In this final live case of the RIO 2025 global programme, chair Richard Schilling (London, UK) links to case operator Roderick Tung (University of Arizona College of Medicine, Phoenix, US) for an epicardial VT ablation in a patient with Brugada syndrome. Panellists Devi Nair (Jonesboro, US), Usha B Tedrow (Boston, US) and Krishna Pothineni (Kansas City, US) first review which patients require epicardial approaches, the role of cardiac MRI and CT with advanced processing, and practical strategies to plan access, avoid adhesions and protect the coronary arteries. They also discuss endpoints in Brugada ablation, including targeting abnormal epicardial electrograms and normalisation of the type 1 ECG pattern.
Roderick Tung’s team then demonstrate stepwise epicardial access, highlighting safe needle technique, use of contrast, double-wiring and pericardiography, followed by epicardial mapping over the right ventricular outflow tract. The case shows characteristic fractionated, late electrograms and real-time ECG changes during targeted ablation, with discussion on distinguishing Brugada from ARVC overlap, managing pericardial effusions and defining how much ablation is enough. The session closes with reflections on procedural efficiency, global experience with Brugada ablation and how refined epicardial VT workflows can improve outcomes in complex ventricular arrhythmia patients.
