Innovative Techniques: Epicardial Access Commentary

DOI: 10.19102/icrm.2011.020409

Samuel J. Asirvatham, MD, FHRS, FACC

Editor-in-Chief

In this issue of the journal published in the Innovative Techniques section is a compelling submission from Drs. Matthew Swale, M.D. and Paul A. Friedman, M.D. (corresponding author) that in many ways highlights the contribution of innovative thought in cardiac electrophysiology. As the authors outline, epicardial access has fast evolved to be a necessary skill for the electrophysiologist dealing with complex arrhythmia and simultaneously has become a platform tool that enables multiple innovative technologies. There are several admirably delineated facets of this innovative technique in their article that uniquely highlights the essence of innovation.

1. Simplicity. While it became apparent early in the course of cardiac ablation that access to the epicardial space was necessary to fully address all possible arrhythmogenic substrates, several attempts using relatively complex technology failed to reach the mainstream. The technique of Sosa et al described and referenced in their manuscript was remarkable for its directness and ingenious use of elementary techniques and tools.

2. Innovation leads to innovation. As well-described in their article, despite the essential simple approach to access the pericardial space, significant innovation is needed to make this a reproducibly safe procedure. In addition, the creation as a result of epicardial access of a new vantage point to reach various cardiac structures (the atrial appendages, cardiac ganglia, etc.) has spawned a pending revolution in innovative approaches to treat cardiac rhythm disorders.

3. Innovative interpretation and correlation of new and old concepts. The authors describe the use of relatively simple tools like electrocardiographic vector analysis to aid selection of patients who would benefit from this new technique and assist in the identification of epicardial substrate. Importantly, they have borrowed from the classical and often involved reasoning behind electrocardiographic vector interpretation in the context of present understanding of arrhythmogenic substrate (slow zones of conduction in reentry versus focus of origin of automatic tachycardia). As a result, their description of patient selection and EKG analysis reminds us that a thorough basis in classic electrophysiology allows us to get the best of an innovative technique or technology.

4. A platform for the future. The authors, in a remarkably concise format, describe what this innovation allows us to consider, plan, and create for the future. The need to re-understand how to interpret electrograms when considering the confounding effect of epicardial fat, neuronal signals, the cardiac ganglia, and vascular structures is both instructive and serves as a reminder that new technology challenges us to redefine our own established understanding to fully unleash the power that the innovation allows to better treat our patients.

We look forward to several other excellently presented reviews of the key innovations for cardiac electrophysiology for the Innovations Techniques section in this journal.

Samuel J. Asirvatham, MD, FHRS, FACC
E-mail: asirvatham.samuel@mayo.edu
Consultant, Division of Cardiovascular Diseases
and Internal Medicine, Division of Pediatric Cardiology
Professor of Medicine and Pediatrics
Mayo Clinic College of Medicine
Rochester, MN