2 9 16 Epicardial Mapping And Ablation Techniques To Control Ventricular Tachycardia Syllabus

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2/8/2016

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HOW TO DECIDE ON AN INITIAL APPROACH: ENDO, EPI, OR BOTH?

Noel G. Boyle MD PhD, Jason Bradfield MD,

Kalyanam Shivkumar, MD PhD

UN IVE RSI TY O F C ALI FORN IA, LO S A NGEL ES

UC LA

BERKELEY • DAVIS • IRVINE • LOS ANGELES • RIVERSIDE • SAN DIEGO • SAN FRANCISCO SANTA BARBARA • SANTA CRUZ

Cardiac Arrhythmia Center

Neurocardiology Research Center of Excellence

Interventional Cardiovascular Programs

The mission of the UCLA Cardiac Arrhythmia Center is to

generate new knowledge in the field of cardiac electrophysiology

and cardiovascular therapeutics

Cardiac Arrhythmia Center

DISCLOSURES: University of California (UCLA campus) has patents

developed by my group in the areas of catheter technology, embolism

prevention technology, minimally invasive methods for cardiac

interventions, cardiac neural diagnostics and therapeutics

2/8/2016

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When to go epicardial

•General concepts

•ECG criteria

•Etiology & Imaging criteria

Anterior Access:

Lateral Tricuspid annulus

Anterior Right Ventricle

Inferior/Posterior/Lateral

Access areas

Lateral mitral annulus

LAA

LV ant and lat wall

Posterior left atrium (via

oblique sinus)

Diaphragmatic surfaces of

RV and LV

SCHEMATIC OF PERICARDIAL SINUSES AND

ACCESS TO VARIOUS EPICARDIAL REGIONS VIA

THE PERICARDIAL SPACE

PAAorta

LAA

C

PA

LIPV

LSPV

RIPV

RSPV

SVC

Aorta

A

EPI

ENDO RV

HIS

CS

HRA RCA

Halo

Sheath in Transverse

Sinus

EPI

ENDO RV

HIS

CS

HRA RCA

Halo

Sheath in front of

Great Arteries

B

Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology Circulation 2012 ;126:1752-1769

Anterior

Inferior

Direction of Needle Entry

EPICARDIAL ACCESS NEEDLES AND LANDMARKS FOR NEEDLE ENTRY

RV

Liver

Curved end faces Heart

Open end away from Heart

toward right inferior quadrant 3-6

O'clock viewed from caudal view

Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology 2012 Circulation 2012 ;126:1752-1769

2/8/2016

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Dangers of Pericardial Access

•RV perforation

•Pericardial bleeding

•Liver Injury

•Abdominal Bleeding

•Entry into left pleural space

epicardial/intramural

hematoma RV perforation Liver entry

ELECTROANATOMIC MAPPING AIDED EPICARDIAL ACCESS

Bradfield J, Tung R, Vaseghi M, Moriarty JM, Boyle NG, Buch E, Mandapati R, Shivkumar K. Our Approach To Minimize Risk Of Epicardial Access:

Standard Techniques With The Addition Of Electroanatomic Mapping Guidance. Journal of Cardiovascular Electrophysiology 2013 (in press)

1. ECG suggest Epicardial VT exit site

2. Prior unsuccessful Endocardial Ablation

3. Define SCAR location with CE imaging:

4. Consider likelihood of Epicardial circuit

for Underlying Substrate:

Sub epicardial or mid-myocardial scar

Perform Endocardial Mapping and Ablation first

ECG Criteria (Berruezo et al Circ 2004)

1) Pseudo-delta >34 ms

2) IDT (V2) >85 ms

3) Shortest RS complex

>121 ms

4) ORS duration >211 ms

1) Absence of inferior Q wave

2) Pseudodelta ≥75 ms

3) MDI >0.59

4) Presence of Q wave in lead I

Probability of Epicardial

Focus (Sacher F et al JACC 2010)

Normal

ICM

NICM

ARVC

Other CM

ECG Criteria for NICM (Valles E Circ AE 2010)

6%

16%

35%

41%

18%

Consider

obtaining

Epicardial

Access for

Mapping

(and

Ablation)

NO

NO

NO

LOW

YES

YES

YES

HIGH

AB

C

ABC

Approach to Assessing Need for Epicardial Access/Ablation

Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology, Circulation 2012;126:1752-1769

2/8/2016

4

When to go epicardial

•General concepts

•ECG criteria

•Etiology & Imaging criteria

1) Absence of inferior Q wave

2) pseudo-delta ≥75 ms

3) MDI >0.59

4) Presence of Q wave in

lead I

ECG CRITERIA FOR NON ISCHEMIC CARDIOMYOPATHY

Valles E, Bazan V, Marchlinski FE. Ecg criteria to identify epicardial ventricular tachycardia in nonischemic

cardiomyopathy. Circ Arrhythm Electrophysiol. 2010;3:63-71

2/8/2016

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1) pseudo-delta >34 ms

2) intrinsicoid deflection

time (v2) >85 ms

3) shortest RS complex >121

ms

4) QRS duration >211 ms

Bazan V, Bala R, Garcia FC, Sussman JS, Gerstenfeld EP, Dixit S, Callans DJ, Zado E, Marchlinski FE.

Twelve-lead ECG features to identify ventricular tachycardia arisingfrom the epicardial right ventricle.

Heart Rhythm. 2006;3:1132-1139

TWELVE-LEAD ECG FEATURES TO IDENTIFY VENTRICULAR

TACHYCARDIA ARISING FROM THE EPICARDIAL RIGHT VENTRICLE

•Pseudodelta wave (PdW)

•Intrinsicoid deflection time (IDT)

•Shortest RS complex (SRS)

•QRS duration (QRSd)

•Maximum deflection index (MDI)

•Q or q wave in lead I (QWL1)

•Absence of q waves in inferior leads aVR/aVL ratio

QRS CHARACTERISTICS FAIL TO RELIABLY IDENTIFY

VENTRICULAR TACHYCARDIAS THAT REQUIRE EPICARDIAL

ABLATION IN ISCHEMIC HEART DISEASE

Martinek M, Stevenson WG, Inada K, Tokuda M, Tedrow UB. QRS characteristics fail to reliably identify

ventricular tachycardias that require epicardial ablation in ischemic heart disease. J Cardiovasc

Electrophysiol. 2012;23:188-193

ECGI: Surface ECG combined with CT imaging to produce 3D

maps of electrical activity on the surface of the human heart.

Shivkumar K , Narayan SM Science Transl Med 2011;3:98fs2-98fs2

2/8/2016

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ECGI ISOCHRONE MAPS FOR LOCALIZATION OF VT SITE OF

ORIGIN

Wang Y, Cuculich PS, Zhang J, Desouza KA, Vijayakumar R, Chen J, Faddis MN, Lindsay BD, Smith

TW, Rudy Y. Noninvasive Electroanatomic Mapping of Human Ventricular Arrhythmias with

Electrocardiographic Imaging. Science Translational Medicine. 2011 3(98):98ra84.

When to go epicardial

•General concepts

•ECG criteria

•Etiology & Imaging criteria

Sacher F, Roberts-Thomson K, Maury P, Tedrow U, Nault I, Steven D, Hocini M, Koplan B, Leroux L,

Derval N, Seiler J, Wright MJ, Epstein L, Haissaguerre M, Jais P, Stevenson WG. Epicardial ventricular

tachycardia ablation a multicenter safety study. J Am Coll Cardiol. 2010;55:2366-2372

2/8/2016

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1. ECG suggest Epicardial VT exit site

2. Prior unsuccessful Endocardial Ablation

3. Define SCAR location with CE imaging:

4. Consider likelihood of Epicardial circuit

for Underlying Substrate:

Sub epicardial or mid-myocardial scar

Perform Endocardial Mapping and Ablation first

ECG Criteria (Berruezo et al Circ 2004)

1) Pseudo-delta >34 ms

2) IDT (V2) >85 ms

3) Shortest RS complex

>121 ms

4) ORS duration >211 ms

1) Absence of inferior Q wave

2) Pseudodelta ≥75 ms

3) MDI >0.59

4) Presence of Q wave in lead I

Probability of Epicardial

Focus (Sacher F et al JACC 2010)

Normal

ICM

NICM

ARVC

Other CM

ECG Criteria for NICM (Valles E Circ AE 2010)

6%

16%

35%

41%

18%

Consider

obtaining

Epicardial

Access for

Mapping

(and

Ablation)

NO

NO

NO

LOW

YES

YES

YES

HIGH

AB

C

ABC

SUMMARY: EPI, ENDO or BOTH

Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology, Circulation 2012;126:1752-1769

Cardiomyopathy & Transplantation:

Gregg C. Fonarow MD

Tamara Horwich MD

Daniel Cruz MD

Arnold Baas MD

Mario Deng MD

Ali Nsair MD

ACHD:

Ravi Mandapati MD

Jamil Aboulhosn MD

Pamela Miner RN NP

Cardiac Surgery:

Hillel Laks MD

Murray Kwon MD

Richard Shemin MD

Peyman Benharash MD

Curtis Hunter MD

Jeffrey L. Ardell PhD, Dir

J. Andrew Armour MD PhD

John Tompkins PhD

Eileen So BS

EP Nurse Practitioners:

Shelly Cote RN MN NP

Jean Gima RN MN NP

Geraldine Pavez RN MN NP

Research Administration:

Julie M. Sorg RN MSN

Radiology:

J. Paul Finn MD PhD

Stephen J. Kee MD

John Moriarty MD

Stefan Ruehm MD

Administrative:

Susana Morales

Carmen Mora BS

Julie Ramirez BS

Health System:

Laura Brandsen-Yost MSHA

Erick Ascencio CVT

Center Director

Kalyanam Shivkumar MD PhD

Co-Directors

Noel G. Boyle MD PhD

Aman Mahajan MD PhD

Specialized Program for AF

Eric F. Buch MD, MS, Dir

Specialized Program for VT

Jason Bradfield, MD, Dir

Implanted Devices Clinic

Osamu Fujimura MD, Dir

Cardiac EP, UCLA Olive View

Carlos Macias, MD Dir

Clinical & Translational Research

Marmar Vaseghi MD MS, Dir

West Los Angeles-VAMC:

Zenaida Feliciano MD, Dir

Malcolm Bersohn MD

Janet Han MD

Electrophysiology Faculty:

Olujimi A. Ajijola MD PhD

Carlos Macias MD

Ravi Mandapati MD

EP Fellows/trainees:

Jonathan Hoffman MD

Houman Khakpour MD

Yuliya Krokhaleva MD

Tadanobu Irie MD PhD

Una Buckley MD

David Hamon MD

Pradeep Rajendran BS (MSTP/PhD)

Ray Chui BS (MCIP/PhD)

Echocardiography:

Barbara Natterson MD

Aman Mahajan MD PhD

Cardiac Anesthesia:

Komal Patel MD

Jonathan Ho MD

Coach John R. Wooden

1910-2010

2/8/2016

1

Outcomes of Combined Epicardial

and Endocardial Ablation

Srinivas Dukkipati, MD

Director, Electrophysiology Lab

Icahn School of Medicine at Mount Sinai

New York, NY

Scar-Related VT

LV RV

RF

LV RV

•Coronary artery territory

•Subendocardial or transmural

•Epicardial scar present in ~10%1

Dilated Cardiomyopathy

1Verma A et al. JCE 2005;16:465-71

2Liuba I et al. Heart Rhythm 2014;11:755-62

Myocardial Infarction

•Mid-myocardial & epicardial, patchy

or longitudinal striae

•Scar progression over time2

•Basal –perivalvular3

•Anteroseptal & inferolateral scar

location in 89% of those with VT4

d’Avila A et al.

Heart Rhythm 2006

3HH et al. Circulation 2003; 108:704-10

4Piers S et al. Circ EP 2013;6:875-83

Disclosures

•Biosense Webster –Research Grant

2/8/2016

2

Post-MI: Endo–Epicardial

Homogenization

Di Biase L et al –JACC 2012;60:132-41

•100% non-inducibility achieved in both groups

81%

51%

DCM: Endocardial Ablation

Hsai HH et al –Circ 2003; 108:704-10

•19 pts with DCM and MMVT

–Basal (peri-mitral) scar in ALL

–Endocardial scar <25% of LV

–Of 57 VTs, 88% of induced VTs

were from basal scar

•After ablation, 14/19 (74%) were

non-inducible

•After 22

±

12 months, only 5 pts

(23%) were alive without VT

recurrence

DCM –Epicardial Scar

Cano O et al –JACC 2009; 54:799-808.

•22 pts with DCM and failed prior endocardial ablation

(n=20) or VT suggestive of epicardial origin (n=2)

•Combined epicardial/endocardial mapping was performed

•Scar Location

Epicardial scar in 18 pts (82%) –basal LV/lateral wall

Endocardial scar in 12 pts (54%) –basal LV

•Scar Area

Epicardial = 55.3 ±33.5 cm2

Endocardial = 22.9 ±32.4 cm2(p < 0.01)

•F/U 18 ±7 months

71% free of VT

2/8/2016

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Cano O et al. JACC 2009;54:799-808

Single Procedure VT-free Survival:

ICM vs. NICM

VT-free Survival at 1 year:

ICM = 57%,

NICM = 40.5%

Results From the Prospective

Heart Centre of Leipzig VT

(HELP-VT) Study

Dinov B et al –

Circulation 2014;129:728-36

•224 pts. (ICM 164, NICM 63)

•Epicardial ablation:

ICM 1.2%

NICM 30.8%

•Acute procedural success (non-

inducibility of VT):

ICM 77.4%

NICM 66.7%

VT-free Survival at 1 year:

ICM = 57%,

NICM = 40.5%

ECM: early CM

DCM: LVEF<45%, mod-severe LV dilatation

•87 pts. with NICM and VT:

Anteroseptal scar 44

inferolateral 43

•Presence of anteroseptal scar

was associated with a HR 5.5

(p<0.001) for VT recurrence

Circ EP 2014;7:414-23

2/8/2016

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Transcoronary

Ethanol Ablation

VT Termination

Sapp J L et al. Circ 2013;128:2289-2295 Koruth JS et al. Heart Rhythm 2012;9:1932-41

INFUSION NEEDLE ABLATION BIPOLAR RFA

RV ENDOCARDIAL EPICARDIAL

RV

Dubrey SW et al. Prog Cardiovasc Dis 2010;52:336-46

AP Burke - http://emedicine.medscape.com

HCM

ARVC

Cardiac

Sarcoidosis

2/8/2016

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•22 pts with HCM & drug

refractory VT undergoing

catheter ablation

•Epicardial RFA in 13 pts

(59%)

•Acute procedural success: 86%

•At 20 ±9 months –73% VT

free

•10 pts. with HCM & drug refractory

VT undergoing combined

epicardial-endocardial ablation

•Epicardial scar present in 8/10

(80%)

•Acute procedural success: 89%

•At 37 ±17 months –78% VT free

Hypertrophic Cardiomyopathy

Circ EP 2011;4:185-194 Heart Rhythm 2010;7:1036-42

Dalal et al JACC 50:432, 2007

ARVC-VT: Endocardial Ablation

ARVC-VT: Combined Endocardial &

Epicardial Ablation

Santangeli P et al –Circ EP 2015;8:1413-21

•62 pts. with ARVC-VT undergoing endocardial ±epicardial ablation

•Follow-up 56 ±44 months

Freedom from Ventricular Arrhythmias VT Frequency

71%

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VT-free Survival at 1 year:

ICM = 57%,

NICM = 40.5%

Circ EP 2012;5:992-1000

•224 pts. with NICM and VT:

•Epicardial ablation:

•DCM 29%

•ARVC 30%

•Sarcoidosis 15%

•HCM 43%

•Congenital 6%

•Valvular 3%

•Secondary endpoint: freedom

from death, transplantation, VT

hospitalization

Final Thoughts

•Unlike in ischemic VT, scar in other substrates is NOT

predominantly limited to the sub-endocardium

•Epicardial scar present in:

ICM ~10%

other substrates ≥ 30%

•An endocardial ±epicardial ablation approach

best results in ICM and ARVC

suboptimal results in DCM (inferolateral scar better than

anteroseptal scar) and Cardiac Sarcoidosis

•Better mapping and ablation technologies are necessary

to improve outcomes

2/8/2016

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Role of Imaging Techniques in

Catheter Ablation of Ventricular

Tachycardia

Amin Al-Ahmad, MD, FACC, FHRS, CCDS

Texas Cardiac Arrhythmia Institute

Austin, Texas

Disclosures

•Medtronic

•St Jude Medical

•Boston Scientific

•Biosense

•Apama Medical

•Khalila Medical

Introduction

•Pathophysiology of VT in complex

•Interplay between substrate, triggers

•Understanding the substrate is helpful in

targeting VT

•Imaging during procedures to guide in

ablation and prevent compliactions

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Pre-Procedural Imaging

•Nuclear

–Perfusion

–Viability

–Innervation

•MRI

–Late enhancement

•CT scan/Rotational Fluoroscopy

Rijnierse et al. JNC 2015

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Rijnierse et al. JNC 2015

Perez-David JACC 2011

Perez-David JACC 2011

2/8/2016

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Desjardins et al. HR 2009

Fernandez-Armenta et al. Circ A&E 2013

Dickfeld et al. Circ A&E 2011

2/8/2016

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Komatsu et al. Circ A&E 2013

Cochet et al. JCE 2013

CT Scan- Wall thinning

Image of LV scar- Rotational

Fluoroscopy

Day 0 Day 30

•29 RF ablation

lesions were

created and

visualized

•All lesions

exhibited a

perfusion defect

•24 lesions

(83%) had a

peripheral

enhancing ring

Visualization of RF Lesions--Rotational

Fluoroscopy

Girard E, Al-Ahmad A. et al. JACC Imaging 4(3): 259-268, 2011

2/8/2016

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Procedural Imaging

•ICE

–2D

–3D

•Fluoroscopy registration tools

ICE for VT

•Placement of the ICE catheter in the RA or RV

or pericardium allows visualization of the left

ventricle

–Structures:

•papillary muscle

•false tendon

•valves

•coronary arteries

2/8/2016

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3D Reconstructed Images

2/8/2016

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Vaseghi et al, HeartRhythm 2006

2/8/2016

9

ICE for VT

•Visualization of areas

of wall thinning or wall

motion abnormalities

Epicardial Scar

Unipolar voltage ICE Image

2/8/2016

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Epicardial VT

Interventional MRI

Nazarian S, et al. Circulation. 2008

Real-time guidance of a passive catheter to the His bundle position in the

canine model. A, Catheter bipolar electrodes (Bi) are shown in the inferior

vena cava. B, The catheter is advanced, with tip (arrow) entering hepatic

vein. C, Catheter buckling as a result of advancement into a hepatic vein.

D, The catheter tip is withdrawn into the inferior vena cava. E, The

catheter tip is advanced beyond the hepatic vein branch in the inferior

vena cava. F, The catheter tip is advanced to the tricuspid annulus. SVC

indicates superior vena cava; L, liver; RV, right ventricle; and RA, right

atrium.

2/8/2016

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Conclusions

•Pre-procedural imaging is helpful in gaining

insight into stuructural and functional

substrate for VT

•CT and MRI correlate well with EA mapping

•Intra-cardiac ultrasound is valuable during VT

ablation for identifying substrate, catheter

location and preventing complications

Thank You

2/2/2016

1

Epicardial Mapping and Ablation Techniques:

How to Prevent and Manage Complications

Mathew D. Hutchinson, MD

Associate Professor of Medicine

University of Pennsylvania

Disclosures

Within the past 12 months, I have received modest

financial support from the following entities:

1. Medtronic- lecture honoraria

2. Biosense Webster- advisory panel

3. Abiomed- lecture honoraria

Perioperative

considerations

•Patient selection

–Habitus

–Prior surgery, pericarditis

•Hematologic issues

–Anticoagulation management

–Blood products

•Equipment

–Access-related

–Coronary angiography

–Phrenic protection

•Surgical backup

N Acute Chronic

Sacher

et al.

156

5.1% 1.9%

Tung et

al.

109

8.8% NR

Della Bella

et al.

218

2.3% 1.8%

Piers et al.

29 7% 3%

Sacher et al. J Am CollCardiol 2010; 55:2366-72

Tung et al. Heart Rhythm 2013; 10:490-498

Della Bella et al. CircArrhythm Electrophysiol 2011; 4:653-9

Piers et al. CircArrhythm Electrophysiol 2013; 6:513-521

Pericardial access complications

2/2/2016

2

Anatomy of the approach

RV LV

Liver

RV

LV

Larrey’s

Space

Catheter

Anterior

Flat Lateral

Tricks and tips

1. Needle techniques

2. Define cardiac border

3. Use ICE, contrast

4. Don’t panic with RV perf

5. Confirm guidewire position

6. Maintain sheath hygiene

AP

RAO 30º LAO 40º

Apex

LV

RV

LAO 50º

RV

LV

Access-related

complications

•Superficial vessels

•Abdominal viscera

•Cardiac chambers

•Epicardial vessels

Inferior

Phrenic A

Anterior

Phrenic N

Superior

Epigastric

Internal

Thoracic

Musculo-

phrenic

Rectus

Abdominus

L Pleural

Cavity

RV LV

Ross et al. Heart Rhythm 2011; 8:318-21

2/2/2016

3

Approach-specific complications

Anterior: In-and-out RV

perforation Posterior: Liver laceration

Koruth et al. Heart Rhythm 2011; 8:1652-7

Ablation-related coronary injury

•Presentation

•Acute occlusion, spasm

•Chronic stenosis

•Likelihood of vessel injury:

•Proximity to vessel (<2mm)

•Internal diameter (<1.8mm)

•Energy source (RF>cryo)

Intimal hyperplasia

D’Avila et al. PACE 2002; 25:1488-92

Lustgarten et al. Heart Rhythm 2005; 2:82-90

Hypotension

during RF

Phrenic nerve protection

Phrenic capture at 20mA

Diaphragm

Fan et al. Heart Rhythm 2009 6(1): 59-64

LV

•Double pericardial access required

•Consider steerable sheath

•Position ablator between LV and balloon

•Alternative air +/- fluid- increased DFT

Diaphragm

LV

B

Non-compliant balloon 18x40

LV

B

2/2/2016

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Re-access after pericarditis/cardiac surgery

•28 pts; 4-9% total epi procedures

•Acute success 17/28

•100% with adhesions (anterior

post surgical)

•Blunt dissection required for

mapping; deflectable sheath

•Complications: ~10% (no deaths)

Sosa et al. J Interv Card Electr 2004; 10:281-288

Roberts-Thompson et al. J Cardiovasc Electrophysiol 2010; 21:406-411

Tschabrunn et al. Heart Rhythm 2013; 10:165-169

Summary- Epi access complications

•Relatively high complication rate

•Adequate planning and equipment is essential to success

•Complications specific to timing and approach

•Develop a specific technique, but modify it as required

Thank You!

2/2/2016

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