Simplified Approach to CO2 Insufflation for Epicardial Access Using Distal Anterior Interventricular Vein Exit Without Venography

Coronary venous exit for carbon dioxide (CO2) insufflation of the pericardial space is increasingly used to facilitate subxiphoid puncture because of the potentially improved safety of this approach. 1 Foo F.S. Sy R.W. D'Ambrosio P. et al. Novel epicardial access technique facilitated by carbon dioxide insufflation of the pericardium for ablation of ventricular arrhythmias: lessons from the early experience from a single centre in Australia. Heart Lung Circ. 2023; 32: 197-204 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ,2 Silberbauer J. Gomes J. O'Nunain S. Kirubakaran S. Hildick-Smith D. McCready J. Coronary vein exit and carbon dioxide insufflation to facilitate subxiphoid epicardial access for ventricular mapping and ablation. JACC Clin Electrophysiol. 2017; 3: 514-521 Crossref PubMed Scopus (32) Google Scholar Adoption is limited in part by the additional procedural time required to access the coronary sinus, to perform venography, to cannulate a target branch, to exit that vessel, and to insufflate CO2. Coronary venography and target vessel cannulation may represent unnecessary and time-consuming steps in this procedure. 3 Cerantola M. Santangeli P. Epicardial access facilitated by carbon dioxide insufflation via intentional coronary vein exit: step-by-step description of the technique and review of the literature. J Interv Card Electrophysiol. 2022; 66: 109-116 Crossref PubMed Scopus (2) Google Scholar To improve the efficiency, we assessed the feasibility of distal anterior interventricular vein (AIV) cannulation and exit for CO2 insufflation without venography. I was blind, but now I see: Growing the evidence base for EpiCO2 epicardial accessHeart RhythmPreviewDry puncture has formed the mainstay of percutaneous subxiphoid epicardial access approaches since first described by Sosa, Scanavacca and colleagues in 1996.1 Despite expanding evidence demonstrating the added value of epicardial ablation to treat ventricular arrhythmias, its widespread use remains limited to high-volume centers because of a higher risk of complications. Most of these complications relate to gaining subxiphoid access, especially in patients with pericardial adhesions.2 It is not difficult to ascertain the reason for this: when using the dry puncture technique, one is trying to access a nonstationary, virtual, and invisible space. Full-Text PDF