Transcoronary Ethanol Ablation Research Articles

Retrograde Coronary Venous Ethanol Infusion for Ablation of Refractory Left Ventricular Summit Arrhythmias.

Chemical ablation using the transcoronary arterial system has a lengthy but arduous history. Although it has shown to be efficacious in controlling ventricular arrhythmias, safety concerns from cannulation of the coronary arterial system to unwanted ethanol downstream effects have limited transcoronary ethanol ablation (TCEA)'s use. Retrograde coronary venous ethanol ablation (RCVEA) has shown promising results. Although it appears to be in its infancy, RCVEA appears to be the future of chemical ablation in comparison to TCEA due to its increased safety and efficacy. Prospective randomized trial data is needed for this adjunctive treatment to radiofrequency ablation.

Atrioventricular Block During Catheter Ablation for Ventricular Arrhythmias.

This study sought to evaluate the incidence and significance of atrioventricular (AV) block associated with ventricular arrhythmia (VA) ablation. Attempted ablation of VAs that arise from the septum carries a risk of AV block. Data from 1,418 patients who had catheter ablation for drug-refractory VAs were evaluated. Two analyses were conducted. The first analysis assessed the patient and procedure characteristics associated with ablation-induced AV block. The second analysis investigated outcome differences between patients with and without AV block. For the second analysis, patients with AV block (Group I) were compared with a 1:2 propensity score-matched control group (Group II) and with patients with pre-existing AV block before ablation (Group III). Twenty-one (1.6%) patients developed AV block. In multivariable analysis, nonischemic cardiomyopathy (odds ratio: 3.33; 95% confidence interval: 1.32 to 8.40; p = 0.011) and transcoronary ethanol ablation (odds ratio: 46.50; 95% confidence interval: 14.10 to 153.00; p< 0.001) were independently associated with AV block. Subsequent to the AV block, 9 patients were upgraded from an implantable cardioverter-defibrillator to cardiac resynchronization therapy with defibrillator (CRT-D), 2 had de novo CRT-D implantation, 5 had pre-existing CRT-D, and 5 had pacing without CRT. VAs recurred in 33% of patients in Group I, 17% in Group II (log-rank p= 0.842), and 35% in Group III (p= 0.636). The composite outcome of heart failure hospitalization, heart transplantation, or death occurred in 29% of patients in Group I, 17% in Group II (p= 0.723), and 45% in Group III (p= 0.303). Complete AV block occurs in fewer than 2% of patients undergoing VA ablation and does not appeartobe associated with the worse outcome of heart failure hospitalization, heart transplantation, or death.

Transcoronary ethanol ablation for incessant ventricular tachycardia: a salvage technique when faced with left ventricular thrombus.

A 77-year-old man with a history of bypass surgery following an anterior myocardial infarction was admitted with a VT storm (Fig. 1A). Coronary angiography revealed occlusion of the left anterior descending (LAD) artery with a patent vein graft to the distal vessel, backfilling the mid-anterior septum. Left ventriculography demonstrated poor left ventricular (LV) systolic function and a calcified apical aneurysm with thrombus (confirmed by contrast echocardiography). LV endocardial mapping was therefore abandoned. Epicardial mapping identified no target. After further shocks and failed medical therapy, endocardial mapping revealed an exit site at the right ventricular septum adjacent to a scar zone and the thrombus within the LV aneurysm (Fig. 2A). The red asterisk marks the site of the best pacemap (Fig. 1B) where the tip of the catheter is on the right side of the interventricular septum. Angiography was performed with the LAD graft (white arrowhead) and the distal LAD (black arrowhead) patent (Fig. 2B). The shaded area denotes the superimposed territory of a mid-LAD septal branch on angiography (Fig. 2A and ​andB).B). An interventional wire was retrogradely advanced into the septal branch of the LAD (black asterisk) that subtended the territory of VT origin (shaded region). A balloon occluded (black arrowhead) the retrograde limb of the LAD with contrast injection confirming the position (white dotted line) (Panel C, Fig. 2). After injection of a single 2mL aliquot of ethanol (dehydrated alcohol, Martindale) over 3 min, final angiographic assessment confirmed occlusion of the retrograde limb of the LAD (Panel D, Fig. 2). Clinical VT was rendered non-inducible. Follow-up at 15 months confirmed no further VT. Transcoronary ethanol ablation represents a viable salvage technique when faced with LV thrombus. Fig. 1 Twelve-lead ECG of ventricular tachycardia (Panel A) and at the site of pacemap match (Panel B) Fig. 2 Fluoroscopic images of best pacemap (red asterisk) at VT exit site on RV side of interventricular septum (Panel A); patent LAD graft (white arrowhead) and distal LAD (black arrowhead) with interventional wire retrogradely inserted into septal branch of ...

Role of alternative interventional procedures when endo- and epicardial catheter ablation attempts for ventricular arrhythmias fail.

Ventricular tachycardia (VT) refractory to antiarrhythmic drugs and standard percutaneous catheter ablation techniques portends a poor prognosis. We characterized the reasons for ablation failure and describe alternative interventional procedures in this high-risk group. Sixty-seven patients with VT refractory to 4±2 antiarrhythmic drugs and 2±1 previous endocardial/epicardial catheter ablation attempts underwent transcoronary ethanol ablation, surgical epicardial window (Epi-window), or surgical cryoablation (OR-Cryo; age, 62±11 years; VT storm in 52%). Failure of endo/epicardial ablation attempts was because of VT of intramural origin (35 patients), nonendocardial origin with prohibitive epicardial access because of pericardial adhesions (16), and anatomic barriers to ablation (8). In 8 patients, VT was of nonendocardial origin with a coexisting condition also requiring cardiac surgery. Transcoronary ethanol ablation alone was attempted in 37 patients, OR-Cryo alone in 21 patients, and a combination of transcoronary ethanol ablation and OR-Cryo (5 patients), or transcoronary ethanol ablation and Epi-window (4 patients), in the remainder. Overall, alternative interventional procedures abolished ≥1 inducible VT and terminated storm in 69% and 74% of patients, respectively, although 25% of patients had at least 1 complication. By 6 months post procedures, there was a significant reduction in defibrillator shocks (from a median of 8 per month to 1; P<0.001) and antiarrhythmic drug requirement although 55% of patients had at least 1 VT recurrence, and mortality was 17%. A collaborative strategy of alternative interventional procedures offers the possibility of achieving arrhythmia control in high-risk patients with VT that is otherwise uncontrollable with antiarrhythmic drugs and standard percutaneous catheter ablation techniques.

Severe Gastrointestinal Bleeding in a Patient With Subvalvular Aortic Stenosis Treated With Thalidomide and Octreotide: Bridging to Transcoronary Ablation of Septal Hypertrophy

Gastrointestinal bleeding (GB) due to angiodysplasias can cause severe, recurrent bleeding, especially in elderly patients. Angiodysplastic bleedings in the gastrointestinal tract have been associated with aortic stenosis and, more recently, hypertrophic obstructive cardiomyopathy, caused by an acquired coagulopathy known as Heyde’s syndrome. Multiple factors are involved in the pathogenesis of angiodysplastic bleeding including genetic factors and increased levels of vascular intestinal growth factor at tissue levels. Endoscopic coagulation therapy is the primary treatment but often fails to resolve bleeding, especially in patients with large numbers of angiodysplasias. In patients with aortic stenosis and GB, the main treatment is aortic valve replacement but the patients may be unfit to undergo surgery due to the complicating anemia. In this case story, we present a patient with severe, GB due to hypertrophic subvalvular obstructive cardiomyopathy. Endoscopic procedures with argon beaming were performed without effect on bleeding. The patient was treated with a combination of both thalidomide and octreotide. Within 3 months, the patient recovered from the anemia and was able to undergo transcoronary ethanol ablation. No further bleeding episodes occurred, and thalidomide and octreotide were arrested. To our knowledge, this case report is the first to describe how this new drug combination therapy is an effective treatment of GB from angiodysplasias and can be used to bridge to surgical or endovascular treatment.

Transcoronary ethanol for incessant epicardial ventricular tachycardia

Introduction In the early 1990s, transcoronary ethanol ablation (TCEA) had been described as an alternative to surgery in patients with incessant ventricular tachycardia (VT). With improving technology, endocardial and epicardial radiofrequency catheter ablation (RFCA) has become first-line therapy in refractory VT. However, there are still patients in whom these techniques are either unsuccessful or contraindicated.

Coronary venous ethanol infusion for the treatment of refractory ventricular tachycardia

Radiofrequency catheter ablation (RFCA) is used increasingly to treat drug-refractory ventricular tachycardias (VTs) (1). Although originally limited to endocardial VTs, access to the pericardial space via a nonsurgical subxyphoid technique has allowed RFCA to target epicardial circuits as well (2). Nevertheless, there still exists a subgroup of VTs that remain refractory to RFCA. This includes VTs with a deep intramural origin, either from reentrant or focal mechanisms. Additionally, there are cases where proximity to the coronary vessels limits attempts at aggressive ablation of the VT origin. Finally, the epicardial approach for RFCA may be difficult if not impossible in cases of prior cardiac surgery (3). Transcoronary ethanol ablation (TCEA) has been used as an alternative strategy to effectively treat these difficult-to-ablate VTs (4). Although TCEA is reasonably successful in treating RCFA refractory VTs, there are technical difficulties and potential complications inherent to coronary artery instrumentation such as coronary arterial dissection, thrombosis, and myocardial infarction. Other complications are related to spillage of ethanol to non-targeted myocardium resulting into interventricular conduction blocks, and infarction of non-selected regions (5, 6). Retrograde coronary venous ethanol ablation (RCVEA) can potentially avoid the aforementioned technical difficulties of TCEA. Catheter instrumentation in the coronary veins lacks the risks of arterial damage, and retrograde flow drives spilled ethanol towards the right atrium where it is diluted to non-damaging concentrations. This approach was first described by Wright et al. in dogs (7) but, to our knowledge, has not yet been tested on human subjects. Here, we describe two cases in which RCVEA successfully terminated persistent VTs refractory to multiple RFCA procedures.

Optimal ablation strategies for different types of ventricular tachycardias

Ablation strategies for almost all types of ventricular tachycardias have now been established. The optimal ablation strategy for ventricular tachycardia is determined by the site of origin and the electrophysiological mechanisms. Electrocardiograms, an understanding of the common sites of basic disease, and identification of the scar site using imaging modalities might be helpful for predicting the originating location. Electrophysiological activation mapping is the gold standard for identification of the ventricular tachycardia substrate. However, when activation mapping of scar-related ventricular tachycardias is not possible, substrate mapping might be performed to identify isolated diastolic potentials. Substrates are commonly located in the endocardium, but transvenous or subxiphoidal intrapericardial approaches can be used to map epicardial substrates. Unusual types of ventricular tachycardia might require special strategies, such as transcoronary ethanol or intramural needle ablation. For idiopathic ventricular tachycardias, ablation might be a first-line therapy because of its high efficacy and very low risk of complications. However, the recurrence rate of scar-related ventricular tachycardias remains considerable, and ablation remains an adjunctive therapy to medical therapy and implantable cardioverter-defibrillators. When incessant ventricular tachycardia or fibrillation requiring defibrillator therapy (electrical storm) is refractory to antiarrhythmic drugs, neuraxial modulation, including sedation, might be the next option before catheter ablation is attempted.

Transcoronary Ethanol Ablation for Recurrent Ventricular Tachycardia After Failed Catheter Ablation

Background— Despite substantial progress, radiofrequency catheter ablation (RFCA) fails in some patients. After encouraging results with transcoronary ethanol ablation (TCEA), we began offering TCEA routinely when endocardial and epicardial RFCA failed or a deep intramural substrate was likely. Methods and Results— Among 274 consecutive patients who underwent 408 ventricular tachycardia (VT) ablation procedures, 27 patients (21 men; age, 63±13 years; left ventricular ejection fraction, 30±11%; ischemic cardiomyopathy, 14) had 29 TCEA procedures attempted. In 5 patients, TCEA was abandoned because of unfavorable anatomy. In 22 patients, a mean of 1.3±0.6 arteries (range, 1–3 arteries) were targeted for TCEA. After ablation, the targeted VT was no longer inducible in 18 of 22 (82%) patients. Complete heart block occurred in 5 patients, and 3 patients with advanced heart failure died within 30 days of the procedure. After the last TCEA procedure, a VT recurred in 64% of patients, and overall, 32% of patients died. Of 11 patients with prior VT storm, 9 were free of VT storm. At repeat study in 8 patients who had a recurrence, 7 had a new QRS morphology of VT originating from the same general substrate region as the prior VT. Conclusions— In patients with difficult-to-control VT in whom RFCA fails, TCEA prevents all VT recurrences in 36% and improves arrhythmia control in an additional 27%. Inadequate target vessels, collaterals, and recurrence of modified VTs limit efficacy, but TCEA continues to play an important role for difficult VTs in these high-risk patients.

In Memoriam: Thomas N. James, MD

diography (Definity, Lantheus Medical Imaging, North Billerica, MA, USA) demonstrated reduced perfusion of the basal inferior septum with borderline left ventricular function. Throughout the remainder of his hospital stay, the patient displayed no evidence of clinical PVCs or VT. He was discharged home 2 days postprocedure. Catheter-based ablation of recurrent sustained monomorphic VT is an important therapeutic option for patients with frequent, drug-refractory ICD shocks. It is not uncommon for VT to arise from the basal interventricular septum, particularly in patients with nonischemic cardiomyopathy. In these cases, radiofrequency ablation may fail, and transcoronary ethanol ablation is an option. To our knowldge, this is the first report of successful transcoronary thanol ablation for VT via an anomalous septal perforating rtery arising from the right sinus of Valsalva. Anomalous

Substrate Characterization and Catheter Ablation for Monomorphic Ventricular Tachycardia in Patients With Apical Hypertrophic Cardiomyopathy

VT Ablation in Apical Hypertrophic Cardiomyopathy. Monomorphic ventricular tachycardia (VT) is uncommon in apical hypertrophic cardiomyopathy (HCM). The purpose of this study was to define the substrate and role of catheter ablation for VT in apical HCM. Four patients with apical HCM and frequent, drug refractory VT (mean age of 46 ± 10 years, left ventricular [LV] ejection fraction; 54 ± 14%) underwent catheter ablation with the use of electroanatomic mapping. Endocardial mapping was performed in 4 patients and 3 patients underwent epicardial mapping. In 3 patients, VT was related to areas of scar in the apical LV where maximal apical wall thickness ranged from 14.5 to 17.8 mm, and 2 patients had apical aneurysms. Endocardial and epicardial substrate mapping revealed low voltage (<1.5 mV) scar in both endocardial and epicardial LV in 2 and only in the epicardium in 1 patient. Inducible VT was abolished with a combination of endocardial and epicardial ablation in 2 patients, but was ineffective in the third patient who had intramural reentry that required transcoronary ethanol ablation of an obtuse marginal vessel for abolition. The fourth patient had focal nonsustained repetitive VT from right ventricular outflow tract (RVOT), consistent with idiopathic RVOT-VT, that was successfully ablated. During follow-ups of 3-9 months, all patients remained free from VT. Monomorphic VT in apical HCM can be due to endocardial, epicardial or intramural reentry in areas of apical scar. Epicardial ablation or transcoronary alcohol ablation is required in some cases.

Abstract 1736: Is There An Indication For Transcoronary Ethanol VT Ablation In 2007?

Introduction: TransCoronary Ethanol Ablation (TCEA) was proposed 15 years ago for incessant VTs resistant to any treatment (medications or ablation). However we sought to investigate whether this therapy could still be useful in the area of modern radiofrequency ablation. Methods: Eight patients (6 males, 55 ±7yo, 2.1 ±0.8 failed VT ablations) out of 586 VT ablation procedures underwent TCEA between 2000 and 2006. After identification of the artery supplying blood to the arrhythmogenic area, an angioplasty balloon was advanced in the artery then VT was induced and cooled saline infusion was performed distal to the balloon. If this did not interrupt VT another artery was targeted. If VT stopped, 1 to 5 ml of pure ethanol (96%) was injected. Results: All patients had scar related VT (septal:7, left inferior wall:1) with 4 pts having a non ischemic cardiomyopathy. Mean left ventricle ejection fraction prior to the procedure was 23 ±9%. In patients with septal scar, 1st and/or 2nd septal artery were targeted in 5 pts whereas for 2 this was not effective and a distal branch of the circumflex and the conus branch of the right coronary artery were targeted in 2. A branch of the posterior descending artery was targeted in the patient with inferior scar. Acute success was obtained in 5/8 (63%). Two patients experienced complications (transient cardiac stunning after ethanol infusion and delayed AV block). Twenty-four hours after the procedure, mean troponin Ic [0 – 0.1 ng/ml] and CPK-MB [0–5 ng/ml] were respectively 19.75 ±12.79 ng/ml and 121 ±108 ng/ml, mean ejection fraction was 18 ±8%(NS compared to before). With a mean follow-up of 29 ±23 months, 6/8 (75%) patients are still alive with no recurrence in 4 (50%). Conclusion: TCEA is an option in cases of refractory VT who fail radiofrequency ablation, especially in cases of septal scar.

Transcoronary ethanol ventricular tachycardia ablation in the modern electrophysiology era

Radiofrequency catheter ablation for ventricular tachycardia (VT) may be unsuccessful when critical portions of the circuit cannot be interrupted with either endocardial or epicardial radiofrequency application. We sought to investigate whether transcoronary ethanol ablation (TCEA) can be used as a therapy for patients with VT who have failed medications and radiofrequency ablation in the modern era. Nine patients (7 men, 55 +/- 9 years old, left ventricular ejection fraction 23% +/- 8%, 2.2 +/- 0.8 failed VT ablations) with at least 1 unsuccessful attempt at radiofrequency catheter ablation for symptomatic VT at our institution between 2000 and May 2007 underwent TCEA. The majority of patients had an ischemic cardiomyopathy (67%), and all patients had VT due to scar-related reentry. In the 7 patients with VT involving a septal scar, a septal perforator artery was a suitable target in 5 patients, whereas in the remaining patients, a distal branch of the circumflex and the conus branch of the right coronary artery were targeted. In the 2 patients in whom VT involved an inferior scar, a branch of the posterior descending artery was targeted. Acute success was obtained in 56% of patients (89% for clinical targeted VT). During a mean follow-up of 29 +/- 23 months, 3 deaths occurred and 67% of the patients were free of recurrence. TCEA may represent an option in patients with refractory VT in whom radiofrequency ablation fails, especially in cases of septal scar in which failure is thought to be caused by inability to provide adequate lesion depth.

Morphology of necrosis and repair after transcoronary ethanol ablation of septal hypertrophy.

The transcoronary ethanol ablation of septum hypertrophy (TASH) results in a necrosis of the myocardium. In contrast to the ischemically induced necrosis, there is not any phagocytosis caused by leukocytes and macrophages, nor does transformation into granulation tissue occur. Even six months after the application of ethanol, the myofibrils can be identified as "ghost cells" surrounded by a web of collagen fibers. This special forming of a scar, unknown to this day, is documented by 13 patients who died between 25 minutes and two years after ethanol-induced ablation of the hypertrophic septum in hypertrophic obstructive cardiomyopathiy (HOCM).