Anterior-oriented epicardial puncture may reduce the risk for complications related to punctures during epicardial ablation procedures for ventricular arrhythmias (VAs), according to a study published in Clinical Research in Cardiology.

In this study, 211 patients (mean age, 61.4±15.6 years) with VA were enrolled at a single center between 2002 and 2017. All patients had ≥1 symptomatic episode of sustained monomorphic ventricular tachycardia and received ≥1 epicardial ablation procedure. In total, patients received 271 epicardial ablation procedures for VAs conducted using an inferior- (n=152) or anterior-oriented (n=59) approach for epicardial access.

The occurrence of puncture-related complications was systematically examined. Major procedural complications were defined as those that were life-threatening or resulted in death or temporal/permanent disability, or as complications that led to interventional or surgical treatment, transfusion of blood products, or prolonged hospital stay. The incidence of adhesions was also assessed during the first and subsequent ablation procedures.

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In this cohort, 12.5% of epicardial ablation procedures resulted in major complications, 8.5% of which were directly associated with epicardial puncture. A higher incidence of puncture-related major complications was observed in the inferior- vs the anterior-oriented access group (10.1% vs 4.9%, respectively).

The most common major complication associated with the procedures was pericardial tamponade, which was reported in 5.5% of procedures. Collateral damage of adjacent structures, including the colon, liver, coronary arteries, and gastric vessels was observed in 3.2% of ventricular tachycardia ablation procedures with inferior epicardial access. During the first procedure, 9% of patients experienced adhesions. The rate of adhesions rose to 47.1% for patients with ≥2 procedures with epicardial access.

Limitations of this study included its retrospective nature and the sole inclusion of cases with intrahospital complications and mortality data.

“[T]he gain of information about procedural complications, their pathomechanisms and management is not only important for further performance of safe epicardial electrophysiological procedures, but also for every cardiologist in terms of acute complication management and performance of safe pericardiocentesis,” noted the study authors.


Mathew S, Feickert S, Fink T, et al. Epicardial access for VT ablation: analysis of two different puncture techniques, incidence of adhesions and complication management [published online July 27, 2020]. Clin Res Cardiol. doi:10.1007/s00392-020-01711-z