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Epicardial VT Ablation — EECC MCQ

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HardArrhythmia & ElectrophysiologyEpicardial VT AblationEECC

A 60-year-old man with ischaemic HFrEF (LVEF 20%) and recurrent VT storms undergoes catheter ablation. Endocardial mapping reveals a large scar in the anteroseptal region. Despite endocardial ablation, VT recurs. What is the next step?

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Correct answer: C — Epicardial catheter ablation via percutaneous subxiphoid pericardial access to target the epicardial VT substrate not reachable from the endocardium

When endocardial VT ablation fails in ischaemic cardiomyopathy, the arrhythmogenic substrate may have a significant epicardial component. Percutaneous epicardial access (via subxiphoid pericardial puncture, originally described by Sosa) allows mapping and ablation of epicardial circuits. The ESC 2022 VA/SCD Guidelines recognise epicardial ablation as an important tool for VT refractory to endocardial approaches. Epicardial substrate is particularly common in non-ischaemic DCM (especially Chagas, ARVC), but can also be present in ischaemic disease, particularly in inferolateral MI scars. Risks include pericardial bleeding, coronary artery injury, and phrenic nerve damage.

Reference: ESC (2022): Guidelines on VA and SCD Prevention; EHRA VT Ablation Consensus