Percutaneous Epicardial Ablation Offers Definitive Treatment for Refractory Inferoparaseptal Accessory Pathways: Case Report

These findings of case report are published in the Indian Pacing and Electrophysiology Journal in January 2026, by Lead author Yogesh Jagannath Kulkarni of Department of Cardiology, at Christian Medical College in Vellore, Tamil Nadu, India

The specifically documented clinical case holds profound and direct significance for modern medical practice by demonstrating a highly viable, structured fallback strategy when standard radiofrequency ablation therapies prove anatomically inadequate for treating patients. It strongly emphasizes that operating electrophysiologists must remain rigorously prepared to confidently transition toward alternative epicardial routes, ensuring they can still achieve definitive therapeutic success in exceptionally challenging, resistant arrhythmia presentations.

A thirty-eight-year-old woman initially presented with severe recurrent palpitations and pre-excited atrial fibrillation, prompting comprehensive electrocardiogram (ECG) and venogram investigations that ultimately diagnosed an inferoparaseptal AP complicated by a distinct CS diverticulum. Following multiple unsuccessful standard internal ablation attempts, the medical team effectively treated her using a percutaneous epicardial ablation applied near the posterior left atrioventricular sulcus, which produced a complete physiological recovery with absolutely no symptom recurrence at the three-month clinical follow-up.

Mechanistically, the aberrant electrical pathway's highly unusual physical location deep within a fusiform dilated posterior vein allowed the problematic conduction circuit to completely evade traditional endocardial energy delivery systems. By strategically bypassing the internal endocardium to directly access the external epicardial space, the surgical team delivered sufficient radiofrequency energy to permanently disrupt the anomalous connection without compromising adjacent vital cardiac structures or overlying vessels.

Thus, the case study concludes cardiology practitioners must seriously consider this specialized percutaneous epicardial technique when actively confronting refractory paraseptal pathways, primarily because it provides remarkably enhanced catheter maneuverability and effectively circumvents restrictive internal anatomical obstacles. Implementing this advanced procedural approach directly elevates overall patient care by offering a definitive cure for otherwise treatment-resistant cases while simultaneously minimizing conventional procedural risks such as unintended valve damage and systemic vascular embolism.

Reference

Kulkarni, Y. J., Srinath, S. C., Manickavasagam, A., & Jacob, J. R. (2026). Accessory pathway ablation: When the going gets tough, the tough go epicardial. Indian Pacing and Electrophysiology Journal, 26, 159–161.