Carbon dioxide insufflation into the pericardial space provides temporary anatomical separation, enabling safer epicardial access for ventricular tachycardia ablation compared to traditional techniques.
This review highlights the evolution of epicardial access techniques for VT ablation, emphasizing the safety and efficacy of contemporary CO2 insufflation methods over traditional approaches.
Epicardial access is often required for effective catheter ablation of ventricular tachycardia (VT) originating from the epicardium, especially in patients with non-ischemic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (ARVC), and cardiac sarcoidosis. Traditional subxiphoid access using large-bore needles remains effective but carries substantial procedural risks, including right ventricular (RV) puncture, coronary artery injury, and injury to intra-abdominal organs. These risks are amplified in patients with prior cardiac surgery, obesity, and distorted anatomy. To mitigate these challenges, several technical advancements have been introduced, including the needle-in-needle (micropuncture) technique and the SAFER approach using RV angiography during apnea. However, these methods do not fully overcome the inherent limitation of minimal separation between the pericardial layers at the time of pericardial puncture. Carbon dioxide (CO2) insufflation into the pericardial space is a recently developed technique that can temporarily separate the parietal and visceral pericardium for safer epicardial access. Coronary venous exit for CO2 has demonstrated safety and efficacy, as confirmed in the multicenter Epi-CO2 Registry. Further advances include the use of radiofrequency (RF)-assisted trans-right atrial appendage (RAA) perforation for CO2 insufflation. In this comprehensive review, the advancement of epicardial access is discussed from the early era to contemporary techniques, especially regarding CO2 insufflation, including its pitfalls and the future direction of this technique.
Higuchi et al. (2026) conducted a review in Ventricular tachycardia. Carbon dioxide insufflation for epicardial access vs. Traditional subxiphoid access was evaluated. Carbon dioxide insufflation into the pericardial space provides temporary anatomical separation, enabling safer epicardial access for ventricular tachycardia ablation compared to traditional techniques.