Clinical consensus statement on epicardial ventricular arrhythmia ablation: key messages

Epicardial ventricular arrhythmias (VAs) are defined as focal VAs originating from the epicardial surface or scar-related re-entrant VAs with an epicardial exit. In such scenarios, epicardial access may be necessary to achieve a successful ablation. The 2025 clinical consensus statement on epicardial VA ablation offers practical advice and a structured framework for the peri-procedural management of epicardial VA ablation, developed collaboratively by European Heart Rhythm Association (EHRA), the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), and the Canadian Heart Rhythm Society (CHRS). The following ten clinical commandments summarize key principles and expert guidance to promote safe and effective practice (Figure 1).1 Epicardial ventricular arrhythmia ablation: from patient selection to ablation strategy and complication prevention. AADs, antiarrhythmic drugs; ARVC, arrhythmogenic right ventricular cardiomyopathy; DOACs, direct oral anticoagulants; CT, computed tomography; MRI, magnetic resonance imaging Epicardial ablation is typically required in one-third of patients undergoing VA ablation, primarily in individuals with a suspected epicardial substrate based on ECG findings, imaging (e.g. cardiac MRI), electroanatomical mapping, or a history of failed endocardial ablation. Certain cardiomyopathies—such as arrhythmogenic right ventricular cardiomyopathy/dysplasia, Chagas disease, or Brugada syndrome—commonly involve epicardial circuits. The standard method for obtaining epicardial access involves subxiphoid percutaneous puncture with a Tuohy or micropuncture needle. In cases with prior surgery or extensive pericardial adhesions, surgical access may be more appropriate. Adjunctive tools such as CO₂ insufflation may improve procedural safety. A hybrid surgical-electrophysiological approach enables controlled access and precise mapping when necessary. Pre-procedural cardiac MRI or CT helps locate the substrate, evaluate wall thickness and epicardial fat, and visualize coronary arteries and the phrenic nerve. Image integration into electroanatomical mapping systems supports precise guidance. Selective coronary angiography is advised prior to ablation for better visualization of areas near the coronary arteries. Uninterrupted anticoagulation is not advised. For patients on vitamin K antagonists, achieving an INR < 1.5 is desirable. Direct oral anticoagulants are typically withheld for at least 24 h before the procedure. The decision to use heparin bridging is made on an individual basis, considering factors like the presence and type of mechanical heart valves, as well as other elements that increase the risk of thrombosis. Further studies are warranted to assess the safety of uninterrupted anticoagulation in epicardial procedures. Understanding the anatomy of the pericardium and coronary arteries, along with their adjacent structures, is crucial for preventing complications. Common issues to anticipate include pericarditis, haemopericardium, tamponade, coronary injury, and phrenic nerve damage. Awareness of individual risk factors (including patient-specific factors, anatomical variations, procedure-related factors, and High PAINESD score) and preventive strategies is critical to minimize procedural hazards. Substrate identification may involve bipolar and unipolar voltage mapping, multilayer mapping, entrainment, and pace mapping. Multielectrode catheters can enhance mapping efficiency and improve identification of the critical substrate of scar-related VAs. Procedural endpoints such as noninducibility and ablation of all late potentials are advised in securing a successful epicardial VA ablation. Post-ablation management includes drainage of the pericardial space, conducting early imaging to exclude pericardial effusion, timely resumption of anticoagulation, and performing device interrogation. Routine use of oral colchicine after the procedure, along with intrapericardial triamcinolone (2 mg/kg) or methylprednisolone (250 mg) at the end of the procedure, may help reduce post-procedural adhesions and symptoms of pericarditis. Follow-up within 4–8 weeks, and then, as routine or remote monitoring, is advised in all patients undergoing epicardial VA ablation to assist in detecting early recurrence. Decision regarding discontinuation of antiarrhythmic medications after ablation is advised to be individualized based on the number of induced VAs, ablation outcome, and substrate complexity. Epicardial access and ablation require specialized skills different from endocardial techniques. Structured training, simulation-based education, and close mentoring can support operators’ proficiency. Procedures are advised to be performed in centres with immediate surgical backup available. Innovations such as image integration, novel mapping catheters and tools, and new energy sources like pulsed field ablation may improve procedural outcomes. Safer access and ablation techniques are under continuous development. All authors declare no disclosure of interest for this contribution.