ClinicalVentricular TachycardiaVenous anatomy of the left ventricular summit: Therapeutic implications for ethanol infusion
Introduction
The left ventricular (LV) summit (LVS) is the most septal and superior aspect of the left ventricular outflow tract (LVOT), bound superiorly and anteriorly by the left main coronary artery (LMCA) bifurcation and laterally by the great cardiac vein (GCV).1, 2, 3 Arrhythmias arising in LVS pose a challenge to ablation because catheter manipulation to reach the LVS can be difficult, and the proximity to the LMCA and its branches can generate risk of catastrophic damage. Intramural branches of the coronary venous system (CVS) offer a unique opportunity for reaching LVS arrhythmogenic foci, and retrograde coronary venous ethanol ablation (VEA) can effectively treat LVS ventricular arrhythmias (VAs).4, 5, 6 Successful VEA requires a comprehensive appreciation of the morphologic arrangement of cardiac veins.7 The number and location of coronary tributaries vary, and their size and course are also notoriously diverse.8 Previous studies have used computed tomography (CT) to describe the relationship between the coronary venous and arterial systems and the main tributaries of the coronary sinus (CS)9,10; however, the epicardial and intramural branches of LVS tributaries have not been studied in detail. LVS vein nomenclature often is imprecise and inconsistent, as LVS veins are referred to as “communicating veins” or “septal perforators,”11, 12, 13 without discriminating their relationship to neighboring structures such as the mitral annulus, aortic root, right ventricular (RV) outflow tract (RVOT), and LVOT.
We have accumulated substantial experience in VEA, during which a detailed appreciation of the anatomic variations of the LVS venous return has been generated.6 Here, we describe the coronary tributaries that drain the LVS and their 3-dimensional (3D) relations with neighboring structures in patients undergoing VEA using intraprocedural venograms and CT, and provide a detailed understanding of the LVS venous return that is critical for VEA reproducibility.
Section snippets
Methods
Procedural and imaging data were collected under a protocol approved by the Institutional Review Board. All patients provided informed consent for the procedures.
Baseline characteristics of the study population
Fifty-three patients who were considered for VEA (age 61 ± 15 years; 57% men) were included (Supplemental Results). The presenting ventricular arrhythmia was premature ventricular complexes in 47 patients (89%) and ventricular tachycardia in 6 (11%).
Venous anatomy
Although the anatomic variability was substantial, there was a consistent pattern of possible venous drainage. These veins were best visualized in left anterior oblique (LAO) (30°–45°), steep caudal (40°–50°) fluoroscopic projection, analogous to
Discussion
In this study, we used a systematic approach to define LVS veins angiographically in several fluoroscopic projections and combined them with 3D maps of the underlying RVOT, LVOT, aorta, and AIV, o display LVS veins in their 3D context. Key findings include the following: (1) a consistent sequence of veins draining the LVS: annular, septal veins, and diagonal veins; (2) common intervenous communications between LVS veins; (3) presence of retroaortic, atrial, retropulmonary vein drainage; (4) a
Conclusion
A comprehensive atlas of LVS veins is provided, along with descriptions of the significant anatomic variability and the relationships between LVS veins and neighboring structures, including the aorta, RVOT, and coronary arteries. Previously vague or ambiguous nomenclature is clarified, and the potential value of preprocedural vCTA is shown.
Acknowledgments
We thank Ponraj Chinnadurai, PhD, for his technical assistance with using syngo.via® to create the anatomic VR images.
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Cited by (19)
Retrograde Coronary Venous Ethanol Infusion for Ablation of Refractory Left Ventricular Summit Arrhythmias
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2023, JACC: Clinical ElectrophysiologyCitation Excerpt :This may be due to either size or anatomy of the vein through which ethanol was infused. We recently described coronary venous anatomy of the LV summit using venous phase computed tomography,11 which could be used to crudely identify the presence and location of LVS veins, but not the extent of tissue reached by VEA. Last, given the novelty of this technique, it is important to ascertain safety of the technique with regard to scar expansion into untargeted areas over time, particularly in patients who received greater amounts of ethanol.
What to do when everything fails…Is alcohol the answer?
2023, HeartRhythm Case Reports
Funding sources: This study was supported by the Charles Burnett III and Lois and Carl Davis Centennial Chair endowments (Houston, Texas), and National Institutes of Health/National Heart, Lung, and Blood Institute (NIH/NHLBI) Grant R01 HL115003 to Dr Valderrábano.
Disclosures: The authors have no conflicts of interest to disclose.