Retrograde Coronary Venous Ethanol Infusion for Ablation of Refractory Ventricular Tachycardia.

BACKGROUND: Radiofrequency ablation (RFA) of ventricular tachycardia (VT) can fail because of inaccessibility to the VT substrate. Transarterial coronary ethanol ablation can be effective but entails arterial instrumentation risk. We hypothesized that retrograde coronary venous ethanol ablation can be an alternative bail-out approach to failed VT RFA. METHODS AND RESULTS: Out of 334 consecutive patients undergoing VT/premature ventricular contraction ablation, 7 patients underwent retrograde coronary venous ethanol ablation. Six out of 7 patients had failed RFA attempts (including epicardial in 3). Coronary venogram-guided venous mapping was performed using a 4F quadripolar catheter or an alligator-clip-connected angioplasty wire. Targeted veins included those with early presystolic potentials and pace-maps matching VT/premature ventricular contraction. An angioplasty balloon (1.5-2×6 mm) was used to deliver 1 to 4 cc of 98% ethanol into a septal branch of the anterior interventricular vein in 5 patients with left ventricular summit VT, a septal branch of the middle cardiac vein, and a posterolateral coronary vein (n=1 each). The clinical VT was successfully ablated acutely in all patients. There were no complications of retrograde coronary venous ethanol ablation, but 1 patient developed pericardial and pleural effusion attributed to pericardial instrumentation. On follow-up of 590±722 days, VT recurred in 4 out of 7 patients, 3 of whom were successfully reablated with RFA. CONCLUSIONS: Retrograde coronary venous ethanol ablation is safe and feasible as a bail-out approach to failed VT RFA, particularly those originating from the left ventricular summit.

Strategies for phrenic nerve preservation during ablation of inappropriate sinus tachycardia.

BACKGROUND: Radiofrequency (RF) ablation can alleviate drug-refractory inappropriate sinus tachycardia (IST). However, phrenic nerve (PN) injury and other complications limit its use. OBJECTIVE: The purpose of this study was to characterize the maneuvers used to avoid PN injury and the long-term clinical outcomes. METHODS: The study consisted of a retrospective analysis of consecutive patients who underwent ablation for IST. RESULTS: RF ablation was performed on 13 consecutive female patients with drug-refractory IST. Eleven patients exhibited PN capture at desired ablation sites. In 1 patient, PN capture was not continuous throughout the respiratory cycle and ventilation holding sufficed to avoid PN injury. In 10 patients, pericardial access (PA) and balloon insertion was required. Initially (n = 4) a posterior PA was used, which was replaced by an anterior PA in the subsequent 6 cases. PA to optimal balloon positioning time was significantly lower in anterior vs posterior PA (16.3 ± 6 minutes vs 58 ± 21.3 minutes, P = .01), as was fluoroscopy time (15.66 ± 16.72 min vs 35.9 ± 1.8 min, P = .03). RF ablation successfully reduced sinus rate to <90 bpm in 13 of 13 patients. Procedure times and total RF times were not significantly different in anterior vs posterior PA. Major complications occurred in 2 patients, including unremitting pericardial bleeding requiring open-chested repair in 1 patient and sinus pauses mandating pacemaker implantation in the other patient. Long-term symptom control after follow-up of 811 ± 42 days was successful in 84.6%. CONCLUSION: Ventilation holding and/or pericardial balloon insertion are frequently warranted in IST ablation. Anterior PA appears to facilitate the procedure over posterior PA.