Multicenter Coronary Venous Carbon Dioxide Insufflation for Subxiphoid Epicardial Access in Ventricular Tachycardia Ablation

Percutaneous subxiphoid epicardial access for ventricular tachycardia ablation carries a substantial risk of catastrophic complications. Intentional coronary venous carbon dioxide insufflation (Epi-CO2) creates a radiolucent pneumopericardium that provides a broad needle target, but evidence is dominated by single-center reports. We retrospectively analyzed 53 consecutive patients undergoing epicardial access for ventricular tachycardia ablation at 3 Japanese tertiary centers (Epi-CO2, n = 28; conventional access, n = 25). Major access-related complications occurred in 0 of 28 Epi-CO2 patients vs 3 of 25 (12.0%) conventional-access patients, including ventricular puncture, tamponade, and 2 in-hospital deaths, without prolonging total procedure time (270 vs 301 minutes; P = 0.142). Core Epi-CO2 metrics, including CO2 volume and epicardial-access fluoroscopy time, were consistent across all 3 centers, and all 6 high-risk patients underwent the procedure without complication. In this first Asian multicenter experience, Epi-CO2 was associated with the absence of major access-related complications, including in anatomically challenging cases.