Feasibility of carbon dioxide insufflation and impact on epicardial approach utilization for ventricular tachycardia ablation in a midvolume referral center.

Background: Epicardial access is often crucial for successful ventricular tachycardia (VT) ablation, but it is often burdened by significant procedural risk. Intentional coronary vein exit and intrapericardial CO insufflation (EpiCO) can facilitate subxiphoid pericardial access.

Objective: This prospective study aimed to assess procedural feasibility, safety, and impact of the introduction of intrapericardial CO insufflation for epicardial access in a referral center for VT ablation.

Methods: All consecutive patients treated with epicardial VT ablation between November 2022 and January 2024 with the EpiCO technique at Pisa University Hospital were prospectively enrolled and compared in terms of feasibility, efficiency, and safety with a local retrospective cohort of patients treated with subxiphoid dry puncture between July 2018 and October 2022.

Results: Twenty-two consecutive patients (90.9% male; mean age, 54.3 years) underwent VT ablation with EpiCO during the study period. Epicardial access was achieved in all patients; median time from coronary sinus (CS) cannulation to epicardial access was 33 minutes. Intentional vein exit was successful in all cases, whereas CO insufflation was not feasible in 1 patient. There were no major complications and no significant bleeding. Since EpiCO introduction, epicardial approach utilization increased from 17.8% to 40% of all VT procedures. Comparison with 20 standard dry approach epicardial ablations showed no significant differences in terms of total procedural duration (322.5 [interquartile range, 296.75-363.75] minutes vs 359 [interquartile range, 323-409] minutes; P = .08).

Conclusion: In our single-center experience, EpiCO was feasible and safe and led to significant increase in procedural volume without affecting total procedural time compared with standard dry puncture.