{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T11:16:32Z","timestamp":1765883792038,"version":"3.48.0"},"reference-count":21,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T00:00:00Z","timestamp":1765843200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Accessing intramural or epicardial arrhythmogenic substrates is limited in endocardial ablation, and in these circumstances, epicardial ablation may overcome these limitations. Because epicardial access may be associated with severe complications, intentional distal coronary vein exit and carbon dioxide (CO2) insufflation have emerged as techniques to facilitate safer access. Methods: We conducted a single-centre retrospective observational analysis of all patients who underwent epicardial ablation using the CO2 insufflation technique between September 2021 and October 2024. Results: Among 21 patients selected for the procedure, successful pericardial access was achieved in 19 (90.5%). The main indication for ablation was ventricular tachycardia (14 patients, 66.7%), and 16 patients (76.2%) had previously undergone endocardial ablation for the same arrhythmia. Most patients had non-ischemic cardiomyopathy (17 patients, 81.0%). Three intra-procedural complications occurred: one (5.3%) was access-related, and two (10.5%) were ablation-related. Early post-procedural complications occurred in three patients (15.8%). Acute procedural success was achieved in 16 of 17 patients (94.1%) who underwent ablation. In-hospital mortality occurred in three cases (15.8%), including one procedure-related death (5.3%). Conclusions: Intentional coronary vein exit and CO2 insufflation provide a safe and reproducible technique to obtain subxiphoid pericardial access for epicardial ablation.<\/jats:p>","DOI":"10.3390\/jcm14248888","type":"journal-article","created":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T11:00:26Z","timestamp":1765882826000},"page":"8888","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Retrospective Observational Study of the Carbon Dioxide Insufflation Technique for Epicardial Access Ablation of Refractory Arrhythmias"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1878-9367","authenticated-orcid":false,"given":"Margarida G.","family":"Figueiredo","sequence":"first","affiliation":[{"name":"Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"}]},{"given":"Bruno","family":"Valente","sequence":"additional","affiliation":[{"name":"Arrhythmology, Pacing and Electrophysiology Unit, Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"}]},{"given":"Leonor","family":"Magalh\u00e3es","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"}]},{"given":"Guilherme","family":"Portugal","sequence":"additional","affiliation":[{"name":"Arrhythmology, Pacing and Electrophysiology Unit, Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5785-0124","authenticated-orcid":false,"given":"H\u00e9lder","family":"Santos","sequence":"additional","affiliation":[{"name":"Arrhythmology, Pacing and Electrophysiology Unit, Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"}]},{"given":"Ana","family":"Lousinha","sequence":"additional","affiliation":[{"name":"Arrhythmology, Pacing and Electrophysiology Unit, Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9465-634X","authenticated-orcid":false,"given":"Pedro Silva","family":"Cunha","sequence":"additional","affiliation":[{"name":"Arrhythmology, Pacing and Electrophysiology Unit, Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"},{"name":"Faculty of Medicine, University of Lisbon, 1649-004 Lisbon, Portugal"},{"name":"Comprehensive Health Research Centre, 1150-082 Lisbon, Portugal"}]},{"given":"Rui Cruz","family":"Ferreira","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8371-8354","authenticated-orcid":false,"given":"M\u00e1rio Martins","family":"Oliveira","sequence":"additional","affiliation":[{"name":"Arrhythmology, Pacing and Electrophysiology Unit, Department of Cardiology, Hospital de Santa Marta, Unidade Local de Sa\u00fade S\u00e3o Jos\u00e9, 1169-024 Lisboa, Portugal"},{"name":"Faculty of Medicine, University of Lisbon, 1649-004 Lisbon, Portugal"},{"name":"Comprehensive Health Research Centre, 1150-082 Lisbon, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1111\/j.1540-8167.1996.tb00559.x","article-title":"A new technique to perform epicardial mapping in the electrophysiology laboratory","volume":"7","author":"Sosa","year":"1996","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_2","first-page":"97","article-title":"Insufflation and Carbonation to Improve the Safety of Epicardial Ablation?","volume":"7","author":"Killu","year":"2021","journal-title":"J. Am. Coll. Cardiol. EP"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"80","DOI":"10.15420\/aer.2017:6:2","article-title":"Percutaneous Catheter Ablation of Epicardial Accessory Pathways","volume":"6","author":"Sternick","year":"2017","journal-title":"Arrhythm. Electrophysiol. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/j.jacep.2020.07.027","article-title":"A New Era in Epicardial Access for the Ablation of Ventricular Arrhythmias: The Epi-Co2 Registry","volume":"7","author":"Bokhari","year":"2021","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1658","DOI":"10.1016\/j.hrthm.2014.05.041","article-title":"Safety and prevention of complications during percutaneous epicardial access for the ablation of cardiac arrhythmias","volume":"11","author":"Lim","year":"2014","journal-title":"Heart Rhythm."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Matteucci, A., Mariani, M.V., Sgarra, L., Bonanni, M., Frazzetto, M., La Fazia, V.M., Pierucci, N., Lavalle, C., Pandozi, C., and Nardi, F. (2024). Epicardial Ablation for Arrhythmogenic Disorders in Patients with Brugada Syndrome. Biomedicines, 13.","DOI":"10.3390\/biomedicines13010027"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2165","DOI":"10.1111\/jce.16776","article-title":"Pentaspline Pulsed Field Ablation Versus High-Power Short-Duration\/Very High-Power Short-Duration Radiofrequency Ablation in Atrial Fibrillation: A Meta-Analysis","volume":"36","author":"Mariani","year":"2025","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1691","DOI":"10.1016\/j.hrthm.2015.03.045","article-title":"\u201cNeedle-in-needle\u201d epicardial access: Preliminary observations with a modified technique for facilitating epicardial interventional procedures","volume":"12","author":"Kumar","year":"2015","journal-title":"Heart Rhythm."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1040","DOI":"10.1016\/j.hrthm.2024.01.034","article-title":"Epicardial carbon dioxide insufflation is a novel technique for the identification of epicardial adhesions and targeting epicardial access","volume":"21","author":"Chaumont","year":"2024","journal-title":"Heart Rhythm."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"514","DOI":"10.1016\/j.jacep.2016.11.002","article-title":"Coronary Vein Exit and Carbon Dioxide Insufflation to Facilitate Subxiphoid Epicardial Access for Ventricular Mapping and Ablation: First Experience","volume":"3","author":"Silberbauer","year":"2017","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"981","DOI":"10.1016\/j.hrthm.2017.02.033","article-title":"Initial international multicenter human experience with a novel epicardial access needle embedded with a real-time pressure\/frequency monitoring to facilitate epicardial access: Feasibility and safety","volume":"14","author":"Burkhardt","year":"2017","journal-title":"Heart Rhythm."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1111\/jce.14237","article-title":"Pericardial access via wire-guided puncture without contrast: The feasibility and safety of a modified approach","volume":"31","author":"Long","year":"2020","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_13","first-page":"908","article-title":"Safety and Efficacy of a Novel Blunt-Tip Concealed-Needle Epicardial Access Device: First-in-Human Feasibility Study","volume":"8","author":"Derejko","year":"2022","journal-title":"J. Am. Coll. Cardiol. EP"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1565","DOI":"10.1016\/j.jacep.2024.05.004","article-title":"The Safety and Efficacy of Epicardial Carbon Dioxide Insufflation Compared With Conventional Epicardial Access","volume":"10","author":"Chaumont","year":"2024","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1016\/j.hrthm.2012.12.013","article-title":"Epicardial ablation of ventricular tachycardia: An institutional experience of safety and efficacy","volume":"10","author":"Tung","year":"2013","journal-title":"Heart Rhythm."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2366","DOI":"10.1016\/j.jacc.2009.10.084","article-title":"Epicardial Ventricular Tachycardia Ablation: A Multicenter Safety Study","volume":"55","author":"Sacher","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1161\/CIRCEP.111.962217","article-title":"Epicardial ablation for ventricular tachycardia: A European multicenter study","volume":"4","author":"Brugada","year":"2011","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1016\/j.repc.2013.10.009","article-title":"Abla\u00e7\u00e3o epic\u00e1rdica percut\u00e2nea em arritmias ventriculares","volume":"33","author":"Santos","year":"2014","journal-title":"Rev. Port. Cardiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1111\/j.1540-8167.2011.02179.x","article-title":"QRS characteristics fail to reliably identify ventricular tachycardias that require epicardial ablation in ischemic heart disease","volume":"23","author":"Martinek","year":"2012","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1842","DOI":"10.1161\/01.CIR.0000125525.04081.4B","article-title":"Electrocardiographic recognition of the epicardial origin of ventricular tachycardias","volume":"109","author":"Berruezo","year":"2004","journal-title":"Circulation"},{"key":"ref_21","first-page":"539","article-title":"An epicardial approach for ablation of relapsing atypical atrial flutter: Thinking outside the box","volume":"11","author":"Portugal","year":"2025","journal-title":"Hear. Case Rep."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/24\/8888\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T11:13:10Z","timestamp":1765883590000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/24\/8888"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,16]]},"references-count":21,"journal-issue":{"issue":"24","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["jcm14248888"],"URL":"https:\/\/doi.org\/10.3390\/jcm14248888","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,16]]}}}