Feasibility of carbon dioxide insufflation and impact on epicardial approach utilization for ventricular tachycardia ablation in a mid-volume referral center.

BACKGROUND: Epicardial access is often crucial for successful ventricular tachycardia (VT) ablation, but it's often burdened by significant procedural risk. Intentional coronary vein exit and intrapericardial CO2 insufflation (EpiCO2 ) can facilitate subxiphoid pericardial access.

OBJECTIVE: This prospective study aims at assessing procedural feasibility, safety and impact of the introduction of intrapericardial CO2 insufflation for epicardial access in a referral center for VT ablation.

METHODS: All consecutive patients treated with epicardial VT ablation between November 2022 and January 2024 with EpiCO2 technique at Pisa University Hospital were prospectively enrolled and compared in terms of feasibility, efficiency, and safety to a local retrospective cohort of patients treated with subxiphoid dry puncture between July 2018 and October 2022.

RESULTS: Twenty-two consecutive patients (90.9% male, mean age 54.3 years) underwent VT ablation with EpiCO2 during study period. Epicardial access was achieved in all patients, median time from CS cannulation to epicardial access was 33 minutes; intentional vein exit was successful in all cases, while CO2 insufflation was not feasible in one patient. There were no major complications and no significant bleeding. Since EpiCO2 introduction epicardial approach utilization increased from 17.8% to 40% of all VT procedures. Comparison to 20 standard dry approach epicardial ablations showed no significant differences in terms of total procedural duration (322.5 [IQR 296.75-363.75] min vs 359 [IQR 323-409] min; P=0.08).

CONCLUSION: In our single center experience, EpiCO2 was feasible and safe and led to significant increase in procedural volume without affecting total procedural time when compared to standard dry puncture.