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, 63Ϯ13 years; left ventricular ejection fraction, 30Ϯ11%; ischemic cardiomyopathy, 14) had 29 TCEA procedures attempted. In 5 patients, TCEA was abandoned because of unfavorable anatomy. In 22 patients, a mean of 1.3Ϯ0.6 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. (Circ Arrhythm Electrophysiol. 2011;4:889-896.)

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Background-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. Methods and Results-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%. Conclusions-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. Guest Editor for this article was Gerhard Hindricks, MD. MethodsPatients in whom ≥1 attempt at percutaneous catheter ablation via the endocardial and epicardial approach (when warranted) had failed, and continued to have symptomatic, drug-refractory ventricular tachycardia (VT) or premature ventricular contractions , and were referred for alternative interventional approaches (TCEA, OR-Cryo, or Epi-window) were included. Sixty-seven of 1436 patients undergoing catheter ablation for ventricular arrhythmias were included (mean age, 62±11 years; 78% men; mean left ventricular [LV] ejection fraction, 32±14%; Table 1). Patients had previously failed 4±2 previous AADs, 2±1 previous catheter ablation attempts (range, 1-10), experienced 14±21 shocks (median, 8; interquartile range 25%-75% [Q25-Q75], 4-17) in the preceding month with 52% experiencing VT storm. The majority were on amiodarone (76%), and 92% of patients were receiving a combination of AADs. The time from last attempted ablation to first alternative intervention was a median of 15 days (Q25-Q75, 4-84 days).All patients gave written informed consent for the procedure. Procedures were perfor...