipulation, or direct delivery of energy to the vessel during catheter ablation. As discussed in the previous chapters, the diaphragm is a highly vascular organ. As a result, diaphragmatic puncture during a percutaneous epicardial procedure could lead to significant bleeding complications. Hence, care should be taken to avoid advancement of the needle or an introducer through the diaphragm.

Rarely, bleeding may occur as a result of injury to the internal mammary artery. The internal mammary artery passes through the space of Larrey as it gives rise to the superior epigastric artery. It lies at the margins of the sternum, ~1 cm from the sternal edge. As such, a very anterior and lateral approach can result in the puncture of this vessel. Khan et al.⁸ reported on left internal mammary arterial injury using an anterior puncture approach in 2 patients referred for epicardial ventricular tachycardia ablation. While one patient was managed conservatively, the other required thoracotomy with urgent repair of the lacerated vessel.

In rare cases, inadvertent puncture and/or perforation of an epicardial vessel may occur during epicardial access. Although theoretically, injury to the bypass grafts can also occur in patients with a history of coronary artery bypass surgery, this has never been reported. However, a marginal artery is typically situated at the acute margin of the right ventricle, which may rarely continue along the diaphragmatic wall of the ventricle to give rise to a short posterior descending artery. In cases of right ventricular dilatation, this marginal artery may be at increased risk of puncture when attempting to gain epicardial access. Such a complication typically manifests as persistent, unremitting intrapericardial bleeding. The diagnosis may be difficult and it sometimes requires surgical intervention. Additionally, in several cases the onset of intrapericardial bleeding has appeared late after epicardial access, suggesting an unpredictable timeline. In one case, coronary angiography precisely identified the site of the bleeding and allowed for successful treatment through repeated angioplasty balloon occlusions proximal to the site of bleeding in the target vessel, eventually leading to thrombosis of the distal segment and control of the bleeding.9 In cases where an injury to an epicardial vessel is suspected, manipulations of the mapping/ablation catheter and the epicardial sheath should be avoided to prevent further adverse events.

Vascular injury can also occur as a consequence of poor sheath management. After the placement of an introducer into the pericardial space, the sheath should never be left unprotected, as this can introduce a risk of myocardial or vascular laceration. To avoid such a complication, a blunt catheter (i.e., a diagnostic mapping or an ablation catheter) should be left at all times through the introducer inside the pericardium. Cases of coronary arterial and venous injury using an unprotected pericardial sheath have been reported (Figure 47.1).¹⁰ Typically, the treatment involves surgical repair. Additionally, arterial stenosis through intimal hyperplasia can also occur as a result of epicardial energy delivery in close proximity to a vessel during catheter ablation. Both radiofrequency^4,7 and cryothermy¹¹ have been shown to result in such a complication. In general, the distance between the ablation catheter tip and the coronary vessel and the diameter of the epicardial vessel are the most important determinants of vascular injury in such a setting.¹¹

Lastly, a case of diffuse and profound coronary artery spasms has been reported with epicardial mapping in patient with a history of ventricular tachycardia in the setting of ischemic cardiomyopathy and vasospastic angina.¹⁰ In this patient, prior to catheter ablation, epicardial mapping along the anterior left ventricular wall adjacent to the main coronary arteries, was immediately followed by sudden hemodynamic collapse, diffuse precordial ST segment elevations, and shock-refractory ventricular fibrillation. Coronary angiography (Figure 47.2) demonstrated diffuse vasospasm involving the left main, left anterior descending, and circumflex arteries with absence of flow to the distal coronary bed. The patient was treated with cardiopulmonary resuscitation, repeated injections of intracoronary nitrates, and intra-aortic balloon pump support, and eventually fully recovered from this complication. While no clear etiology for this adverse event was found, it was believed to have been elicited by catheter manipulations and epicardial mapping over and adjacent to the epicardial arteries.

Figure 47.1 Coronary sinus laceration during epicardial mapping. An intraoperative image of a surgically repaired laceration (arrow) to a large-caliber posterolateral branch of the coronary sinus. This vascular tear occurred during epicardial advancement of an SL-3 introducer along the posterior left atrium. This was followed by a sudden drop in the blood pressure and drainage of 2 L of venous blood, ultimately requiring urgent thoracotomy with surgical repair of the lacerated vessel. Image was reproduced with permission from Koruth et al., Circ Arrhythm Electrophysiol. 2011;4:882–888. Abbreviation: LV, left ventricle.

Two rare types of cardiac injury in the setting of epicardial ablation have been observed. One has involved a case of double right ventricular puncture in which an epicardial introducer enters and exits the right ventricular wall in two different sites. It is believed that such a complication would primarily occur with an inferior epicardial puncture, such that the needle may be advanced unnoticed through the inferior wall and subsequently through the free wall of the right ventricle. Consequently, the needle is then exchanged for an epicardial introducer over a guidewire, and epicardial mapping and ablation may be completed without immediate sequelae via the introducer placed through and through the right ventricle. But upon its removal at the end of the procedure, catastrophic intrapericardial bleeding will ensue (Figure 47.3). Another rare case of cardiac injury has been reported during epicardial mapping in a patient with a history of prior cardiac surgery undergoing catheter ablation of ventricular tachycardia. In this case, percutaneous subxiphoid access was obtained using an inferior approach without sequelae. However, during disruption of the epicardial adhesion performed using the curved elbow (“blunt” portion) of the catheter, a sudden drop in the blood pressure and hemodynamic collapse was observed. Consequently, patient underwent a repeat sternotomy, which revealed a left ventricular tear likely as a result of disruption of the adhesions (Figure 47.4). Both patients were successfully treated with surgical intervention and eventually made full recovery.

Figure 47.3 Double right ventricular puncture. Panel A: A cross-sectional schematic of the heart showing advancement of an epicardial introducer (EPI) into the pericardium using an inferior puncture approach. The catheter is seen entering and exiting the right ventricle. Panel B: A cross-sectional schematic of the heart showing perforation of the right ventricle at the entry and exit sites following removal of the introducer. Removal of the sheath would be followed by immediate and torrential intrapericardial bleeding from the two puncture sites within the right ventricle (blue arrows). Panel C: A case of a double right ventricle puncture confirmed at cardiac surgery in a patient who underwent epicardial catheter ablation of ventricular tachycardia. The epicardial introducer (EPI) is visible at the entry and exit sites (dotted circles) in the right ventricle as marked by blue arrows. Figure was modified with permission from Aryana et al., Card Electrophysiol Clin. 2017;9:119–131. Abbreviations: LV, left ventricle; RV, right ventricle.

To date, two cases of guidewire fracture with dislodgement have been reported in conjunction with an epicardial access. Both involved the use of smaller/thinner guide-wires (0.018 or 0.025 in) within the pericardial space. The first case occurred following the exchange of a Tuohy needle for an introducer over a 0.025-in guidewire.12 Difficulties encountered in removing the guidewire from the sheath demanded repeated manipulations that ultimately culminated in a fracture of the wire’s distal tip with a fragment dislodging inside the pericardium (Figure 47.5). Consequently, the dislodged wire fragment was snared percutaneously through a second epicardial access and successfully removed. A similar case has also been observed by the authors when performing an inferior epicardial puncture in a small patient using the “needle-in-needle” technique.¹³ In this case, precautions were taken to avoid the needle puncturing the diaphragm. Due to an acute angle of entry into the pericardium, the 0.018-in guidewire used through the long 21-gauge micropuncture needle became kinked at the site of entry into the pericardial space. With careful and consistent manipulations, the needle was ultimately withdrawn from the kinked guidewire and successfully removed. However, kinking of the wire had created a sharp, piercing elbow/edge at the site of the kink, and repeated manipulations led to a right ventricular laceration requiring surgical repair.

Figure 47.5 Guidewire dislodgement inside the pericardium. In the process of exchanging the Tuohy needle for an introducer over a 0.025” guidewire following an epicardial puncture, difficulties were encountered in removing the guidewire from the sheath. This resulted in a fracture of the guidewire’s distal tip with a wire fragment dislodging in the pericardial space. Panels A and B illustrate the fractured and dislodged guidewire fragment (red arrows) in left and right anterior oblique projections, respectively. The dislodged wire fragment was subsequently snared percutaneously (yellow arrow) through a second epicardial access and successfully removed (Panel C). Images were reproduced with permission from Killu et al., Heart Rhythm. 2013;10:1613–1621.

HEPATIC INJURY

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