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The aim of this study was to assess the long-term efficacy and outcomes of retrograde venous ethanol ablation in treating ventricular arrhythmias (VAs).Retrograde coronary venous ethanol ablation (RCVEA) can be effective for radiofrequency ablation (RFA)-refractory VAs, particularly those arising in the LV summit (LVS).Patients with drug and RFA-refractory VAs were considered for RCVEA after RF failure attempts. Intramural coronary veins (tributaries of the great cardiac, anterior interventricular, lateral cardiac, posterolateral, and middle cardiac) were mapped using an angioplasty wire. Ethanol infusion was delivered in veins with appropriate signals.Of 63 patients (age 63 ± 14 years; 60% men) with VAs (71% extrasystole, 29% ventricular tachycardia, 76% LVS origin), RCVEA was performed in 56 patients who had suitable vein branches. These were defined as those amenable to cannulation and with intramural signals that preceded those mapped in the epicardium or endocardium and had better matching pace maps or entrainment responses. Seven patients had no suitable veins and underwent RFA. In 38 of 56 (68%) patients, the VAs were successfully terminated exclusively with ethanol infusion. In 17 of 56 (30%) patients, successful ablation was achieved using ethanol with adjunctive RFA in the vicinity of the infused vein due to acute recurrence or ethanol-induced change in VA morphology. Overall, isolated or adjuvant RCVEA was successful in 55 of 56 (98%) patients. At 1-year follow-up, 77% of patients were free of recurrent arrhythmias. Procedural complications included 2 venous dissections that led to pericardial effusions.RCVEA offers a significant long-term effective treatment for patients with drug and RF-refractory VAs.

The subcutaneous implantable cardioverter defibrillator (S-ICD) is an important, recently introduced alternative to conventional transvenous defibrillators. The S-ICD has some theoretic advantages over transvenous defibrillators. The S-ICD is easily implanted without fluoroscopy. The S-ICD has minimal programmability. The S-ICD avoids the procedural risks and long-term hazards of transvenous lead implantation. The S-ICD effectively detects and terminates ventricular fibrillation. The S-ICD inappropriate shock rate is comparable with that of transvenous defibrillators. The S-ICD is not suitable for patients who require cardiac pacing but can be combined with a separate bipolar pacemaker. Long-term follow-up is awaited, and a randomized trial comparing the subcutaneous and transvenous defibrillators is under way.

Adults with congenital heart disease (CHD) frequently have cardiac arrhythmias, many of which are best treated with radiofrequency ablation (RFA). We present our experience in this group.Retrospective chart based review of diagnosis, arrhythmia type, results of cardiac electrophysiological assessment, and procedural and long-term clinical success of radiofrequency ablation.Forty-five patients were identified with CHD and arrhythmias undergoing RFA; including surgically repaired atrial septal defects (21), Ebstein's anomaly (12), repaired transposition of the great arteries (3), repaired Tetralogy of Fallot (4), repaired ventricular septal defect (3), repaired coarctation (1) and unrepaired anomalous pulmonary venous anatomy (1). Arrhythmias were atrial flutter (24), atrial fibrillation (1), atrial tachycardia (3), atrioventricular nodal re-entrant tachycardia (5), and atrioventricular re-entrant tachycardia (12). Procedural success was ultimately obtained in 36 patients, with 6 having unsuccessful ablation and 3 an undetermined result. Twelve patients required a repeat procedure. One patient required a third procedure and had insertion of permanent pacemaker and atrioventricular nodal ablation. With follow-up (range 2-264 months) 31 patients (69%) remained in sinus rhythm, 9 have developed atrial fibrillation, 3 are in atrial flutter or atrial tachycardia, 1 patient reports ongoing palpitations with no documented arrhythmia and 1 patient has died. Procedural complications were major venous access bleeding (2), transient heart block during slow pathway ablation with late complete heart block (1).The majority of arrhythmias in adult patients with congenital heart defects can be successfully treated with radiofrequency ablation at a relatively low risk.