Skip to main content
Log in

Venous Ethanol Ablation Approaches for Radiofrequency-Refractory Cardiac Arrhythmias

  • Invasive Electrophysiology and Pacing (EK Heist, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

In this review, we summarize the procedural approach and outcomes of venous ethanol infusion in the treatment of ventricular arrhythmias with intramural site of origin.

Recent Findings

Coronary venous ethanol infusion has emerged as a novel, safe, and effective adjunctive strategy to radiofrequency ablation of drug refractory ventricular arrhythmias with an intramural origin.

Summary

Radiofrequency catheter ablation is the first-line treatment for drug refractory ventricular arrythmias. Its success is highly dependent on the ability to reach targeted myocardium. Radiofrequency failures are common in patients with ventricular arrhythmias arising from deep intramural substrates, and those whose origin is in close proximity to vital structures such as coronary arteries or the phrenic nerve. Coronary venous ethanol infusion has emerged as a novel technique that circumvents these limitations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: •  Of importance •• Of major importance

  1. Peachey H, Pedersen CT, Kay GN, et al. EHRA/HRS/APHRS Expert Consensus on Ventricular Arrhythmias. Heart Rhythm. 2014;11(10):e166–96. https://doi.org/10.1016/j.hrthm.2014.07.024.

    Article  Google Scholar 

  2. Sapp JL, Wells GA, Parkash R, et al. Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs. N Engl J Med. 2016;375(2):111–21. https://doi.org/10.1056/nejmoa1513614.

    Article  CAS  PubMed  Google Scholar 

  3. Tokuda M, Kojodjojo P, Tung S, et al. Acute failure of catheter ablation for ventricular tachycardia due to structural heart disease: causes and significance. J Am Heart Assoc. 2013;2(3). https://doi.org/10.1161/JAHA.113.000072.

  4. Neira V, Santangeli P, Futyma P, et al. Ablation strategies for intramural ventricular arrhythmias. Heart Rhythm. 2020;17(7):1176–84. https://doi.org/10.1016/j.hrthm.2020.02.010.

    Article  PubMed  Google Scholar 

  5. Stevenson WG, Tedrow UB, Reddy V, et al. Infusion needle radiofrequency ablation for treatment of refractory ventricular arrhythmias. J Am Coll Cardiol. 2019;73(12):1413–25. https://doi.org/10.1016/j.jacc.2018.12.070.

    Article  PubMed  Google Scholar 

  6. Aziz Z, Moss JD, Jabbarzadeh M, Hellstrom J, Balkhy H, Tung R. Totally endoscopic robotic epicardial ablation of refractory left ventricular summit arrhythmia: first-in-man. Heart Rhythm. 2017;14(1):135–8. https://doi.org/10.1016/j.hrthm.2016.09.005.

    Article  PubMed  Google Scholar 

  7. Nguyen DT, Tzou WS, Sandhu A, et al. Prospective multicenter experience with cooled radiofrequency ablation using high impedance irrigant to target deep myocardial substrate refractory to standard ablation. JACC Clin Electrophysiol. 2018;4(9):1176–85. https://doi.org/10.1016/j.jacep.2018.06.021.

    Article  PubMed  Google Scholar 

  8. Schurmann P, Peñalver J, Valderrábano M. Ethanol for the treatment of cardiac arrhythmias. Curr Opin Cardiol. 2015;30(4):333–43. https://doi.org/10.1097/HCO.0000000000000183.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Inoue H, Waller BF, Zipes DP. Intracoronary ethyl alcohol or phenol injection ablates aconitine-induced ventricular tachycardia in dogs. J Am Coll Cardiol. 1987;10(6):1342–9. https://doi.org/10.1016/S0735-1097(87)80139-0.

    Article  CAS  PubMed  Google Scholar 

  10. Brugada P, de Swart H, Smeets L, Wellens HJ. Clinical investigation transcoronary chemical ablation of ventricular tachycardia address for correspondence and reprints. http://ahajournals.org.

  11. Neal Kay G, Epstein AE, Bubien RS, et al. Intracoronary ethanol ablation for the treatment of recurrent sustained ventricular tachycardia. 19.

  12. Verna E, Repetto S, Saveri C, Forgione N, Merchant S, Binaghi G. Myocardial dissection following successful chemical ablation of ventricular tachycardia. 13:1992.

  13. Tokuda M, Sobieszczyk P, Eisenhauer AC, et al. Transcoronary ethanol ablation for recurrent ventricular tachycardia after failed catheter ablation an update. Published online. 2011. https://doi.org/10.1161/CIRCEP.111.966283/-/DC1.

    Article  Google Scholar 

  14. Sacher F, Sobieszczyk P, Tedrow U, et al. Transcoronary ethanol ventricular tachycardia ablation in the modern electrophysiology era. Heart Rhythm. 2008;5(1):62–8. https://doi.org/10.1016/j.hrthm.2007.09.012.

    Article  PubMed  Google Scholar 

  15. Gabus V, Jeanrenaud X, Eeckhout E, Pruvot E. Transcoronary ethanol for incessant epicardial ventricular tachycardia. Heart Rhythm. 2014;11(1):143–5. https://doi.org/10.1016/j.hrthm.2013.09.058.

    Article  PubMed  Google Scholar 

  16. Wright KN, Morley Bsbme T, Bicknell J, Bishop SP, Walcott GP, Neal Kay G. Retrograde coronary venous infusion of ethanol for ablation of canine ventricular myocardium.

  17. Baher A, Shah DJ, Valderrabano M. Coronary venous ethanol infusion for the treatment of refractory ventricular tachycardia. Heart Rhythm. 2012;9(10):1637–9. https://doi.org/10.1016/j.hrthm.2012.06.003.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Kreidieh B, Rodríguez-Mañero M, Schurmann PA, Ibarra-Cortez SH, Dave AS, Valderrábano M. Retrograde coronary venous ethanol infusion for ablation of refractory ventricular tachycardia. Circ Arrhythm Electrophysiol. 2016;9(7). https://doi.org/10.1161/CIRCEP.116.004352.

  19. Okishige K, Nakamura R, Yamauchi Y, Keida T, Sasano T, Hirao K. Chemical ablation of ventricular tachycardia arising from the left ventricular summit. Clin Case Rep. 2019;7(11):2036–41. https://doi.org/10.1002/ccr3.1397.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Yokokawa M, Good E, Chugh A, et al. Intramural idiopathic ventricular arrhythmias originating in the intraventricular septum mapping and ablation. Circ Arrhythm Electrophysiol. 2012;5(2):258–63. https://doi.org/10.1161/CIRCEP.111.967257.

    Article  PubMed  Google Scholar 

  21. Briceño DF, Enriquez A, Liang JJ, et al. Septal coronary venous mapping to guide substrate characterization and ablation of intramural septal ventricular arrhythmia. JACC Clin Electrophysiol. 2019;5(7):789–800. https://doi.org/10.1016/j.jacep.2019.04.011.

    Article  PubMed  Google Scholar 

  22. Komatsu Y, Nogami A, Shinoda Y, et al. Idiopathic ventricular arrhythmias originating from the vicinity of the communicating vein of cardiac venous systems at the left ventricular summit. Circ Arrhythm Electrophysiol. 2018;11(1). https://doi.org/10.1161/CIRCEP.117.005386.

  23. Loukas M, Bilinsky S, Bilinsky E, El-Sedfy A, Anderson RH. Cardiac veins: a review of the literature. Clin Anat. 2009;22(1):129–45. https://doi.org/10.1002/ca.20745.

    Article  PubMed  Google Scholar 

  24. Tavares L, Fuentes S, Lador A, et al. Venous anatomy of the left ventricular summit: therapeutic implications for ethanol infusion. Heart Rhythm. 2021;18(9):1557–65. https://doi.org/10.1016/j.hrthm.2021.05.008.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Tavares L, Valderrábano M. Retrograde venous ethanol ablation for ventricular tachycardia. Heart Rhythm. 2019;16(3):478–83. https://doi.org/10.1016/j.hrthm.2018.09.010.

    Article  PubMed  Google Scholar 

  26. • Patel A, Nsahlai M, Flautt T, et al. Advanced techniques for ethanol ablation of left ventricular summit region arrhythmias. Circ Arrhythm Electrophysiol. 2022;15(8):519–29. https://doi.org/10.1161/CIRCEP.122.011017. This study delineates techniques to navigate through challenging venous anatomy when targeting LV summit ventricular arrhythmias.

    Article  CAS  Google Scholar 

  27. Da-Wariboko A, Lador A, Tavares L, et al. Double-balloon technique for retrograde venous ethanol ablation of ventricular arrhythmias in the absence of suitable intramural veins. Heart Rhythm. 2020;17(12):2126–34. https://doi.org/10.1016/j.hrthm.2020.05.027.

    Article  PubMed  PubMed Central  Google Scholar 

  28. •• Tavares L, Lador A, Fuentes S, et al. Intramural venous ethanol infusion for refractory ventricular arrhythmias: outcomes of a multicenter experience. JACC Clin Electrophysiol. 2020;6(11):1420–31. https://doi.org/10.1016/j.jacep.2020.07.023. Findings of this study support the effectiveness of venous ethanol infusion.

    Article  PubMed  Google Scholar 

  29. • Fuentes Rojas SC, Malahjfi M, Tavares L, et al. Acute and long-term scar characterization of venous ethanol ablation in the left ventricular summit. JACC Clin Electrophysiol. Published online October 2022. https://doi.org/10.1016/j.jacep.2022.08.035. Finds of this study support the safety of venous ethanol ablation with regards to extent of lesion created by ethanol acutely and in long term follow up.

  30. Kumar S, Tedrow UB, Stevenson WG. Adjunctive interventional techniques when percutaneous catheter ablation for drug refractory ventricular arrhythmias fail. Circ Arrhythm Electrophysiol. 2017;10(2). https://doi.org/10.1161/CIRCEP.116.003676.

  31. Vergara P, Trevisi N, Ricco A, et al. Late potentials abolition as an additional technique for reduction of arrhythmia recurrence in scar related ventricular tachycardia ablation. J Cardiovasc Electrophysiol. 2012;23(6):621–7. https://doi.org/10.1111/j.1540-8167.2011.02246.x.

    Article  PubMed  Google Scholar 

  32. Acosta J, Fernández-Armenta J, Penela D, et al. Infarct transmurality as a criterion for first-line endo-epicardial substrate–guided ventricular tachycardia ablation in ischemic cardiomyopathy. Heart Rhythm. 2016;13(1):85–95. https://doi.org/10.1016/j.hrthm.2015.07.010.

    Article  PubMed  Google Scholar 

  33. Izquierdo M, Sánchez-Gómez JM, Ferrero de Loma-Osorio A, et al. Endo-epicardial versus only-endocardial ablation as a first line strategy for the treatment of ventricular tachycardia in patients with ischemic heart disease. Circ Arrhythm Electrophysiol. 2015;8(4):882–889. https://doi.org/10.1161/CIRCEP.115.002827.

  34. Tung R, Michowitz Y, Yu R, et al. Epicardial ablation of ventricular tachycardia: an institutional experience of safety and efficacy. Heart Rhythm. 2013;10(4):490–8. https://doi.org/10.1016/j.hrthm.2012.12.013.

    Article  PubMed  Google Scholar 

  35. di Biase L, Santangeli P, Burkhardt DJ, et al. Endo-epicardial homogenization of the scar versus limited substrate ablation for the treatment of electrical storms in patients with ischemic cardiomyopathy. J Am Coll Cardiol. 2012;60(2):132–41. https://doi.org/10.1016/j.jacc.2012.03.044.

    Article  PubMed  Google Scholar 

  36. Nakahara S, Tung R, Ramirez RJ, et al. Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy. J Am Coll Cardiol. 2010;55(21):2355–65. https://doi.org/10.1016/j.jacc.2010.01.041.

    Article  PubMed  PubMed Central  Google Scholar 

  37. •• Valderrábano M, Fuentes Rojas SC, Lador A, et al. Substrate ablation by multivein, multiballoon coronary venous ethanol for refractory ventricular tachycardia in structural heart disease. Circulation. Published online November 29, 2022.https://doi.org/10.1161/circulationaha.122.060882. Findings of this study highlight the effectiveness of multiballoon and multivein venous ethanol ablation of complex substrate in patients with structural heart disease.

Download references

Funding

The authors report the following funding: NIH/NHLBI R01HL115003, R01HL168277.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Miguel Valderrábano.

Ethics declarations

Conflict of Interest

None relevant.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fuentes, S., Valderrábano, M. Venous Ethanol Ablation Approaches for Radiofrequency-Refractory Cardiac Arrhythmias. Curr Cardiol Rep 25, 917–924 (2023). https://doi.org/10.1007/s11886-023-01914-6

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-023-01914-6

Keywords

Navigation