title: Percutaneous epicardial access for mapping and ablation is feasible in patients with prior cardiac surgery, including coronary bypass surgery.
abstract: BACKGROUND
  Prior cardiac surgery, especially the presence of coronary artery bypass grafts, is thought to preclude percutaneous epicardial access (EpiAcc) and, therefore, mapping and ablation. We evaluated the feasibility and safety of EpiAcc in patients with a prior cardiac operation.
  
  
  RESULTS
  We retrospectively analyzed all patients who underwent EpiAcc for ablation for ventricular tachycardia or symptomatic premature ventricular complexes between 2004 and 2013 at Mayo Clinic, Rochester, MN. Of 162 patients who underwent EpiAcc, 18 had prior cardiac surgery (median age, 64 years, all men). This included 10 coronary artery bypass grafts, 2 epicardial implantable cardioverter defibrillator placement, 5 valve surgery, 2 septal myectomy, 1 aortic arch replacement, 1 myocardial bridge unroofing, and 1 myocardial perforation repair (3 patients had multiple procedures). Access was successful in 12 of 18; the inferior approach was used in 78%. Successful access was achieved in 6 of 10 patients with prior coronary artery bypass grafts. Adhesiolysis was required in 10 patients with the sheath, access wire, and pigtail or ablation catheter. Intraprocedural coronary angiography was performed in 8 patients. A total of 45 ventricular tachycardias/premature ventricular complexes were ablated. Thirteen patients underwent endocardial-only ablation, 2 had epicardial-only ablation, whereas 3 had endocardial-epicardial ablation. Ablation was deemed successful in 13 of 18 patients. Four patients had bleeding complications (pericardial effusion, pericardial hematoma, hemoperitoneum, and pericardial tamponade). In patients with coronary grafts, there was no evidence of acute graft disruption.
  
  
  CONCLUSIONS
  Percutaneous EpiAcc is feasible in patients with previous cardiac surgery, including coronary artery bypass grafts. However, adhesiolysis is frequently required. Although the risk of coronary graft injury is low, life-threatening complications may occur.
authors.affiliation: From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN. killu.ammar@mayo.edu.
authors.forename: Ammar M
authors.initials: AM
authors.lastname: Killu
authors.affiliation: From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN.
authors.forename: Elisa
authors.initials: E
authors.lastname: Ebrille
authors.affiliation: From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN.
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Asirvatham
authors.affiliation: From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Munger
authors.affiliation: From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: McLeod
authors.affiliation: From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Packer
authors.affiliation: From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Friedman
authors.affiliation: From the Department of Medicine, Division of Cardiovascular Diseases (A.M.K., E.E., S.J.A., T.M.M., C.J.M., D.L.P., P.A.F., S.K.M.) and Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN.
authors.forename: Siva K
authors.initials: SK
authors.lastname: Mulpuru
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects; D056149:Epicardial Mapping / Q000009:adverse effects; D005240:Feasibility Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D018879:Ventricular Premature Complexes / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*
keywords: catheter ablation; epicardial mapping; general surgery; percutaneous epicardial mapping; pericardium; tachycardia, ventricular; ventricular premature complexes