Safety of Carbon Dioxide–Facilitated vs Conventional Epicardial Access

BACKGROUND Percutaneous epicardial access has been increasingly adopted in clinical practice, particularly for ventricular tachycardia ablation. "Dry" epicardial puncture (Dry-EPI) carries a considerable risk of access-related complications, even with modified techniques. Pericardial carbon dioxide insufflation (EpiCO2) has emerged as a promising alternative, potentially enhancing safety by increasing anatomical clearance between pericardial layers. OBJECTIVES This study compared the safety and efficacy of EpiCO2 vs traditional Dry-EPI techniques through systematic review, meta-analysis, and meta-regression. METHODS PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane databases were searched using medical subject heading terms "epicardial access," "carbon dioxide insufflation," "complications," and similar key words. Random-effects meta-analyses of proportions and means, subgroup analyses, and meta-regressions were conducted. RESULTS One hundred nineteen studies (8,784 procedures) were included; most (95.0%) were of moderate or high quality. Ventricular tachycardia ablation was the main access indication (n = 7,178). EpiCO2 was used in 493 procedures (5.6%) and Dry-EPI in 8,291 (94.4%). Among 5,786 Dry-EPI cases with specified needle type, 5,184 (89.6%) used a large-bore needle and 602 (10.4%) a micropuncture needle. EpiCO2 was associated with significantly fewer complications requiring surgery compared with Dry-EPI (0.24% 95% CI: 0.00-0.93 vs 1.55% 95% CI: 1.27-1.86, P < 0.010), large-bore needle (0.24% 95% CI: 0.00%-0.93% vs 1.58% 95% CI: 1.23-1.97, P < 0.010), and micropuncture (0.24 95% CI: 0.00-0.93 vs 1.66% 95% CI: 0.60-3.17, P = 0.020). Inadvertent ventricular puncture was also lower with EpiCO2 compared with Dry-EPI (0.28% 95% CI: 0.00-1.00 vs 3.17% 95% CI: 2.36-4.10, P < 0.010). CONCLUSIONS Compared with Dry-EPI, EpiCO2 was associated with significantly lower risk of inadvertent ventricular puncture and complications requiring surgery, supporting broader clinical adoption.