Venous Ethanol Ablation as the Sole Treatment for Intramural Ventricular Arrhythmias

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

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

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.

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.

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