Feasibility of retrograde coronary venous ethanol ablation for ventricular arrhythmias in patients with persistent left superior vena cava
H Lopez Martinez, A Dave, D Burkland, M ValderrabanoAbstract
Background
Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly, resulting from incomplete regression of the left anterior cardinal vein into the ligament of Marshall.1 Distorted coronary sinus (CS) anatomy due to PLSVC can complicate mapping and ablation of cardiac arrhythmias, as well as catheterization of the CS and its tributaries due to catheter instability and altered maneuverability.2 Retrograde coronary venous ethanol ablation (RCVEA) is an established therapy for otherwise inaccessible substrates,3 but its use for ventricular arrhythmias (VAs) in the context of PLSVC has never been explored.
Purpose
To report the first clinical experience with RCVEA for the treatment of VAs in patients with PLSVC. We aimed to demonstrate the feasibility, safety, and efficacy of this approach, and to describe technical adaptations that enabled successful ethanol delivery in the setting of this unique venous anatomy.
Methods
We conducted a retrospective analysis of PLSVC patients who underwent VEA for VAs between 2022-2025 at our center. Clinical and procedural data and acute outcomes were assessed.
Results
Three patients (53.7±4 years; 2 male) with PLSVC underwent VEA for VAs: One for premature ventricular complexes from the left ventricular summit (LVS), one for idiopathic ventricular tachycardia (VT) also from the LVS, and one for VT related to an extensive non-ischemic substrate in the anterior-anteroseptal basal LV. All were drug-refractory and had prior failed ablations. Angiography of CS tributaries was hindered by a ‘wash out phenomenon’ due to high flow in the CS; in one case, introduction of the ICE catheter into the CS was required to locate the great cardiac vein (GCV) ostium. The GCV ostium displayed variable CS insertion site between patients. Deep selective cannulation of the GCV with a guiding catheter enabled complete venography and stability during subsequent instrumentation. Extensive collateral venous networks were observed to varying degrees; in one patient, the GCV-anterior interventricular vein (AIV) continuity was interrupted and bridged by dense collaterals at the target site. The critical substrate was located with a miniaturized catheter or by guidewire unipolar signals. Ethanol delivery was successfully achieved in all targeted sites via an annular vein at the GCV-AIV junction, septal branches of the AIV, and collaterals between the GCV and AIV, respectively. The single balloon technique was used in all; the double balloon was also required in one case. Acute success was achieved in all; no complications occurred.
Conclusions
RCVEA is a feasible and promising approach for refractory VAs in patients with PLSVC. Complex anatomical variations of the CS and its tributaries may complicate the procedure, for which thorough pre- and intraprocedural imaging, operator expertise, and careful technical adjustments tailored to individual anatomy are crucial for achieving favorable outcomes.Venous anatomy of included patientsProcedural approach and results on MRI