Feasibility, safety, and efficacy of epicardial CO2 insufflation to facilitate epicardial access for VT ablation: A systematic review and meta-analysis.

BACKGROUND: Percutaneous epicardial access (EA) is essential for catheter ablation of ventricular tachycardia (VT), yet conventional "dry" subxiphoid puncture remains technically challenging and carries substantial risks, particularly in patients with previous cardiac interventions or pericardial adhesions. Epicardial carbon dioxide insufflation (EpiCO2) has recently emerged as a novel strategy to enhance pericardial visualization and facilitate safer, more efficient EA. OBJECTIVE: This study aimed to evaluate the feasibility, safety signals, and procedural performance of EpiCO2-assisted EA in adults undergoing VT ablation. METHODS: We conducted a systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered on the International Prospective Register of Systematic Reviews (CRD420251162014) to evaluate the feasibility, safety, and procedural performance of EpiCO2-assisted EA in adults undergoing VT ablation. A comprehensive search of PubMed, Scopus, Web of Science, Cochrane, and Embase identified 7 observational studies comprising 336 patients. RESULTS: EpiCO2-assisted EA demonstrated high feasibility, with a pooled procedural success rate of 94% (95% confidence interval 90-96). Mean carbon dioxide volume insufflated was 155.9 mL, EA time averaged 23.5 minutes, and fluoroscopy time averaged 47.0 minutes. Major complications were infrequent, including pericarditis (4%), bleeding of ≥80 mL (5%), and death (1%). Pericardial adhesions were observed in 7% of patients. Limited comparative meta-analysis revealed no significant differences in procedural success or total procedure time between EpiCO2-assisted and conventional EA technique. CONCLUSION: EpiCO2-assisted EA is feasible with acceptable safety profile in observational VT cohorts. Well-designed prospective multicenter comparative studies are needed to define its potential advantages over conventional "dry" EA.