title: Successful percutaneous epicardial access in challenging scenarios.
abstract: BACKGROUND
  This case-series highlights strategies used for successful epicardial access in challenging cases. Percutaneous epicardial access has become a valuable tool for mapping and ablating arrhythmias. However, this technique can be especially difficult in certain circumstances and is frequently avoided.
  
  
  METHODS
  All cases of epicardial access for ablation from our institution were reviewed searching for exceptionally difficult cases in patients with complex pericardial and thoracic anatomy. The successful strategies are characterized in this report.
  
  
  RESULTS
  Among 144 patients who underwent an epicardial ablation procedure between January 2004 and June 2013, four required unconventional approaches for epicardial access for ventricular tachycardia ablation. Two patients (one with previous cardiac surgery and one with prior pericardial effusion) had substantial fibrous pericardial adhesions with no virtual pericardial space and required adhesiolysis. One patient, status postpartial colectomy, underwent computed tomography-guided intercostal epicardial access due to the presence of bowel throughout the subdiaphragmatic space in the upper abdomen. The fourth patient had partial congenital absence of the pericardium and underwent epicardial access through the creation of a subxiphoid window. All epicardial accesses were successful and performed without major complication.
  
  
  CONCLUSIONS
  With precise procedural planning and cardiac imaging, percutaneous epicardial access is feasible even in patients with significant anatomical challenges.
authors.affiliation: Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Elisa
authors.initials: E
authors.lastname: Ebrille
authors.forename: Ammar M
authors.initials: AM
authors.lastname: Killu
authors.forename: Nandan S
authors.initials: NS
authors.lastname: Anavekar
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Packer
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Munger
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: McLeod
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Asirvatham
authors.forename: Paul A
authors.initials: PA
authors.lastname: Friedman
mesh_terms: D000368:Aged; D017115:Catheter Ablation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium; D017180:Tachycardia, Ventricular / Q000601:surgery*
keywords: ablation; challenging; epicardial access; percutaneous; ventricular tachycardia