Safety of Carbon Dioxide-Facilitated vs Conventional Epicardial Access: Systematic Review and Meta-Analysis.

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.