Ethanol ablation via a coronary sinus branch as an effective option in recurrent ventricular tachycardia and epicardial inaccessibility

We report a case of 71-year-old man with non-ischaemic dilated cardiomyopathy and ventricular dysfunction. A cardiac defibrillator was implanted for a recovered sudden death. The patient had multiple episodes of different monomorphic ventricular tachycardia (VT) with some electrical storms. He received up to four endocardial VT ablation showing in bipolar voltage mapping a heterogeneous scar at the basal left ventricular level, and also two failed attempts of epicardial access due to pericardial adhesions (Panel A). An upgrade to cardiac resynchronization therapy was performed, optimizing intervals for synchronous pacing at high frequency; and later also an external ablation with radiotherapy focalized to area of interest. A percutaneous left stellate ganglion block was done without response. Finally, we did a retrograde transvenous epicardial chemical ablation with ethanol through right subclavian vein and coronary sinus cannulation. Venography showed a long postero-lateral vein, with small-caliber postero-basal branch, superimposed on a scar area. There was an early onset of the ventricular electrogram of −32 ms with monopolar QS pattern during tachycardia (mapping by angioplasty guide with a distal electrode). Complete selective occlusion using a double lumen balloon was followed by infusion of 100% ethanol and immediate VT cessation (Panel B). The patient had no recurrences up to 1 year later. The full-length version of this report can be viewed at: https://www.escardio.org/Education/E-Learning/Clinical-cases/Electrophysiology.