Epicardial access facilitated by carbon dioxide insufflation via intentional coronary vein exit: step-by-step description of the technique and review of the literature.

Pericardial access from a subxiphoid approach is often necessary to gain access to a critical epicardial substrate that is inaccessible from the endocardium. Although relatively safe, a rate of up to 5% of acute and 2% delayed complications has been reported. Intentional perforation of a distal coronary vein branch with pericardial insufflation of CO 2 to create a negative contrast space anterior to the right ventricle is an emerging approach to facilitate pericardial access. In this report, we describe the technique of intentional coronary vein exit with CO 2 insufflation to perform epicardial mapping and ablation of ventricular tachycardia (VT) in a step-by-step approach and review the published literature on this topic.