Epicardial Ablation

Epicardial ablation is a rhythm treatment performed from the outer surface of the heart. Faulty electrical spots that cause an irregular heartbeat are silenced with heat energy. Once the troublesome spot is shut off, the heart goes back to its steady rhythm.

In most cases, the spots that drive an arrhythmia (the medical term for an abnormal heartbeat) sit on the inner lining of the heart. These can be reached through a vein and treated from the inside. This is known as catheter ablation. But sometimes the source is not on the inside; it lies just under the outer surface of the heart. When that is the case, going through a vein is not enough, and the heart has to be approached from the outside. This is what the word “epicardial” points to. “Epi” means outer and “cardial” refers to the heart. So the procedure works on the outer side of the heart muscle.

Who is this treatment for?

Not every rhythm problem calls for this approach. Standard ablation done from inside the heart is enough for most patients. But in some cases the faulty area is too deep to reach from the inside, or it sits on the outer layer of the heart. If a patient has had a standard ablation before but the rhythm problem has returned, this is often the reason.

Some forms of ventricular tachycardia fall into this group. Ventricular tachycardia is a fast heartbeat that starts in the lower chambers of the heart, called the ventricles, which pump blood out to the body. Certain inherited heart rhythm disorders and some conditions where the heart muscle structure has changed also tend to involve outer-layer spots. The decision is made after looking at the patient’s history, rhythm recordings, and imaging studies together.

How is it done?

The patient is put to sleep under general anesthesia. This keeps both pain and movement away during the procedure. Access is gained through a small puncture just below the breastbone, slightly above the belly. A thin needle is guided into the sac that surrounds the heart, called the pericardium. The pericardium is a thin pouch that wraps around the heart from outside. Once the needle reaches inside this pouch, a slim catheter is passed through it.

A catheter is a thin, flexible tube with a tip that can deliver energy. It is moved over the outer surface of the heart. First, the team maps the area to find out exactly where the irregular signals are coming from. Once the right spot is found, a small dose of energy is applied, and that tiny patch of tissue is taken out of action. The faulty signal source is silenced.

Some patients need work done on both the inner and outer surfaces. In that case, both approaches are combined in the same session. The procedure usually lasts between three and six hours, depending on the location and number of spots.

A clear word about risks

This is an advanced procedure and calls for more care than a standard catheter ablation. Because the needle has to pass into the sac around the heart, nearby structures must be watched closely. The main concern is bleeding around the heart. When this happens, it is usually noticed during the procedure and managed at the same time.

Other possibilities include irritation of the pericardium, mild trauma to nearby thin layers, and rarely, injury to neighboring structures. In experienced hands, serious problems are uncommon. Even so, this treatment is only done at centers with teams trained for it.

After the procedure

Once the patient wakes up, a few hours are spent in an intensive care or observation unit. An overnight hospital stay is the rule. A small amount of fluid can collect around the heart, and this is watched closely.

The puncture spot below the breastbone may feel tender for a day or two. The pain is usually mild and eased with simple pain relievers. Some patients feel a dull chest ache that gets worse when breathing in. This comes from a brief irritation of the pericardium and clears with a short course of medication.

Most patients go home within one or two days. For about a week, heavy lifting and demanding sports should be put aside, and the entry site should be kept clean. Desk work can usually be picked up within a week. Walking and light daily activity can start a few days after going home.

How lasting are the results?

Success depends on which rhythm problem is being treated. Some patients see their rhythm settle in a single session, with no return for years. In others, the source is too widespread to silence fully. The attacks become less frequent and less intense but may not disappear completely. A second procedure may come up in time.

Medication after the procedure is not the same for everyone. For some, rhythm drugs are reduced or stopped. For others, a low dose continues. The call is made based on how the heart behaves at follow-up visits.

When to call the doctor

If chest pain that keeps growing, shortness of breath, fever, or redness and swelling at the entry site appear during recovery, the doctor should be reached without waiting. These can point to pericardial irritation or a problem at the site.

Sudden dizziness, fainting, or fast and uneven heartbeats coming back also need to be checked. A returning palpitation does not always mean the procedure has failed, but it does need a follow-up.