Background
Radiofrequency ablation (RFA) of ventricular tachycardia (VT) can fail due to inaccessibility to the VT substrate. Trans-arterial coronary ethanol ablation (TCEA) can be effective, but entails arterial instrumentation risk. We hypothesized that retrograde coronary venous ethanol ablation (RCVEA) can be an alternative bail-out approach to failed VT RFA.
Methods and Results
Out of 334 consecutive patients undergoing VT/PVC ablation, seven patients underwent RCVEA. Six of seven patients had failed RFA attempts (including epicardial in 3). Coronary venogram-guided venous mapping was performed using a 4F quadripolar catheter or an alligator-clip-connected angioplasty wire. Targeted veins included those with early pre-systolic potentials and pace-maps matching VT/PVC. An angioplasty balloon (1.5-2 × 6 mm) was used to deliver 1-4 cc of 98% ethanol into a septal branch of the anterior interventricular vein (AIV) in 5 patients with LV summit VT, a septal branch of the middle cardiac vein, and a postero-lateral coronary vein (n=1 each). The clinical VT was successfully ablated acutely in all patients. There were no complications of RCVEA, but one patient developed pericardial and pleural effusion attributed to pericardial instrumentation. On follow-up of 590 ±722 days, VT recurred in 4/7 patients, three of whom were successfully re-ablated with RFA.
Conclusions
RCVEA is safe and feasible as a bail-out approach to failed VT RFA, particularly those originating from the LV summit.
Patients with life-threatening VAs secondary to CAS are at particularly high-risk for recurrence, especially when insufficient medical therapy is administered. Non-dihydropyridine CCBs are capable of suppressing episodes, whereas beta-blocker treatment is predictive of VAs. Ultimately, in spite of medical intervention, some patients exhibited arrhythmogenic events in the long-term, suggesting that ICD implantation may still be indicated for all.
Background
Radiofrequency (RF) ablation can alleviate drug-refractory inappropriate sinus tachycardia (IST). However, phrenic nerve (PN) injury and other complications limit its use.
Objective
We sought to characterize the maneuvers utilized to avoid PN injury and the long-term clinical outcomes.
Methods
Retrospective analysis of consecutive patients who underwent ablation for IST.
Results
RF ablation was carried out on 13 consecutive female patients with drug-refractory IST. Eleven patients exhibited PN capture at desired ablation sites. In one patient, PN capture was not continuous throughout the respiratory cycle and ventilation holding sufficed to avoid PN injury. In 10 patients, pericardial access (PA) and balloon (PB) insertion was required. Initially (n=4) a posterior PA was utilized, which was replaced by an anterior PA in the subsequent 6 cases. PA to optimal balloon positioning time was significantly lower in anterior vs. posterior PA (16.3±6 min vs. 58±21.3 min p=0.01), as was fluoroscopy time (15.66±16.72 min vs. 35.9±1.8 min, p=0.03). RF ablation successfully reduced sinus rate to less than 90 bpm in 13/13 patients. Procedure times and total radiofrequency times were not significantly different in anterior vs posterior PA. Major complications occurred in 2 patients, including unremitting pericardial bleeding requiring open-chested repair in one patient and sinus pauses mandating pacemaker implantation in another. Long-term symptom control after a follow-up of 811±42 days was successful in 84.6%.
Conclusion
Ventilation holding and/or pericardial balloon insertion are frequently warranted in IST ablation. Anterior PA appears to facilitate the procedure over posterior PA.
Inappropriate sinus tachycardia ablation/modification achieves acute success in the vast majority of patients. Complications are fairly common and diverse. However, symptomatic relief decreases substantially over longer follow-up periods, with a corresponding high recurrence rate.
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