Practical Approaches to Coronary Venous Ethanol Ablation for Refractory Ventricular Arrhythmias: Technique Selection and Clinical Outcomes

BACKGROUND: Coronary venous ethanol ablation (CVEA) is a promising alternative for refractory ventricular arrhythmias (VAs); however, it has limited availability, lacks guideline support, and comprises heterogeneous procedural techniques. OBJECTIVE: To evaluate the acute efficacy, safety, and long-term outcomes of CVEA in refractory VAs and outline practical techniques of CVEA. METHODS: Consecutive patients undergoing VA ablation at our center between December 2017 and December 2025 were screened; CVEA was performed after unsuccessful endocardial RFA. We performed CVEA using either tip injection, conventional double-balloon, or modified double-balloon techniques based on venous anatomy. RESULTS: Among 204 consecutive patients undergoing VA ablation, 55 had VAs refractory to endocardial RFA. Of these, 42 with a coronary venous electrogram preceding VA onset by >20 ms underwent CVEA, including 33 with premature ventricular contraction (PVC) and 9 with ventricular tachycardia (VT). Acute success was achieved in 32/33 patients with PVC and all patients with VT. During a median follow-up of 1,024 days, long-term success was achieved in 22 patients with PVC and 5 with VT. No association was observed between intraprocedural findings and long-term recurrence. CVEA-related procedural complications occurred in 13 patients, with no fatal events reported. Exploratory analyses suggested favorable outcomes for the modified double-balloon technique in anatomically selected cases and an association between higher ethanol volume and ethanol-related complications. CONCLUSION: In patients with VAs refractory to endocardial RFA, CVEA was associated with favorable acute and long-term outcomes, with no fatal complications. Technique selection should be tailored to the venous anatomy, with judicious ethanol volume adjustment.