title: Hybrid procedures for epicardial catheter ablation of ventricular tachycardia: value of surgical access.
abstract: BACKGROUND
  Prior chest surgery limits the ability to obtain epicardial access in patients referred for catheter ablation of ventricular tachycardia (VT).
  
  
  OBJECTIVE
  The purpose of this study was to describe the utility of different surgical approaches to access the epicardium for VT ablation.
  
  
  METHODS
  Clinical data of 14 patients with drug-refractory VT who underwent hybrid surgical epicardial access for catheter mapping and ablation in the electrophysiology lab were reviewed. Baseline patient and procedural characteristics including access, exposure, mapping techniques, and ablation were analyzed.
  
  
  RESULTS
  Of a total of 14 patients (age 63.2 ± 10.3 years), 11 had a subxiphoid window performed, and three patients underwent limited anterior thoracotomy to access the epicardium. The indication for surgical access was prior cardiac surgery (n = 12), previous failed epicardial access (n = 1), and ablation in close proximity to the coronary arteries and phrenic nerve (n = 1). Mapping in patients with subxiphoid surgical access was limited to the inferior and diaphragmatic surface of the heart extending posteriorly to the basal lateral wall. With limited anterior thoracotomy, access to the apex, anterior, and mid to apical anterolateral walls was obtained. In these regions, adhesions were more severe and repeat entry into the epicardial region at a different intercostal level was needed in two of three patients.
  
  
  CONCLUSIONS
  Surgical access with subxiphoid window and limited anterior thoracotomy in the electrophysiology lab is feasible and safe. The surgical approach can be tailored to the region of interest in the ventricle to be mapped and ablated.
authors.affiliation: UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1679, USA.
authors.forename: Yoav
authors.initials: Y
authors.lastname: Michowitz
authors.forename: Nilesh
authors.initials: N
authors.lastname: Mathuria
authors.forename: Roderick
authors.initials: R
authors.lastname: Tung
authors.forename: Fardad
authors.initials: F
authors.lastname: Esmailian
authors.forename: Murray
authors.initials: M
authors.lastname: Kwon
authors.forename: Shiro
authors.initials: S
authors.lastname: Nakahara
authors.forename: Tara
authors.initials: T
authors.lastname: Bourke
authors.forename: Noel G
authors.initials: NG
authors.lastname: Boyle
authors.forename: Aman
authors.initials: A
authors.lastname: Mahajan
authors.forename: Kalyanam
authors.initials: K
authors.lastname: Shivkumar
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures; D017115:Catheter Ablation / Q000379:methods*; D056149:Epicardial Mapping / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium; D012189:Retrospective Studies; D017180:Tachycardia, Ventricular / Q000601:surgery*; D016896:Treatment Outcome