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Reaching the LV summit aloneCoronary Venous Alcohol Ablation

Miguel Valderrábano

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

Hospital, Houston, TX

LV Summit ablation approachesEnriquez A et al Heart Rhythm 2017: 14, 141-148

Great cardiac vein/anterior interventricular vein (Obel et al J Am Coll Cardiol. 2006 Nov 7;48(9):1813-7)

Adjacent LVOT endocardium / coronary cusp

Adjacent RVOT/Bipolar RF

Septal artery ethanol (Atienza et al Circulation: A&E.

2013;6:e80-e84)

LV summit VT ablation outcomes

Yamada et al Circulation:

Arrhythmia and

Electrophysiology. 2010;3:616-

623

GCV, 14, 52%

Epi, 4, 15%

Abandoned, 9, 33%

Santangeli et al Circulation:

Arrhythmia and

Electrophysiology. 2015;8:337-

343

LV Summit arteries and veins

Atienza et al Circ: Arrhythmia and Electrophysiol. 2013;6:e80-e84

Triangle of Brocq and MouchetAndrade et al J Morphol Sci. 2010; 27: 127–129.

Unipolar wire mapping

Kreideh, Valderrábano. Circ Arrhythm Electrophysiol. 2016 Jul;9(7).

Segal et al J Interv Card Electrophysiol. 2007;18:143–154.

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Venous ethanol ablation for LV summit PVCs

Step 1: Map PVC in venous anatomy Stable CS sheath cannulation (Preface, SL1 or Agilis)

Subselective venograms to identify potential branches:

Diagonal LV

earliest

activationpotential

target

Venous ethanol ablation for LV summit PVCs

Step 2: Identify venules at earliest site

RAO RAO caudal

Step 2: Anatomy variations:

Septal AIV branches

LIMA angioplasty guide

Step 2: Anatomy variations:

Septal AIV branches

Step 2: Anatomy variations:

LV Summit communicating vein Curved torqueable angioplasty guide insertion (LIMA)

Advance pre-loaded angioplasty wire (NON-coated, BMW) on

angioplasty balloon (or FineCross catheter) and cannulate targeted

branch

Advance balloon over wire to control “active electrode” size and

record signals/pace

Venous ethanol ablation for LV summit PVCs

Step 3: Cannulate and map venules

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If signals and pace-map support targeting the cannulated branch:

Retract wire

Inject contrast selectively in targeted branch

Goal: myocardium staining

Inject ethanol and assess therapeutic response: REPEAT INJECTION

Venous ethanol ablation for LV summit PVCs

Step 4: Ethanol injectionVenous ethanol ablation for LV summit PVCs

Step 5: Assess effect-repeat injection

Post-ethanol

Pre-ethanolFinecross®

myocardial staining

Pre-ethanol

Post-ethanol

Tavares L, Valderrábano M. Heart Rhythm. 2018 Sep 18. pii: S1547-5271(18)30933-0.

RV

LV

CS

AIV

LV

AIV

I II III

aVR aVL aVF

V1 V2 V3 V4 V5 V6

CSp

CSd

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

balloon balloon balloon

balloon

balloon

II

aVF

V1

wire

II

aVF

V1

wire

II

aVF

V1

wire

a b

c d e f g

pvc deca s3 s1 s2deca

s3

s1

s2

81% 88% 76% 94%

h

pre

posti 1s

Kreideh, Valderrábano. Circ Arrhythm Electrophysiol. 2016 Jul;9(7).

LV summit ethanol-induced scar

Less than ideal cases:

Too big a septal vein-Intramural dissection

wire

Tavares L, Valderrábano M. Heart Rhythm. 2018 Sep 18. pii: S1547-5271(18)30933-0.

Less than ideal cases:

No septal veins at best site

DDd

DDp

earliest site

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Intra-septal collateral

Initial ethanol success

angioplasty balloon

Recurrent PVCs 30 min later

LV subaortic mapping and ablation

angioplasty

balloon

AIV

D

G H

EA B

LAO cranial

I

LAO cranial

LAO cranial

earliest

signal

CS

C

potential

target

AIV

F

LAO cranial

Pre

ethanol

Post

ethanol

J

myocardial

staining

Ethanol in anterior wall vein

Nonischemic cardiomyopathyI

IIIII

aVRaVLaVF

V1V2V3V4V5V6

CSp

CSd

Tavares L, Valderrábano M. Heart Rhythm. 2018 Sep 18. pii: S1547-5271(18)30933-0.

Large epicardial ethanol ablation

Double balloon technique

MCV

PL

CS

MCV

PL

CS

AP

CS

MCV

PL

angioplasty

balloon 1

angioplasty

balloon 2

A B C

D E

Tavares L, Valderrábano M. Heart Rhythm. 2018 Sep 18. pii: S1547-5271(18)30933-0.

Retrograde venous ethanol

Complications: CS dissection (3/27), pericardial

effusion (1). Intramural dissection without relevance.

Venous anatomy represents a unique opportunity to

reach arrhythmogenic substrates in LV summit region

and other intramural substrates

Wire mapping helps delineate location

Venous ethanol is safe and can be effective Limitations by anatomical variability and procedural complexity

Potentially poor selectivity of myocardial regions targeted

Sharply delineated scar by MRI

Long-term effects not established.

Septal vein ethanol

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Ventricular venous circulationVon Lüdinghousen Clin Anat. 1995;8: 169-189

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