Venous anatomy of the left ventricular summit: Therapeutic implications for ethanol infusion

Tavares, Liliana; Fuentes, Stephanie; Lador, Adi; Da-Wariboko, Akanibo; Wang, Sufen; Schürmann, Paul; Dave, Amish S.; Valderrábano, Miguel

doi:10.1016/j.hrthm.2021.05.008

Cited by 25 publications

(27 citation statements)

References 17 publications

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“…The redundancy of myocardial venous circulation has been amply demonstrated. 7,8 Collateral flow can divert ethanol away from targeted areas and lead to suboptimal VEA results or recurrence. However, it can also expose a double path for venous return of the arrhythmogenic area that can be capitalized to deliver VEA via 2 separate veins into the one targeted area.…”

Section: Resultsmentioning

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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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: Resultsmentioning

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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“…Timing of contrast application was geared toward visualization of the coronary arteries and the intramural part of the septal veins were incompletely visualized. Accordingly, this study focused on the most proximal septal vein and its implications for ablation procedures, and not the more distal branches that were described by others recently 6 . Improvement of contrast application may further help to improve visualization of the entire septal veins.…”

Section: Discussionmentioning

confidence: 98%

“…Accordingly, this study focused on the most proximal septal vein and its implications for ablation procedures, and not the more distal branches that were described by others recently. 6…”

Section: Limitationsmentioning

confidence: 99%

Anatomy of the proximal septal vein in patients with focal intramural ventricular arrhythmias

Tam

Liang

Ghannam

et al. 2022

Cardiovasc electrophysiol

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Background: Focal ventricular arrhythmias (VAs) originating from the intramural myocardium of the basal septum are difficult to localize and ablate. Proximal septal veins emptying into the great cardiac vein can reach close to the origin of intramural arrhythmias.Objective: To assess characteristics of proximal septal coronary veins in patients with intramural VAs.Methods and Results: Among 84 consecutive patients with intramural VAs, 29 patients (age 60 ± 11years, 16 males, ejection fraction 47 ± 13%) underwent preprocedural cardiac computed tomographic angiography (CTA). In 14 of these patients, the intramural site of origin (SOO) was identified with multipolar catheters. The intramural SOO could not be accessed with mapping catheters in the other 15 patients while mapping the coronary venous system. The CTA identified sizable proximal septal veins in all patients in whom the SOO could be accessed with mapping catheters. In the patients in whom the intramural SOO was not identified, the proximal septal veins were often either small (<2 mm at the branching site) or non-existent (n = 9, p = .001). The proximal septal veins in patients in whom the SOO was identified were larger than in the patients in whom the SOO could not be identified (3.0 ± 0.6 mm vs. 2.1 ± 0.9 mm, p = .01).Conclusions: Preprocedural imaging with CTAs can be beneficial in identifying the anatomy of proximal septal coronary veins that allow adequate mapping of patients with suspected intramural VAs.

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“…However, in some cases, the J o u r n a l P r e -p r o o f 9 microcatheter cannot be introduced into the distal AIV due to the steep angle at the GCV-AIV transition or the tortuous AIV. 7 Tavares et al 7 have reported that approximately 30% (16/52 patients) of the cases examined for the GCV-AIV angle had a steep angle (<100°), and forcefully inserting a microcatheter into a vessel with a steep angle may cause pericardial effusion or cardiac tamponade due to venous injury. The key to a successful ablation of VAs originating from the LV summit is the safe introduction of a microcatheter into the AIV.…”

Section: Discussionmentioning

confidence: 99%

Utility of the novel microcatheter in left ventricular summit arrhythmias with a tortuous anterior interventricular vein

Sagawa

Yamauchi

Ohgino

et al. 2022

HeartRhythm Case Reports

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Venous anatomy of the left ventricular summit: Therapeutic implications for ethanol infusion

Cited by 25 publications

References 17 publications

Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias

Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias

Anatomy of the proximal septal vein in patients with focal intramural ventricular arrhythmias

Utility of the novel microcatheter in left ventricular summit arrhythmias with a tortuous anterior interventricular vein

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