Successful Transcoronary Ethanol Ablation for Refractory Ventricular Tachycardia Originating From the Intramural Septum.

BACKGROUND

Ventricular arrhythmias (VAs), particularly those originating from intramural or deep myocardial layers, pose significant challenges in ablation therapy.

CASE SUMMARY: A 42-year-old man with frequent ventricular tachycardia (VT) and declining ejection fraction was admitted for further ablation following 6 unsuccessful procedures. Activation mapping results indicated an intramural septal origin, and initial radiofrequency ablation was ineffective. Ethanol ablation through the coronary venous system was attempted but failed owing to unfavorable anatomical properties. A transcoronary approach was then pursued. We cannulated a guidewire into the first septal perforator branch of the left anterior descending artery, adjacent to the earliest mapped site. Ice-cold saline injection through the over-the-wire lumen terminated VT immediately. Subsequently, 0.5 mL of dehydrated ethanol (95%) was injected twice, and VAs were no longer inducible.

DISCUSSION: Transcoronary ethanol ablation remains a viable alternative for intramural septal VAs when conventional and venous approaches are unsuccessful.

TAKE-HOME MESSAGES: Transvascular ethanol ablation can serve as a bailout solution for VAs originating from the intramural septum. Although the transvenous approach has safety advantages, the transcoronary approach remains a viable alternative when no suitable veins are available.