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Utility of the Lateral Fluoroscopic View for Subxiphoid
Pericardial Access
Rukshen Weerasooriya, BMedSci, MBBS; Pierre Jais, MD;
Frederic Sacher, MD; Sebastien Knecht, MD; Matthew Wright, MBBS, PhD;
Nicolas Lellouch, MD; Isabelle Nault, MD; Seiichiro Matsuo, MD;
Meleze Hocini, MD; Jacques Clementy, MD; Michel Haissaguerre, MD
T
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Biosense-Webster). In the same patient, Movie 2 shows the
spread of contrast, indicating successful access of the pericardial
space, which is only a virtual space in this instance. Some
contrast staining of the epicardial aspect of the right ventricle can
also be appreciated. Figure 2 demonstrates the lateral fluoroscopic view during drainage of acute cardiac tamponade
complicating an atrial fibrillation ablation procedure. Contrast can be seen filling the widened pericardial space.
In a different patient (Movie 3) who had cardiac tamponade during catheter ablation of the left isthmus, the same view
was used to perform emergency drainage via the subxiphoid
approach using a Tuohy needle. The movie demonstrates the
injection of contrast within the expanded pericardial space
with outlining of the epicardial aspect of the right ventricle
under tamponade.
ranspericardial access is an important procedure in clinical cardiac electrophysiology. The ability to access the
pericardial space is critical for rapid drainage in acute cardiac
tamponade and is also increasingly used to perform epicardial
mapping and ablation of a range of ventricular and atrial
arrhythmias.1–3 The seminal description of this technique by
Sosa described the use of the left anterior oblique fluoroscopic projection.4 After performing trials, we now prefer the
left lateral fluoroscopic projection because it more clearly
defines the desired needle pathway and maximally separates
the mediastinal, pericardial, and myocardial planes without
any intervening structures.
Figure 1 demonstrates the lateral fluoroscopic view demonstrating the orientation of the Tuohy needle as it enters the
anterior aspect of the dry pericardial space. Small amounts of
contrast are injected as the needle is advanced; the black
arrow demonstrates mediastinal staining and the white arrow
demonstrates pericardial staining, which is later confirmed by
advancing a wire into the pericardial space and creating a
large, residual loop. The defibrillator lead and 2 right ventricular endocardial mapping catheters—Pentaray (BiosenseWebster, Diamond-Bar, Calif) and an externally irrigated
mapping/ablation catheter (Celsius Thermocool, BiosenseWebster, Diamond-Bar, Calif)—are also visible.
The movies show the utility of this projection during
subxiphoid pericardial access in 2 patients. Movie 1 shows
elective anterior transpericardial access using a Tuohy needle
in a patient with a previously implanted defibrillator for
arrhythmogenic right ventricular dysplasia undergoing epicardial mapping and ablation of ventricular tachycardia. The
first injection of contrast is within the mediastinum immediately adjacent to the pericardium. The 2 mapping catheters
within the right ventricle are a Pentaray and an externally
irrigated mapping/ablation catheter (Celsius Thermocool,
Disclosures
None.
References
1. Phillips KP, Natale A, Sterba R, Saliba WI, Burkhardt JD, Wazni O,
Liberman L, Schweikert RA. Percutaneous pericardial instrumentation for
catheter ablation of focal atrial tachycardias arising from the left atrial
appendage. J Cardiovasc Electrophysiol. 2008;19:430 – 433.
2. Yamada T, Murakami Y, Okada T, Yoshida N, Ninomiya Y, Toyama J,
Yoshida Y, Tsuboi N, Inden Y, Hirai M, Murohara T, McElderry HT,
Epstein AE, Plumb VJ, Kay GN. Non-pulmonary vein epicardial foci of
atrial fibrillation identified in the left atrium after pulmonary vein isolation.
Pacing Clin Electrophysiol. 2007;30:1323–1330.
3. Daniels DV, Lu YY, Morton JB, Santucci PA, Akar JG, Wilber DJ.
Idiopathic epicardial left ventricular tachycardia originating remote from
the sinus of Valsalva: electrophysiological characteristics, catheter ablation,
and identification from the 12-lead electrocardiogram. Circulation. 2006;113:
1659–1666.
4. Sosa E, Scavanacca M, D’Avilla A, Pillegi F. A new technique to perform
epicardial mapping in the electrophysiology laboratory. J Cardiovasc Electrophysiol. 1996;7:537–538.
From the Hopital Cardiologique du Haut Leveque (R.W., P.J., F.S., S.K., M.W., N.L., I.N., S.M., M.H., J.C., M.H.), Bordeaux-Pessac, France;
Universite Victor Segalen II (R.W., P.J., F.S., S.K., M.W., N.L., I.N., S.M., M.H., J.C., M.H.), Bordeaux, France; and University of Western Australia
(R.W.), Crawley, Western Australia.
The online-only Data Supplement is available at http://circep.ahajournals.org/cgi/content/full/2/4/e15/DC1.
Correspondence to Rukshen Weerasooriya, BMedSci, Hôpital Cardiologique du Haut-Lévêque, 33604 Bordeaux-Pessac, France. E-mail
[email protected]
(Circ Arrhythmia Electrophysiol. 2009;2:e15-e17.)
© 2009 American Heart Association, Inc.
Circ Arrhythmia Electrophysiol is available at http://circep.ahajournals.org
e15
DOI: 10.1161/CIRCEP.108.803676
e16
Circ Arrhythmia Electrophysiol
August 2009
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Figure 1. Lateral fluoroscopic view demonstrates the orientation of the Tuohy needle as it enters the anterior aspect of the dry pericardial space.
Weerasooriya et al
Lateral View Pericardial Access
e17
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Figure 2. Lateral fluoroscopic view during drainage of acute cardiac tamponade complicating an atrial fibrillation ablation procedure.
Utility of the Lateral Fluoroscopic View for Subxiphoid Pericardial Access
Rukshen Weerasooriya, Pierre Jais, Frederic Sacher, Sebastien Knecht, Matthew Wright,
Nicolas Lellouch, Isabelle Nault, Seiichiro Matsuo, Meleze Hocini, Jacques Clementy and
Michel Haissaguerre
Downloaded from http://circep.ahajournals.org/ by guest on May 2, 2017
Circ Arrhythm Electrophysiol. 2009;2:e15-e17
doi: 10.1161/CIRCEP.108.803676
Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville
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Copyright © 2009 American Heart Association, Inc. All rights reserved.
Print ISSN: 1941-3149. Online ISSN: 1941-3084
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Movie 1 – elective pericardial access 1
Movie 2 – elective pericardial access 2
Movie 3 – emergency pericardial access