Double-balloon technique for retrograde venous ethanol ablation of ventricular arrhythmias in the absence of suitable intramural veins

Da-Wariboko, Akanibo; Lador, Adi; Tavares, Liliana; Dave, Amish S.; Schürmann, Paul; Peichl, P; Kautzner, Josef; Papiashvili, Giorgi; Valderrábano, Miguel

doi:10.1016/j.hrthm.2020.05.027

Cited by 19 publications

(29 citation statements)

References 8 publications

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“…We had previously described the double-balloon approach to achieve large-substrate ablations. 4 Here, we expand it by showing that restricted VEA can be successfully achieved in the context of LVS VA. After VEA via the proximal balloon, myocardial staining was restricted to the interballoon portion of the vein. By positioning the balloons proximal and distal to the VA site of origin, successful ablation was achieved without obvious damage to untargeted myocardium.…”

Section: Discussionmentioning

confidence: 77%

“…Our approach for mapping of the coronary venous system has been previously described. 4 Briefly, the CS was cannulated with a large sheath (Preface, Biosense Webster or Agilis, Abbott, St Paul, MN) from the femoral vein or right internal jugular vein to serve as a platform for further instrumentation. A multipolar catheter (DevaNav, Biosense Webster) was inserted into the CS, GCV, and AIV for pacing and recording and to create 3-dimensional matrix.…”

Section: Methodsmentioning

confidence: 99%

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Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias

Patel

Nsahlai

Flautt

et al. 2022

Circ: Arrhythmia and Electrophysiology

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Background: Coronary venous ethanol ablation (VEA) can be used as a strategy to treat ventricular arrhythmias arising from the left ventricular summit, but collateral flow and technical challenges cannulating intramural veins in complex venous anatomies can limit its use. Advanced techniques for VEA can capitalize on collateral vessels between target and nontarget sites to improve success. Methods: Of 55 patients with left ventricular summit ventricular arrhythmia, advanced techniques were used in 15 after initial left ventricular summit intramural vein mapping failed to show suitable targets for single vein, single-balloon VEA. All patients had previous radiofrequency ablation attempts. Techniques included: double-balloon for distal protection to block distal flow and target the proximal portion of a large intramural vein where best signal was proximal (n=6); balloons in 2 different left ventricular summit veins for a cross-fire multivein VEA (n=4); intramural collateral vein-to-vein cannulation to reach of targeted vein via collateral with antegrade ethanol and proximal balloon block (n=2); prolonged ethanol dwell time for vein sclerosis of large intramural vein and subsequent VEA (n=3); and intramural collateral VEA (n=1). Results: Fifteen (8 females) patients (age 60.6±17.6 years) required advanced techniques. Procedure time was 210±49.9 minutes, fluoroscopy time was 25.3±14.1 minutes, and 113±17.9 cc of contrast was utilized. A median of 7 cc of ethanol was delivered (range, 4–15 cc). Intraprocedural radiofrequency ablation was delivered before ethanol in 9 out of 15 patients but failed. Ethanol achieved acute success in all 15 patients. Ethanol was used as the sole treatment in two patients. At a median follow-up of 194 days, one patient experienced recurrence. Conclusions: Advanced techniques capitalizing on venous anatomy can enable successful VEA and selective targeting of arrhythmogenic sites, by blocking distal flow, utilization of collaterals between nontarget and target veins and multivein VEA. Understanding individual anatomy is critical for VEA success.

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Section: Discussionmentioning

confidence: 77%

Section: Methodsmentioning

confidence: 99%

Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias

Patel

Nsahlai

Flautt

et al. 2022

Circ: Arrhythmia and Electrophysiology

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“…The overall incidence of procedural complications was 14.1% (CI 95% : 9.8–19.8). Four studies reported no procedural complications 17,19,22–23 . In the remaining six studies, the rate of procedural complications varied between 7.9% to 43%.…”

Section: Resultsmentioning

confidence: 93%

“…Concomitant radiofrequency catheter ablation was performed during the same session in 21 cases (11.3%). Three‐dimensional mapping was used in six studies 15–17,19–21 . An anterograde transarterial coronary approach was utilized in seven studies 5,15,18,19,22,23 consisting of 96 patients (55.2%), while a retrograde coronary venous approach was used in the remaining.…”

Section: Resultsmentioning

confidence: 99%

“…28 A controlled intramural perforation of the venule adjacent to the arrhythmogenic area, or a "double-balloon" technique where a second angioplasty balloon is placed downstream of the ethanol injection (to force the ethanol into any intramural branches between the balloons), has been described a possible strategy to overcome challenging coronary venous anatomies. 17,28 The long-term outcomes of EA might also be affected by the new development of new collaterals bypassing the vessel targeted during the procedure; however, a repeated EA targeting the collaterals supplying the arrhythmogenic myocardium has been shown to be feasible in selected cases. 5 To summarize, our findings suggest that even though EA can be employed in patients with VAs refractory to conventional medical and ablation treatment, strong and high-quality data supporting its use and efficacy are absent.…”

Section: Discussionmentioning

confidence: 99%

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Ethanol ablation for ventricular arrhythmias: A systematic review and meta‐analysis

Creta

Earley

Schilling

et al. 2022

Cardiovasc electrophysiol

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Introduction: Ethanol ablation (EA) is an alternative option for subjects with ventricular arrhythmias (VAs) refractory to conventional medical and ablative treatment. However, data on the efficacy and safety of EA remain sparse.Methods: A systematic literature search was conducted. The primary outcomes were 1) freedom from the targeted VA and 2) freedom from any VAs post-EA.Additional safety outcomes were also analyzed.Results: Ten studies were selected accounting for a population of 174 patients (62.3 ± 12.5 years, 94% male) undergoing 185 procedures. The overall acute success rate of EA was 72.4% (confidence interval [CI 95% ]: 65.6-78.4). After a mean followup of 11.3 ± 5.5 months, the incidence of relapse of the targeted VA was 24.4% (CI 95% : 17.1-32.8), while any VAs post-EA occurred in 41.3% (CI 95% : 33.7-49.1). The overall incidence of procedural complications was 14.1% (CI 95% : 9.8-19.8), with pericardial complications and complete atrioventricular block being the most frequent. An anterograde transarterial approach was associated with a higher rate of VA recurrences and complications compared to a retrograde transvenous route; however, differences in the baseline population characteristics and in the targeted ventricular areas should be accounted. Conclusion:EA is a valuable therapeutic option for VAs refractory to conventional treatment and can result in 1-year freedom from VA recurrence in 60%-75% of the patients. However, anatomical or technical challenges preclude acute success in almost 30% of the candidates and the rate of complication is not insignificant, highlighting the importance of well-informed patient selection. The certainty of the evidence is low, and further research is necessary.

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Epicardial mapping and ablation of ventricular tachycardia in patients after coronary artery bypass surgery: don’t forget the coronary venous system!

Siontis

Liang

2022

J Interv Card Electrophysiol

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Double-balloon technique for retrograde venous ethanol ablation of ventricular arrhythmias in the absence of suitable intramural veins

Cited by 19 publications

References 8 publications

Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias

Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias

Ethanol ablation for ventricular arrhythmias: A systematic review and meta‐analysis

Epicardial mapping and ablation of ventricular tachycardia in patients after coronary artery bypass surgery: don’t forget the coronary venous system!

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