BACKGROUND: Venous ethanol infusion via an occlusive balloon has been used as a bailout approach to treat ablation-refractory ventricular arrhythmias (VAs). Unfavorable venous anatomy (lack of intramural veins at the targeted site or collateral vein-ethanol shunting) limits its efficacy. Blocking collateral flow with a second balloon may optimize myocardial ethanol delivery. OBJECTIVE: The purpose of this study was to validate the "double-balloon" approach to enhance ethanol delivery in cases of unfavorable venous anatomy. METHODS: Eight patients referred after failed ablations (3 left ventricular [LV] summit, 5 scar-related ventricular tachycardia) underwent endocardial mapping and additional radiofrequency ablation without VA resolution. Coronary veins were mapped using a multipolar catheter or wire, and selective venograms were obtained. The double balloon was used when (1) distal collateral branches shunted flow away from the targeted region; (2) the target vein had optimal signals only proximally; or (3) a large vein was targeted that had multiple branches for a large area of interest. RESULTS: Acute successful ethanol infusion myocardial delivery and resolution of VA was accomplished using the posterolateral LV veins (n = 2 patients, 3 procedures), lateral LV vein (n = 1), apical anterior interventricular vein (AIV; n = 1), middle cardiac vein (n = 1), and septal branches of the AIV (n = 3). At median follow-up of 313.5 days, 2 patients experienced recurrence. CONCLUSION: The double-balloon technique can enhance ethanol delivery to target isolated vein segments, block collateral flow, or target extensive areas, and can expand the utility of venous ethanol for treatment of VAs.

Arrhythmia Unit Jo Ann Medical Center Tbilisi Georgia

Division of Cardiac Electrophysiology Department of Cardiology Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas

Institute for Clinical and Experimental Medicine Prague Czech Republic

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Baher A, Shah DJ, Valderrabano M. Coronary venous ethanol infusion for the treatment of refractory ventricular tachycardia. Heart Rhythm 2012; 9:1637–1639. PubMed PMC

Kreidieh B, Rodriguez-Manero M, Schurmann PA, Ibarra-Cortez SH, Dave AS, Valderrabano M. Retrograde coronary venous ethanol infusion for ablation of refractory ventricular tachycardia. Circ Arrhythm Electrophysiol 2016; 9:e004352. 10.1161/CIRCEP.116.004352. PubMed DOI PMC

Tavares L, Valderrabano M. Retrograde Venous ethanol ablation for ventricular tachycardia. Heart Rhythm 2019;16:478–483. PubMed

Segal OR, Wong T, Chow AW, et al. Intra-coronary guidewire mapping—a novel technique to guide ablation of human ventricular tachycardia. J Interv Card Electrophysiol 2007;18:143–154. PubMed

Komatsu Y, Nogami A, Shinoda Y, et al. Idiopathic ventricular arrhythmias originating from the vicinity of the communicating vein of cardiac venous systems at the left ventricular summit. Circ Arrhythm Electrophysiol 2018;11:e005386. PubMed

von Ludinghausen M The venous drainage of the human myocardium. Adv Anat Embryol Cell Biol 2003;168(I–VIII):1–104. PubMed

Wright KN, Morley T, Bicknell J, Bishop SP, Walcott GP, Kay GN. Retrograde coronary venous infusion of ethanol for ablation of canine ventricular myocardium. J Cardiovasc Electrophysiol 1998;9:976–984. PubMed

Di Biase L, Santangeli P, Burkhardt DJ, et al. Endo-epicardial homogenization of the scar versus limited substrate ablation for the treatment of electrical storms in patients with ischemic cardiomyopathy. J Am Coll Cardiol 2012;60:132–141. PubMed

Neira V, Santangeli P, Futyma P, et al. Ablation strategies for intramural ventricular arrhythmias. Published online February 20. Heart Rhythm 2020; 10.1016/j.hrthm.2020.02.010. PubMed DOI