Transcoronary chemical ablation of arrhythmias

Chemical or electrical ablation of an arrhythmogenic ventricular area and the atrioventricular (AV) node is still an experimental technique. After we introduced alcohol ablation in the clinical situation we conducted this study to develop the catheter technique for delivering alcohol in patients with incessant ventricular tachycardia after myocardial infarction and patients with atrial fibrillation and flutter with uncontrollable ventricular rates.

In patients with incessant ventricular tachycardia, the coronary artery supplying blood to the site of origin of the tachycardia could be identified by the combined information from coronary and left ventricular angiography and from programmed electrical stimulation, including endocardial mapping and pace mapping. In the 12 patients with incessant ventricular tachycardia we selected, the coronary artery supplying blood to the site of origin of the tachycardia could be identified and catheterized in ten patients. Ethanol ablation was successful in all of them. With a follow-up from 2 to 44 months, seven of the ten treated patients are still alive and six remain free of tachycardia. In patients with atrial fibrillation or flutter and uncontrollable ventricular rates, the AV artery could be catheterized and ethanol injected in 13 of the 19 patients. Complete block was produced in ten patients and AV conduction was sufficiently modified to control symptoms in three patients. Long-term results with ethanol ablation have remained excellent in this setting.

Chemical ablation is a technique that may be of enormous value and even lifesaving for patients with an incessant form of tachycardia not responding to any form of medical therapy. Transcoronary ablation of AV conduction should be considered in patients with a right dominant coronary circulation in whom radiofrequency ablation has failed.