Sustained Apnea for Epicardial Access With Right Ventriculography: The SAFER Epicardial Approach

Jorge E Romero; Juan C Diaz; Paul C Zei; Nathaniel A Steiger; Bruce A Koplan; Carlos D Matos; Isabella Alviz; Carolina Hoyos; Jorge E Marín; Mauricio Duque; Julian Aristizabal; Sunil Kapur; Charles B Nyman; Cesar D Niño; Oriana Bastidas; Thomas M Tadros; David T Martin; Usha B Tedrow; William H Sauer

doi:10.1016/j.jacep.2023.05.016

Sustained Apnea for Epicardial Access With Right Ventriculography: The SAFER Epicardial Approach

JACC Clin Electrophysiol. 2023 Aug;9(8 Pt 2):1487-1499. doi: 10.1016/j.jacep.2023.05.016. Epub 2023 May 18.

Authors

Jorge E Romero¹, Juan C Diaz², Paul C Zei³, Nathaniel A Steiger³, Bruce A Koplan³, Carlos D Matos³, Isabella Alviz³, Carolina Hoyos³, Jorge E Marín⁴, Mauricio Duque², Julian Aristizabal⁴, Sunil Kapur³, Charles B Nyman⁵, Cesar D Niño⁴, Oriana Bastidas², Thomas M Tadros³, David T Martin³, Usha B Tedrow³, William H Sauer³

Affiliations

¹ Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: jeromero@bwh.harvard.edu.
² Cardiac Arrythmia Center, Division of Cardiology, Clinica Las Vegas, Universidad CES, Medellín, Colombia.
³ Cardiac Arrhythmia Service, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁴ Cardiac Arrhythmia Institute, Division of Cardiology, Department of Medicine, Clinica Las Americas, Medellin, Colombia.
⁵ Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

PMID: 37486280
DOI: 10.1016/j.jacep.2023.05.016

Abstract

Background: Epicardial access (EA) has emerged as an increasingly important approach for the treatment of ventricular arrhythmias and to perform other interventional cardiology procedures. EA is frequently underutilized because the current approach is challenging and carries a high risk of life-threatening complications.

Objective: The purpose of this study was to determine the efficacy and safety of the SAFER (Sustained Apnea for Epicardial Access With Right Ventriculography) epicardial approach.

Methods: Consecutive patients who underwent EA with the SAFER technique were included in this multicenter study. The primary efficacy outcome was the successful achievement of EA. The primary safety outcomes included right ventricular (RV) perforation, major hemorrhagic pericardial effusion (HPE), and bleeding requiring surgical intervention. Secondary outcomes included procedural characteristics and any complications. Our results were compared with those from previous studies describing other EA techniques to assess differences in outcomes.

Results: A total of 105 patients undergoing EA with the SAFER approach from June 2021 to February 2023 were included. EA was used for ventricular tachycardia ablation in 98 patients (93.4%), left atrial appendage closure in 6 patients (5.7%), and phrenic nerve displacement in 1 patient (0.9%). EA was successful in all subjects (100%). The median time to EA was 7 minutes (IQR: 5-14 minutes). No cases of RV perforation, HPE, or need of surgical intervention were observed in this cohort. Comparing our results with previous studies about EA, the SAFER epicardial approach resulted in a significant reduction in major pericardial bleeding.

Conclusions: The SAFER epicardial approach is a simple, efficient, effective, and low-cost technique easily reproducible across multiple centers. It is associated with lower complication rates than previously reported techniques for EA.

Keywords: cardiac arrhythmias; catheter ablation; epicardial access; quality improvement; radiofrequency ablation; ventricular arrhythmias.

Publication types

Multicenter Study

MeSH terms

Apnea
Arrhythmias, Cardiac
Cardiac Surgical Procedures* / methods
Heart Injuries*
Hemorrhage
Humans
Pericardium / diagnostic imaging
Pericardium / surgery
Tachycardia, Ventricular* / surgery