Double balloon technique for retrograde venous ethanol ablation of ventricular arrhythmias in the absence of suitable intramural veins.

Abstract Background Venous ethanol infusion via an occlusive balloon has been utilized as bail-out approach to treat ablation-refractory ventricular arrhythmias (VA). 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 To validate the "double balloon" approach to enhance ethanol delivery in cases of unfavorable venous anatomy. Methods Eight patients referred after failed ablations (LV summit, n=3, scar related ventricular tachycardia, VT n=5) 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 with multiple branches for a large area of interest. Results Acute successful ethanol infusion myocardial delivery and resolution of VA was accomplished utilizing the following veins: the posterolateral LV veins (n=2 patients, 3 procedures), lateral LV vein (n=1), the apical anterior interventricular vein (AIV, n=1), the middle cardiac vein (MCV, n=1) and septal branches of the AIV (n=3). At a median 313.5 days of follow-up, 2 patients experienced recurrences. 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 VAs.