Does pericardial carbon dioxide insufflation reduce access-related complications compared to traditional dry epicardial puncture in patients undergoing percutaneous epicardial access?
Pericardial carbon dioxide insufflation significantly reduces the risk of inadvertent ventricular puncture and complications requiring surgery compared to traditional dry epicardial puncture.
BACKGROUND Percutaneous epicardial access has been increasingly adopted in clinical practice, particularly for ventricular tachycardia ablation. "Dry" epicardial puncture (Dry-EPI) carries a considerable risk of access-related complications, even with modified techniques. Pericardial carbon dioxide insufflation (EpiCO2) has emerged as a promising alternative, potentially enhancing safety by increasing anatomical clearance between pericardial layers. OBJECTIVES This study compared the safety and efficacy of EpiCO2 vs traditional Dry-EPI techniques through systematic review, meta-analysis, and meta-regression. METHODS PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane databases were searched using medical subject heading terms "epicardial access," "carbon dioxide insufflation," "complications," and similar key words. Random-effects meta-analyses of proportions and means, subgroup analyses, and meta-regressions were conducted. RESULTS One hundred nineteen studies (8,784 procedures) were included; most (95.0%) were of moderate or high quality. Ventricular tachycardia ablation was the main access indication (n = 7,178). EpiCO2 was used in 493 procedures (5.6%) and Dry-EPI in 8,291 (94.4%). Among 5,786 Dry-EPI cases with specified needle type, 5,184 (89.6%) used a large-bore needle and 602 (10.4%) a micropuncture needle. EpiCO2 was associated with significantly fewer complications requiring surgery compared with Dry-EPI (0.24% 95% CI: 0.00-0.93 vs 1.55% 95% CI: 1.27-1.86, P < 0.010), large-bore needle (0.24% 95% CI: 0.00%-0.93% vs 1.58% 95% CI: 1.23-1.97, P < 0.010), and micropuncture (0.24 95% CI: 0.00-0.93 vs 1.66% 95% CI: 0.60-3.17, P = 0.020). Inadvertent ventricular puncture was also lower with EpiCO2 compared with Dry-EPI (0.28% 95% CI: 0.00-1.00 vs 3.17% 95% CI: 2.36-4.10, P < 0.010). CONCLUSIONS Compared with Dry-EPI, EpiCO2 was associated with significantly lower risk of inadvertent ventricular puncture and complications requiring surgery, supporting broader clinical adoption.
Castello-Branco et al. (Sun,) studied this question.