Ethanol Ablation of Refractory Premature Ventricular Complex Originating from a Left Ventricular Summit Communicating Vein after Radiofrequency Catheter Ablation Failed in a Dilated Cardiomyopathy Patient

Figures

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  Figure 1.. A: 12-lead electrocardiogram on admission showed frequent monomorphic premature ventricular complexes with bigeminy, an inferior axis, a left bundle block pattern, and a precordial transition zone in lead V4. B: CMR indicated septal and basal intramural late gadolinium enhancement. C: Pre-ablation high-resolution contrast-enhanced computed tomography confirmed the position of the communicating vein (CV) branching from the great cardiac vein-anterior interventricular vein (GCV-AIV) junction. D: A coronary sinus (CS) venogram showed the communicating vein branching from the GCV-AIV junction. E: Through the lumen of the 6-Fr CS catheter, a 2-Fr microcatheter was introduced into the CV.

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  Figure 2.. A: Activation and 3D mapping showed the earliest activation time of 25 ms at the right ventricular outflow tract posteroseptum. Several radiofrequency (RF) ablation procedures were performed but failed to eliminate the premature ventricular complexes (PVCs). B: Further mapping and generation of a pace map via the retrograde aortic approach at the right coronary cusp (RCC) yielded a high PaSo score and earliest activation time of 30 ms. Additional RF ablation was delivered at the RCC, resulting in the a temporary disappearance of the PVCs. C: PVCs recurred with a new QRS pattern, different from the initial PVC morphology but less frequently and with prolonged coupling intervals (436 to 450 ms). D: Activation mapping showed the earliest activation time of 32 ms and a perfect pace map from the microcatheter inserted in the communicating vein. E: Additional RF ablation from the LVOT using the microcatheter as a target failed to terminate the PVC.

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  Figure 3.. A: At the beginning of the second ablation procedure, several radiofrequency ablation attempts from the left coronary cusp targeting the microcatheter were performed but failed to terminate the premature ventricular complexes (PVCs). B: A 2.0×8-mm balloon was cannulated into the communicating vein (CV) and inflated to block retrograde flow from the CV. Injection of contrast confirmed the complete occlusion of the vein. C: Upper electrocardiogram (ECG): a cold saline infusion test was performed twice and resulted in temporarily slowing of the rate but not complete termination of PVCs. Lower ECG: After 1 cc of 100% ethanol was injected into the occluded CV from the tip of the balloon catheter, the PVCs were terminated.