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Vol. 72. Issue 10.
Pages 873-874 (October 2019)
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Vol. 72. Issue 10.
Pages 873-874 (October 2019)
Scientific letter
DOI: 10.1016/j.rec.2019.03.003
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Epicardial Access for Ventricular Tachycardia Ablation: Experience With the Needle-in-needle Technique
Acceso epicárdico para ablación de taquicardia ventricular: experiencia con la técnica de micropunción
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Ignasi Anguera
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ianguera@bellvitgehospital.cat

Corresponding author:
, Marta Aceña, Zoraida Moreno-Weidmann, Paolo D. Dallaglio, Andrea Di Marco, Marcos Rodríguez
Unidad de Arritmias, Servicio de Cardiología, Área del Corazón, Hospital Universitario de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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Tables (1)
Table 1. Characteristics of patients managed using needle-in-needle epicardial access
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To the Editor,

Ventricular tachycardias are an increasingly common ablation target in electrophysiology laboratories, pose major challenges due to the presence of complex substrates, and often require multiple access sites. The epicardial substrate is accessible via percutaneous puncture using the Sosa technique,1 first described more than 20 years ago. In Spain, 14% of ventricular tachycardia ablation procedures are currently performed via an epicardial approach, and it is more frequently used in nonischemic cardiomyopathy (25.3% of cases) than in ischemic (9.2% of cases).2 In the last 2 decades, operators have gained experience and confidence in percutaneous epicardial access, but complications remain, some of which are potentially fatal. Subxiphoid epicardial puncture is performed with an 18-G Tuohy needle (Braun, Kronberg, Germany), an epidural puncture needle with a curved tip that has now become the standard for epicardial access. Epicardial puncture is still a challenge, with a complication rate of 5% to 20%. It is thus only performed in specific centers with experience and on-site surgical facilities. One series reported a 10% rate of severe hemopericardium treated with pericardial drainage.3 In another study of 218 patients managed with the Sosa technique, cardiac tamponade occurred in 8 patients (3.7%), which was resolved with pericardial drainage in 6 patients and with emergent surgery in 2.4 Other complications of epicardial access, rare but very serious, are hepatic puncture with hemoperitoneum, laceration of a vein or coronary artery, or right ventricular (RV)-abdominal fistula.

The needle-in-needle technique has recently been developed for epicardial access using a needle of much smaller caliber and with considerable potential in terms of safety.4 The needle-in-needle technique is based on puncture with a thin needle (21 G) that is supported inside a larger-bore (18 G) needle. Here, we describe our experience with using the needle-in-needle technique to obtain epicardial access.

From July 2015 to October 2018, ventricular tachycardia ablation was performed in 19 consecutive patients using the needle-in-needle technique and an epicardial approach.

In this technique, the external 18-G needle is advanced under the xiphoid process. Once the 18-G needle is positioned, the 21-G micropuncture needle is inserted (Mini Access Kit, 21G-L.150mm, Merit; Utah, United States), advanced until the heartbeat is felt, and introduced into the pericardial space. Radiopaque contrast agent is injected to confirm the optimal location and then a 0.018-inch guidewire is advanced (Nitrex, 0.018 in-L.180cm; Minnesota, United States) inside the micropuncture needle. Once its correct location within the pericardial space is verified, the needle is withdrawn, a flexible introducer is advanced, and the 0.018-inch guidewire is exchanged for a 0.032-inch wire, on which a standard 8-Fr introducer can be advanced.

Table 1 shows the characteristics of the patients requiring epicardial access in our center using the needle-in-needle technique. The predominant heart disease was idiopathic dilated cardiomyopathy (58%). Epicardial access with the needle-in-needle technique was successful in 17 of 19 patients (89%). There were no incidences of hemopericardium, and no patient required pericardial drainage. In 1 patient, the hardness of the diaphragm resisted the passage of such a fine needle, requiring the use of a conventional Tuohy needle. In another patient, significant pericardial adhesions impeded epicardial access and a surgical approach was required. Another patient experienced inadvertent RV puncture, and the 0.018-inch guidewire was advanced into the cavity. When the guidewire was removed, it caught the end of the needle, split into 2 fragments, and caused embolization of the distal fragment. The same micropuncture needle provided access to the epicardium, and the procedure was successfully completed. The next day, the distal fragment of the 0.018-inch guidewire was removed with a loop catheter, without further problems or hemopericardium.

Table 1.

Characteristics of patients managed using needle-in-needle epicardial access

Age, y  BMI  Sex  Etiology  LVEF, %  Successful, %  Hemodynamic support  Complications 
77  31  DCM  32  Yes  No   
31  27  Myocarditis  68  Yes  No   
66  31  DCM  29  Yes  No   
71  35  DCM  26  Yes  No   
34  25  ARVD  70  Yes  No   
25  26  DCM  42  Yes  No   
72  27  DCM  43  Yes  No   
57  26  IHD  28  Yes  No   
46  27  DCM  45  Yes  No   
68  25  DCM  24  Yes  ECMO   
72  26  DCM  35  Yes  No  Rupture of the 0.014-inch guidewire in the RV and migration of the distal segment to the AP. Subsequent epicardial access without incident and ablation completed successfully 
57  35  DCM  35  Yes  No   
57  26  IHD  28  Yes  ECMO   
48  24  IHD  30  No  ECMO  Change to Tuohy needle. Very hard tissue 
42  26  IHD  63  Yes  No   
79  24  DCM  12  Yes  No   
73  29  IHD  34  Yes  No   
63  27  IHD  36  No  No  Severe pericardial adhesions. Surgical access required 
66  26  DCM  36  Yes  No   

ARVD, arrhythmogenic right ventricular dysplasia; BMI, body mass index; DCM, dilated cardiomyopathy; ECMO, extracorporeal membrane oxygenation; IHD, ischemic heart disease; LVEF, left ventricular ejection fraction; M, man; PA, pulmonary artery; RV, right ventricle; W, woman.

In our experience, as well as in the literature, the needle-in-needle technique is the safest way to obtain epicardial access, and no cases have been reported of hemopericardium with tamponade or the need for cardiac surgery.

Kumar et al.5 described the needle-in-needle micropuncture technique for the first time in 2015, comparing their series of 23 patients with a retrospective group of 291 patients managed with the Sosa technique. In the retrospective group, 5 patients (1.7%) required emergent surgery due to severe hemopericardium and 1 died. In contrast, none of the hemopericardia due to the needle-in-needle technique required surgical intervention. In the largest published study, the incidence of severe hemopericardium was significantly higher in the 18-G needle group than in the micropuncture needle group (8.1% vs 0.9%; P <.001), and 42% of these patients with inadvertent RV puncture required cardiac surgery. No patient with inadvertent RV puncture managed using the needle-in-needle technique required surgery.6

Our results show that epicardial access through the needle-in-needle technique can be achieved in a very safe and largely trauma-free way. There were no cases of significant hemopericardium, abdominal bleeding, or RV or epicardial coronary artery damage. This technique provides the operator with increased confidence and helps to reduce the stress associated with pericardial puncture. It may also be useful to improve the safety of conventional pericardiocentesis, particularly in patients with little pericardial effusion, whose risk of RV puncture is higher.

References
[1]
E. Sosa, M. Scanavacca, A. d’Avila, F. Pilleggi.
A new technique to perform epicardial mapping in the electrophysiology laboratory.
J Cardiovasc Electrophysiol., 7 (1996), pp. 531-536
[2]
F.J. García-Fernández, J.L. Ibáñez, A. Quesada, Spanish Catheter Ablation Registry. 17th Official Report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2017).
Rev Esp Cardiol., 71 (2018), pp. 941-951
[3]
F. Sacher, K. Roberts-Thomson, P. Maury, et al.
Epicardial ventricular tachycardia ablation: a multicenter safety study.
J Am Coll Cardiol., 55 (2010), pp. 2366-2372
[4]
P. Della Bella, J. Brugada, K. Zeppenfeld, et al.
Epicardial ablation for ventricular tachycardia: a European multicenter study.
Circ Arrhythm Electrophysiol., 4 (2011), pp. 653-659
[5]
S. Kumar, R. Bazaz, C.R. Barbhaiya, et al.
Needle-in-needle” epicardial access: preliminary observations with a modified technique for facilitating epicardial interventional procedures.
Heart Rhythm., 12 (2015), pp. 1691-1697
[6]
S. Gunda, M. Reddy, J. Pillarisetti, et al.
Differences in complication rates between large bore needle and a long micropuncture needle during epicardial access: time to change clinical practice?.
Circ Arrhythm Electrophysiol., 8 (2015), pp. 890-895
Copyright © 2019. Sociedad Española de Cardiología
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