Indications in children
Currently, no relevant guideline exists for the epicardial LAA AT treatment in children. Although, endocardial CA was considered to be the best strategy for the child in the present study if AT could be terminated without any complications. The complex anatomy of the left atrial appendage makes it a difficult intracardiac structure in which to manipulate catheters safely9. In one report, firm forward pressure was exerted on the ablating catheter, causing the appendage to straighten9. However, this maneuver could result in LAA perforation10 and thus was not attempted in the reported case.
Thus, the epicardial CA may be an alternative approach to endocardial CA. CA using an epicardial access by a pericardial puncture may be necessary and is a proven feasible route for the management of a variety of arrhythmias6. But the response to radiofrequency applications in epicardial areas differs markedly from the response in endocardial areas because incomplete ablation might result from a lack of contact with the ablation electrode and the thermal homeostatic effect of cavitary saline infusion on the LAA muscles11. And the limited space of pericardial cavity makes it still difficult to manipulate catheter safely.