Hybrid surgical vs percutaneous access epicardial ventricular tachycardia ablation

Abstract

Background: There is limited experience of surgical epicardial access in the contemporary era of ventricular tachycardia ablation after cardiac surgery.

Objectives: The purpose of this study was to describe our institutional experience with surgical epicardial access and the influence of surgical approach and compare outcomes with those of a propensity-matched percutaneous epicardial access control group.

Methods: We performed a retrospective study of consecutive surgical epicardial ventricular tachycardia (VT) ablation cases from a single center. Surgical cases were propensity-matched to percutaneous epicardial ablation controls and short-term and long-term outcomes were compared.

Results: Between 2004 and 2016, 38 patients underwent 40 surgical epicardial access procedures (subxiphoid, n = 22; thoracotomy, n = 18). The commonest indication was prior coronary artery bypass grafting (45%), valve surgery (22%), or ventricular assist device (VAD) (10%). The mean procedure time was 444 minutes (standard deviation, 107 minutes). Mapped epicardial geometry area was 149 cm² (interquartile range 182 cm²), which comprised 36% of the mapped epicardial geometric area of a percutaneous control group. Subxiphoid access gave preferential access to the inferior and inferolateral left ventricular segments and was less frequently able to access the anterior, anterolateral, and apical segments compared with a thoracotomy approach. When compared with results from a propensity-matched percutaneous-access group, short-term outcomes, complication rates, and 1-year survival free from a combined end point of VT recurrence, death, or transplantation were not statistically different.

Conclusions: Surgical epicardial access after cardiac surgery for ablation of VT in patients with careful preprocedure evaluation can be performed with acceptable safety with no statistical difference in long-term outcomes compared with a propensity-matched percutaneous epicardial cohort. The region of left ventricular epicardium that can be mapped is limited compared with that of percutaneous cases and is determined by the surgical approach.

Keywords: Ablation; Cardiac surgery; Epicardial; Surgical access; Ventricular tachycardia.