Parasternal intercostal approach as an alternative to subxiphoid approach for epicardial catheter ablation: A case report Koji Miyamoto, MD, Takashi.

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Presentation transcript:

Parasternal intercostal approach as an alternative to subxiphoid approach for epicardial catheter ablation: A case report Koji Miyamoto, MD, Takashi Noda, MD, PhD, Takeshi Aiba, MD, PhD, Kengo Kusano, MD, PhD HeartRhythm Case Reports Volume 1, Issue 3, Pages 150-155 (May 2015) DOI: 10.1016/j.hrcr.2014.12.014 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Computed tomographic (CT) image of pericardial access. Transverse views (A–F) corresponding to the anteroposterior view (G) on preprocedural contrast-enhanced CT are shown. Note that the liver and stomach are present throughout the subdiaphragmatic space in the upper abdomen, which are on the trajectory for the subxiphoid epicardial approach. The epicardial needle was inserted at the 5th intercostal space (arrow), where was consistent with plane B. We confirmed by CT that no vital structures, including liver, stomach, transverse colon, and ITAs, were located on the needle trajectory. To avoid the ITAs (red circles), we selected a site 2.5 cm lateral to the parasternal border for needle entry (arrow). I: Avoidance of vital structures was also confirmed by echocardiography. Arrow indicates the entry site of the needle. H: The pigtail catheter was indwelling in the epicardial space after the procedure. Asterisk indicates location of epicardial needle entry for the parasternal intercostal approach. Arrowhead indicates location of needle entry for the standard subxiphoid approach. ITA = internal thoracic artery. HeartRhythm Case Reports 2015 1, 150-155DOI: (10.1016/j.hrcr.2014.12.014) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 Fluoroscopic images of epicardial access by the parasternal intercostal approach (A, B) and right coronary angiography (C, D). Panels A and C are left anterior oblique views; panels B and D are anteroposterior views. Arrow indicates the 5th intercostal space. There are no coronary arteries, including the right ventricular marginal artery, on the trajectory of the epicardial access from the entry site at the parasternal 5th intercostal space to the heart. Asterisk indicates location of epicardial needle entry to the heart. HeartRhythm Case Reports 2015 1, 150-155DOI: (10.1016/j.hrcr.2014.12.014) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 Bipolar voltage maps of the epicardium (A) and endocardium (B) of the left ventricle. The low-voltage zone (LVZ) was defined as <1.0 mV in the epicardium and 1.5 mV in the endocardium. Representative electrograms at the LVZ are also shown. A: Epicardial voltage mapping. Left panel is anteroposterior (AP) view and right panel is left posterior oblique view. B: Endocardial voltage mapping. Left panel is AP view and right panel is left lateral view. HeartRhythm Case Reports 2015 1, 150-155DOI: (10.1016/j.hrcr.2014.12.014) Copyright © 2015 Heart Rhythm Society Terms and Conditions