Reinventing Larrey’s approach for epicardial mapping: The closed pericardiostomy technique

Epicardial mapping has become indispensable in electrophysiology (EP). Primarily used for the management of ventricular arrhythmias, the epicardial surface of the heart is gaining a new level of importance. Recent developments such as hybrid ablation based on dissociated layers of the atrium in maintaining atrial fibrillation (AF), ganglionic mapping, and neurohormonal modulation bring epicardial access (EA) into urgent focus. 1 Chaumont C. Suffee N. Gandjbakhch E. Balse E. Anselme F. Hatem S.N. Epicardial origin of cardiac arrhythmias: clinical evidences and pathophysiology. Cardiovasc Res. 2022; 118: 1693-1702 Crossref PubMed Scopus (1) Google Scholar ,2 Bisleri G. Pandey A.K. Verma S. et al. Combined minimally invasive surgical and percutaneous catheter ablation of atrial fibrillation: JACC Review Topic of the Week. J Am Coll Cardiol. 2023; 81: 606-619 Crossref PubMed Scopus (1) Google Scholar Traditionally, EA has been achieved by accessing the dry pericardial space (PS) percutaneously with a large-bore Touhy needle - Sosa’s technique described 27 years ago, with several adaptations since. 3 Sosa E. Scanavacca M. d’Avila A. Pilleggi F. A new technique to perform epicardial mapping in the electrophysiology laboratory. J Cardiovasc Electrophysiol. 1996; 7: 531-536 Crossref PubMed Scopus (678) Google Scholar ,4 Romero J. Shivkumar K. Di Biase L. et al. Mastering the art of epicardial access in cardiac electrophysiology. Heart Rhythm. 2019; 16: 1738-1749 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar However, even with 27 years’ experience, percutaneous EA is still associated with 6%–25% risk of complications, even in experienced tertiary centers. 5 Juliá J. Bokhari F. Uuetoa H. et al. A new era in epicardial access for the ablation of ventricular arrhythmias: the Epi-Co2 Registry. JACC Clin Electrophysiol. 2021; 7: 85-96 Crossref PubMed Scopus (14) Google Scholar This risk makes EA a stressful undertaking to many operators, requiring a sophisticated understanding of anatomy, experienced hands, and surgical backup to manage complications, thus limiting widespread patient access to the procedure.