title: Accessory atrioventricular pathways refractory to catheter ablation: role of percutaneous epicardial approach.
abstract: BACKGROUND
  Epicardial mapping and ablation of accessory pathways through a subxiphoid approach can be an alternative when endocardial or epicardial transvenous mapping has failed.
  
  
  RESULTS
  We reviewed acute and long-term follow-up of 21 patients (14 males) referred for percutaneous epicardial accessory pathway ablation. There was a median of 2 previous failed procedures. All patients were highly symptomatic, 8 had atrial fibrillation (3 with cardiac arrest) and 13 had frequent symptomatic episodes of atrioventricular reentrant tachycardia. Six patients (28.5%) had a successful epicardial ablation. Five patients (23.8%) underwent a successful repeated endocardial mapping, and ablation after epicardial mapping yielded no early activation site. Epicardial mapping was helpful in guiding endocardial ablation in 2 patients (9.5%), showing that the earliest activation was simultaneous at the epicardium and endocardium. Four patients (19%) underwent successful open-chest surgery after failing epicardial/endocardial ablation. Two patients (9.5%) remained controlled under antiarrhythmic drugs after unsuccessful endocardial/epicardial ablation. Two patients had a coronary sinus diverticulum and one a right atrium to right ventricle diverticulum. Three patients acquired postablation coronary sinus stenosis. There was no major complication related to pericardial access.
  
  
  CONCLUSIONS
  Percutaneous epicardial approach is an alternative when conventional endocardial or transvenous epicardial ablation fails in the elimination of the accessory pathway. A new attempt by endocardial approach was successful in a significant number of patients. Open-chest surgery may be required in symptomatic cases refractory to endocardial-epicardial approach.
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.). mauricio.scanavacca@incor.usp.br.
authors.forename: Maurício Ibrahim
authors.initials: MI
authors.lastname: Scanavacca
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Eduardo Back
authors.initials: EB
authors.lastname: Sternick
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Cristiano
authors.initials: C
authors.lastname: Pisani
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Sissy
authors.initials: S
authors.lastname: Lara
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Carina
authors.initials: C
authors.lastname: Hardy
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: André
authors.initials: A
authors.lastname: d'Ávila
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Frederico Soares
authors.initials: FS
authors.lastname: Correa
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Francisco
authors.initials: F
authors.lastname: Darrieux
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Denise
authors.initials: D
authors.lastname: Hachul
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Miguel Barbero
authors.initials: MB
authors.lastname: Marcial
authors.affiliation: From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d'.A.).
authors.forename: Eduardo A
authors.initials: EA
authors.lastname: Sosa
mesh_terms: D058606:Accessory Atrioventricular Bundle / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001145:Arrhythmias, Cardiac / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001938:Brazil; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D056149:Epicardial Mapping; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000503:physiopathology / Q000601:surgery*; D011237:Predictive Value of Tests; D012086:Reoperation; D017211:Treatment Failure; D055815:Young Adult
chemical_list: D000889:Anti-Arrhythmia Agents
keywords: Wolff–Parkinson–White syndrome; arrhythmias, cardiac; cardiac surgical procedures; catheter ablation; electrophysiology; epicardial mapping