Po-05-007 coronary venous ethanol ablation of subepicardial substrate in patients with ventricular tachycardia and left ventricular assist device.

Patients with a left ventricular assist device (LVAD) and ventricular tachycardia (VT) often have subepicardial substrate, which may not be amenable to epicardial ablation due to sternotomy-related adhesions and the LVAD itself. As an alternative approach, coronary venous ethanol ablation (VEA) can be used to ablate VT substrates without needing pericardial access. To assess the feasibility and acute safety of VEA in patients with LVAD and VT. We retrospectively studied patients with LVAD who underwent VT ablation using VEA between 8/2015 – 11/2022 at a tertiary referral medical center. Baseline patient and procedural characteristics were obtained. Of the 10 patients included, 7 presented with VT storm, 5 had prior VT ablation, 3 had multiple prior sternotomies, all were on amiodarone, 8 were on 2 or more antiarrhythmic drugs in the prior year, all had prior defibrillator implants, and 9 had shocks in the prior year. Across the cohort, 4 different vein territories were targeted for VEA, including the middle cardiac vein, posterolateral branch vein, anterolateral branch vein, and septal branch of the anterior interventricular vein. In 4 cases, 2 separate vein territories were targeted. An average of 17 ± 10 cc of ethanol was used per case. Concomitant radiofrequency ablation was used in all 10 patients. Procedure and fluoroscopy times were 290 ± 56 minutes, and 32 ± 15 minutes, respectively. Acute procedural success, defined as no inducible VT, was achieved in 9 cases. There was 1 complication, which was transiently increased threshold on the LV pacing lead and RV failure necessitating prolonged inotropic support. All the patients survived to hospital discharge. In an inherently high-risk LVAD population with VT, VEA can be used as an alternative approach to target subepicardial substrate that would otherwise be inaccessible via standard percutaneous access of the pericardial space. Acute procedural success was high in this limited cohort. Further study with larger numbers of cases and longer follow up is warranted.