Logistics of safe and stress-free epicardial access in the electrophysiology lab: creative percutaneous subxiphoid pericardiostomy
Authors: Burg M , Gonna H , Anderson R D , Chandra Srinath Patloori S , Acosta Velez J G , Bhaskaran A , Nair K , Spears D , Chauhan V S , Ha A C T , Cusimano R J , Nanthakumar K 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Professor Nanthakumar is a recipient of the mid-career investigator award from the Heart & Stroke Foundation of Ontario.

Introduction
Dry epicardial access (EA) into the virtual pericardial space carries a 6-25% risk of collateral damage to important adjacent structures including the right ventricle and the coronary and internal thoracic arteries.1 This renders conventional dry EA a potentially daunting and stressful undertaking. Separation of the parietal and visceral pericardial layers by CO2 insufflation has been described and may mitigate some risk , however even in experienced tertiary centres, injury to superior epigastric arteries, liver, stomach, and transverse colon, has been reported. Furthermore, insufflating the pericardial space may cause unwanted haemodynamic changes . There is thus the need for an approach that separates the pericardial layers and avoids injury to right ventricle and coronary arteries while also avoiding abdominal and thoracic structures by direct visualisation.

Purpose
We describe the logistics of a creative technique that combines percutaneous EA with a minimally-invasive subxiphoid pericardiostomy that can be done with a surgeon in the electrophysiology (EP) lab for the initial 20 minutes of the procedure.

Methods
We performed the procedure with a surgeon in 4 patients in a single tertiary centre. The procedure was done in the EP lab under general anaesthesia with standard surgical asepsis and IV cefazolin administered pre-operatively. The subxiphoid area is infiltrated with local anaesthesia. Following a limited 5cm midline incision, the linea alba is dissected exposing the preperitoneal fat but the peritoneal space is not entered. The lower sternum is retracted anteriorly to expose the diaphragm and cardiophrenic fat pad. The diaphragm is progressively sutured to the skin to bring the pericardium into view. A 0-silk suture is then used to tent the pericardium at which point an incision is made in the pericardium to create the window. The steerable sheath and pericardial drain are inserted in the standard over-the-wire percutaneous technique through separate adjacent punctures with direct pathway visualisation through the window. Following this, the surgical incision is closed, allowing the surgeon to leave, and mapping to ensue.

Results
The time from skin incision to pericardial drain insertion was 18±5 minutes. None of our patients had acute or delayed bleeding or adjacent organ injury peri-procedurally. The pericardial drain was removed within 12-24 hours. One patient had mild pericarditis that resolved after a short course of non-steroidal anti-inflammatory agents. The subxiphoid wound healed well in all patients.

Conclusions
Percutaneous EA with easy entry into the pericardial space under direct visualisation and realtime monitoring via a pericardiostomy can be readily attained with surgical collaboration. We propose this as an alternative approach to EA, particularly in situations in which the percutaneous access will be challenging (e.g. obesity, or in presence of adhesions).