Venous Ethanol Ablation as the Sole Treatment for Intramural Ventricular Arrhythmias

BACKGROUND: Venous ethanol ablation (VEA) can be effective in radiofrequency ablation (RFA) failure but has not been tested as a stand-alone procedure.

OBJECTIVES: The goal of this study was to determine the value of VEA alone as the sole ablation strategy in intramural ventricular arrhythmias (VAs).

METHODS: Patients (N = 52; prior failed RFA procedures in 24 patients) underwent mapping of the right and left ventricular endocardium and coronary sinus (CS) branches identified by venography. VEA was a first strategy if the CS intramural veins had earlier pre-systolic or mid-diastolic signals than those elsewhere. If VEA was successful, RFA was omitted. Ablated volume was estimated by intracardiac echocardiography or cardiac magnetic resonance imaging.

RESULTS: VAs were either premature ventricular contraction (n = 36) or ventricular tachycardia (VT) (n = 16). Intramural venous signals were 40 milliseconds pre-QRS (Q1-Q3: 32-44 milliseconds) compared with 8 milliseconds (Q1-Q3: 0-15 milliseconds) for best endocardial or CS signals (P < 0.0001). Acute VA suppression occurred in all patients after a median 8 mL (Q1-Q3: 5-15 mL) of ethanol. Ablated volume was 2.5 mL (Q1-Q3: 1.6-4 mL) according to intracardiac echocardiography or 2.8 mL (Q1-Q3: 2.3-7.4 mL) according to cardiac magnetic resonance imaging. VEA resulted in reduction in premature ventricular contraction burden from 21% to 0.5% (P < 0.0001) and the need for ICD therapy in 71% of patients. Six patients experienced recurrence after a median follow-up of 9.5 months, which required repeat procedures in 3 patients. Postoperative complications included pericarditis in 3 patients, groin hematoma in 1, and transient right bundle branch block in 2.

CONCLUSIONS: VEA-only can be effective as the sole ablation strategy when vein mapping indicates an intramural origin.