Retrograde coronary venous ethanol ablation (RCVEA) may prevent the recurrence of arrhythmias in the long-term in patients with ventricular arrhythmias refractory to drugs and radiofrequency ablation (RFA), according to a study published in JACC: Clinical Electrophysiology.
RCVEA was conducted in 56 patients of 63 patients (mean age, 63±14 years; 60% men; ventricular arrhythmias: 71% extrasystole; 29% ventricular tachycardia; 76% with left ventricular summit [LVS] origin) with drug- and RFA-refractory ventricular arrhythmias. Patients with adequate vein branches were selected to undergo the procedure. An angioplasty wire was used to map intramural coronary veins, and ethanol infusion was delivered with appropriate signals.
Of patients who underwent RCVEA, ventricular arrhythmia was successfully terminated with ethanol infusion in 68%. In 17 patients (30%) in whom ethanol infusion led to changes in ventricular arrhythmia morphology, successful ablation was achieved using ethanol with adjunctive RFA near the infused vein. Isolated or adjuvant RCVEA was successful in 55 of 56 participants (98%).
One year after the procedure, 77% of patients were free of recurrent arrhythmias without antiarrhythmic drugs. Recurrent arrhythmias occurred in 12 of 55 patients (22%), all of whom were treated with antiarrhythmic drugs, with sustained ventricular tachycardia as the predominant arrhythmia in 3 patients, and premature ventricular contraction in 9 patients. In these patients, recurrence occurred at a median of 72 days.
“In a challenging patient population in which radiofrequency either failed or was proven to be undeliverable, RCVEA proved to be acutely successful,” noted the investigators. “In most patients (68%), ethanol alone was sufficient to acutely eliminate ventricular arrhythmias, whereas in 30%, ethanol either did not lead to a sufficiently durable success or only led to a change in the ventricular arrhythmia morphology.”
Study limitations include the fact that it did not have a randomized controlled design and that RCVEA was not compared with other approaches.
“This multicenter, prospective, international registry confirmed that RCVEA offered a significant long-term effective treatment for patients with recurrent ventricular arrhythmias with excellent long-term safety,” the study authors concluded. “When ethanol reached the targeted myocardium, both LVS and non-LVS substrates could be effectively and safely eliminated. This was a cheap, readily available approach that could be used in a wide range of health systems with routine existing equipment and without requiring expensive technologies.”
Tavares L, Lador A, Fuentes S, et al. Intramural venous ethanol infusion for refractory ventricular arrhythmias: Outcomes of a multicenter experience [published online September 30, 2020]. J Am Coll Cardiol EP.doi: https://doi.org/10.1016/j.jacep.2020.07.023