Utilization of Coronary Venous Ethanol Ablation for Intramural Ventricular Arrhythmias in Two Different Scenarios: A How-To Approach

Catheter-based radiofrequency (RF) ablation is a recommended treatment modality for various ventricular arrhythmias. However, challenging sites that may not be accessible due to anatomical reasons, as well as intramural sites, where RF energy penetration may be limited, pose challenges that limit the success rate of RF ablation. Ethanol ablation may be an alternative option for treatment of ventricular arrhythmias that are not amenable to treatment by RF ablation. This report describes two cases of successful venous alcohol ablation for refractory ventricular tachycardia to standard RF ablation procedure. In the first case, a patient with a ventricular tachycardia (VT) originating from intramural outflow tract, having failed an endocardial ablation, underwent a successful ethanol ablation, via a double balloon technique. In the second case, we describe a patient with a history of transcatheter aortic valve replacement and premature ventricular complexes (PVCs) originating from intramural outflow tract. Radiofrequency ablation in this patient was limited by both the far-field appearing signals and the proximity prosthetic valve to the site of these signals. Therefore, this patient also underwent successful ethanol ablation of annular vein with the over the wire system after venography of coronary sinus. No complications were observed in both patients. In conclusion, coronary venous ethanol ablation may be a safe and successful technique for ablation of intramural ventricular arrhythmias in different clinical scenarios.