{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,2]],"date-time":"2026-05-02T11:31:20Z","timestamp":1777721480390,"version":"3.51.4"},"reference-count":23,"publisher":"IMR Press","issue":"4","license":[{"start":{"date-parts":[[2026,4,22]],"date-time":"2026-04-22T00:00:00Z","timestamp":1776816000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Rev. Cardiovasc. Med."],"abstract":"<jats:p>Epicardial access is often required for effective catheter ablation of ventricular tachycardia (VT) originating from the epicardium, especially in patients with non-ischemic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (ARVC), and cardiac sarcoidosis. Traditional subxiphoid access using large-bore needles remains effective but carries substantial procedural risks, including right ventricular (RV) puncture, coronary artery injury, and injury to intra-abdominal organs. These risks are amplified in patients with prior cardiac surgery, obesity, and distorted anatomy. To mitigate these challenges, several technical advancements have been introduced, including the needle-in-needle (micropuncture) technique and the SAFER approach using RV angiography during apnea. However, these methods do not fully overcome the inherent limitation of minimal separation between the pericardial layers at the time of pericardial puncture. Carbon dioxide (CO2) insufflation into the pericardial space is a recently developed technique that can temporarily separate the parietal and visceral pericardium for safer epicardial access. Coronary venous exit for CO2 has demonstrated safety and efficacy, as confirmed in the multicenter Epi-CO2 Registry. Further advances include the use of radiofrequency (RF)-assisted trans-right atrial appendage (RAA) perforation for CO2 insufflation. In this comprehensive review, the advancement of epicardial access is discussed from the early era to contemporary techniques, especially regarding CO2 insufflation, including its pitfalls and the future direction of this technique.<\/jats:p>","DOI":"10.31083\/rcm47009","type":"journal-article","created":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T10:31:56Z","timestamp":1777458716000},"source":"Crossref","is-referenced-by-count":0,"title":["Advances in Epicardial Access for Ventricular Tachycardia Ablation: From Historical Techniques to Carbon Dioxide Insufflation"],"prefix":"10.31083","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9218-1966","authenticated-orcid":true,"given":"Koji","family":"Higuchi","sequence":"first","affiliation":[{"name":"Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2490-5106","authenticated-orcid":true,"given":"Jakub","family":"Sroubek","sequence":"additional","affiliation":[{"name":"Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2823-9243","authenticated-orcid":true,"given":"Justin","family":"Lee","sequence":"additional","affiliation":[{"name":"Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0023-9666","authenticated-orcid":true,"given":"Pasquale","family":"Santangeli","sequence":"additional","affiliation":[{"name":"Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"16242","published-online":{"date-parts":[[2026,4,22]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","unstructured":"Berruezo A, Mont L, Nava S, Chueca E, Bartholomay E, Brugada J. Electrocardiographic recognition of the epicardial origin of ventricular tachycardias. Circulation. 2004; 109: 1842\u20131847.","DOI":"10.1161\/01.CIR.0000125525.04081.4B"},{"key":"ref2","doi-asserted-by":"publisher","unstructured":"Maccabelli G, Mizuno H, Della Bella P. Epicardial ablation for ventricular tachycardia. Indian Pacing and Electrophysiology Journal. 2012; 12: 250\u2013268.","DOI":"10.1016\/s0972-6292(16)30564-2"},{"key":"ref3","doi-asserted-by":"publisher","unstructured":"Maccabelli G, Tsiachris D, Silberbauer J, Esposito A, Bisceglia C, Baratto F, et al. Imaging and epicardial substrate ablation of ventricular tachycardia in patients late after myocarditis. Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: Journal of the Working Groups on Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology. 2014; 16: 1363\u20131372.","DOI":"10.1093\/europace\/euu017"},{"key":"ref4","doi-asserted-by":"publisher","unstructured":"Hutchinson MD, Gerstenfeld EP, Desjardins B, Bala R, Riley MP, Garcia FC, et al. Endocardial unipolar voltage mapping to detect epicardial ventricular tachycardia substrate in patients with nonischemic left ventricular cardiomyopathy. Circulation. Arrhythmia and Electrophysiology. 2011; 4: 49\u201355.","DOI":"10.1161\/CIRCEP.110.959957"},{"key":"ref5","doi-asserted-by":"publisher","unstructured":"Vall\u00e8s E, Bazan V, Marchlinski FE. ECG criteria to identify epicardial ventricular tachycardia in nonischemic cardiomyopathy. Circulation. Arrhythmia and Electrophysiology. 2010; 3: 63\u201371.","DOI":"10.1161\/CIRCEP.109.859942"},{"key":"ref6","doi-asserted-by":"publisher","unstructured":"Sosa E, Scanavacca M, d\u2019Avila A, Pilleggi F. A new technique to perform epicardial mapping in the electrophysiology laboratory. Journal of Cardiovascular Electrophysiology. 1996; 7: 531\u2013536.","DOI":"10.1111\/j.1540-8167.1996.tb00559.x"},{"key":"ref7","doi-asserted-by":"publisher","unstructured":"Sacher F, Roberts-Thomson K, Maury P, Tedrow U, Nault I, Steven D, et al. Epicardial ventricular tachycardia ablation a multicenter safety study. Journal of the American College of Cardiology. 2010; 55: 2366\u20132372.","DOI":"10.1016\/j.jacc.2009.10.084"},{"key":"ref8","doi-asserted-by":"publisher","unstructured":"Chaumont C, Oraii A, Garcia FC, Supple GE, Santangeli P, Kumareswaran R, et al. The Safety and Efficacy of Epicardial Carbon Dioxide Insufflation Compared With Conventional Epicardial Access. JACC. Clinical Electrophysiology. 2024; 10: 1565\u20131573.","DOI":"10.1016\/j.jacep.2024.05.004"},{"key":"ref9","doi-asserted-by":"publisher","unstructured":"Bisceglia C, Limite LR, Baratto F, D\u2019Angelo G, Cireddu M, Della Bella P. Road-Map to Epicardial Approach for Catheter Ablation of Ventricular Tachycardia in Structural Heart Disease: Results From a 10-Year Tertiary-Center Experience. Circulation. Arrhythmia and Electrophysiology. 2024; 17: e012181.","DOI":"10.1161\/CIRCEP.123.012181"},{"key":"ref10","doi-asserted-by":"publisher","unstructured":"Leyton-Mange JS, Sze EY, Conley C, Vasaiwala SC, Sesselberg HW. Epicardial access facilitated by carbon dioxide insufflation for redo ventricular tachycardia ablation in a patient with arrhythmogenic right ventricular dysplasia and dense adhesions. HeartRhythm Case Reports. 2021; 7: 197\u2013202.","DOI":"10.1016\/j.hrcr.2020.12.008"},{"key":"ref11","doi-asserted-by":"publisher","unstructured":"Mathew S, Feickert S, Fink T, Rillig A, Reissmann B, Rottner L, et al. Epicardial access for VT ablation: analysis of two different puncture techniques, incidence of adhesions and complication management. Clinical Research in Cardiology: Official Journal of the German Cardiac Society. 2021; 110: 810\u2013821.","DOI":"10.1007\/s00392-020-01711-z"},{"key":"ref12","doi-asserted-by":"publisher","unstructured":"Piorkowski C, Kronborg M, Hourdain J, Piorkowski J, Kirstein B, Neudeck S, et al. Endo-\/Epicardial Catheter Ablation of Atrial Fibrillation: Feasibility, Outcome, and Insights Into Arrhythmia Mechanisms. Circulation. Arrhythmia and Electrophysiology. 2018; 11: e005748.","DOI":"10.1161\/CIRCEP.117.005748"},{"key":"ref13","doi-asserted-by":"publisher","unstructured":"Kumar S, Bazaz R, Barbhaiya CR, Enriquez AD, Helmbold AF, Chinitz JS, et al. \u201cNeedle-in-needle\u201d epicardial access: Preliminary observations with a modified technique for facilitating epicardial interventional procedures. Heart Rhythm. 2015; 12: 1691\u20131697.","DOI":"10.1016\/j.hrthm.2015.03.045"},{"key":"ref14","doi-asserted-by":"publisher","unstructured":"Gunda S, Reddy M, Pillarisetti J, Atoui M, Badhwar N, Swarup V, et al. Differences in complication rates between large bore needle and a long micropuncture needle during epicardial access: time to change clinical practice? Circulation. Arrhythmia and Electrophysiology. 2015; 8: 890\u2013895.","DOI":"10.1161\/CIRCEP.115.002921"},{"key":"ref15","doi-asserted-by":"publisher","unstructured":"Aryana A, Tung R, d\u2019Avila A. Percutaneous Epicardial Approach to Catheter Ablation of Cardiac Arrhythmias. JACC: Clinical Electrophysiology. 2020; 6: 1\u201320.","DOI":"10.1016\/j.jacep.2019.10.016"},{"key":"ref16","doi-asserted-by":"publisher","unstructured":"Romero JE, Diaz JC, Zei PC, Steiger NA, Koplan BA, Matos CD, et al. Sustained Apnea for Epicardial Access With Right Ventriculography: The SAFER Epicardial Approach. JACC. Clinical Electrophysiology. 2023; 9: 1487\u20131499.","DOI":"10.1016\/j.jacep.2023.05.016"},{"key":"ref17","doi-asserted-by":"publisher","unstructured":"Greenbaum AB, Rogers T, Paone G, Flynn SE, Guerrero ME, O\u2019Neill WW, et al. Intentional Right Atrial Exit and Carbon Dioxide Insufflation to Facilitate Subxiphoid Needle Entry Into the Empty Pericardial Space: First Human Experience. JACC. Clinical Electrophysiology. 2015; 1: 434\u2013441.","DOI":"10.1016\/j.jacep.2015.06.007"},{"key":"ref18","doi-asserted-by":"publisher","unstructured":"Silberbauer J, Gomes J, O\u2019Nunain 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: First Experience. JACC. Clinical Electrophysiology. 2017; 3: 514\u2013521.","DOI":"10.1016\/j.jacep.2016.11.002"},{"key":"ref19","doi-asserted-by":"publisher","unstructured":"Juli\u00e1 J, Bokhari F, Uuetoa H, Derejko P, Traykov VB, Gwizdala A, et al. A New Era in Epicardial Access for the Ablation of Ventricular Arrhythmias: The Epi-Co2 Registry. JACC. Clinical Electrophysiology. 2021; 7: 85\u201396.","DOI":"10.1016\/j.jacep.2020.07.027"},{"key":"ref20","doi-asserted-by":"publisher","unstructured":"Zucchelli G, Parollo M, Di Cori A, Mazzocchetti L, Segreti L, Grifoni G, et al. Feasibility of carbon dioxide insufflation and impact on epicardial approach utilization for ventricular tachycardia ablation in a midvolume referral center. Heart Rhythm. 2024; 21: 1032\u20131039.","DOI":"10.1016\/j.hrthm.2024.02.041"},{"key":"ref21","doi-asserted-by":"publisher","unstructured":"Santangeli P, Hight N, Younis A, Liuba I, Lee J, Higuchi K, et al. A Novel Radiofrequency-Assisted Trans-RAA Perforation Technique for Pericardial CO2 Insufflation to Facilitate Epicardial Access. JACC. Clinical Electrophysiology. 2025; 11: 1145\u20131155.","DOI":"10.1016\/j.jacep.2025.01.020"},{"key":"ref22","doi-asserted-by":"publisher","unstructured":"Higuchi K, Abbasi M, Roselli E, Wazni O, Santangeli P. Conus Artery Injury During Radiofrequency-Assisted RAA Perforation for Pericardial CO2 Insufflation. JACC. Clinical Electrophysiology. 2025; 11: 2079\u20132082.","DOI":"10.1016\/j.jacep.2025.04.030"},{"key":"ref23","doi-asserted-by":"publisher","unstructured":"Liuba I, Younis A, Vasandani P, Sroubek J, Higuchi K, Lee J, et al. A dedicated radiofrequency microcatheter assembly for trans-right atrial appendage pericardial carbon dioxide insufflation to facilitate epicardial access. Heart Rhythm. 2025; 22: 1728\u20131735.","DOI":"10.1016\/j.hrthm.2025.03.1977"}],"container-title":["Reviews in Cardiovascular Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.imrpress.com\/journal\/RCM\/27\/4\/10.31083\/RCM47009","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T10:32:17Z","timestamp":1777458737000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.imrpress.com\/journal\/RCM\/27\/4\/10.31083\/RCM47009"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,22]]},"references-count":23,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026]]}},"alternative-id":["S1530-6550(26)02704-0"],"URL":"https:\/\/doi.org\/10.31083\/rcm47009","relation":{},"ISSN":["1530-6550","2153-8174"],"issn-type":[{"value":"1530-6550","type":"print"},{"value":"2153-8174","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,22]]},"article-number":"47009"}}