Elsevier

Heart Rhythm

Volume 18, Issue 9, September 2021, Pages 1557-1565
Heart Rhythm

Clinical
Ventricular Tachycardia
Venous anatomy of the left ventricular summit: Therapeutic implications for ethanol infusion

https://doi.org/10.1016/j.hrthm.2021.05.008Get rights and content

Background

Venous ethanol ablation (VEA) is effective for treatment of left ventricular (LV) summit (LVS) arrhythmias. The LVS venous anatomy is poorly understood and has inconsistent nomenclature.

Objective

The purpose of this study was to delineate the LVS venous anatomy by selective venography and 3-dimensional (3D) mapping during VEA and by venous-phase coronary computed tomographic angiography (vCTA).

Methods

We analyzed (1) LVS venograms and 3D maps of 53 patients undergoing VEA; and (2) 3D reconstructions of 52 vCTAs, tracing LVS veins.

Results

Angiography identified the following LVS veins: (1) LV annular branch of the great cardiac vein (GCV) (19/53); (2) septal (rightward) branches of the anterior ventricular vein (AIV) (53/53); and (3) diagonal branches of the AIV (51/53). Collateral connections between LVS veins and outflow, conus, and retroaortic veins were common. VEA was delivered to target arrhythmias in 38 of 53 septal, 6 of 53 annular, and 2 of 53 diagonal veins. vCTA identified LVS veins (range 1–5) in a similar distribution. GCV–AIV transition could either form an angle close to the left main artery bifurcation (n = 16; 88° ± 13°) or cut diagonally (n = 36; 133°±12°) (P ≤.001). Twenty-one patients had LV annular vein. In 28 patients only septal LVS veins were visualized in vCTA, in 2 patients only diagonal veins and in 22 patients both septal and diagonal veins were seen. In 39 patients the LVS veins reached the outflow tracts and their vicinity.

Conclusion

We provide a systematic atlas and nomenclature of LVS veins related to arrhythmogenic substrates. vCTA can be useful for noninvasive evaluation of LVS veins before ethanol ablation.

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.

References (17)

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Cited by (19)

  • Revisiting the Anatomy of the Left Ventricular Summit

    2023, Cardiac Electrophysiology Clinics
  • Acute and Long-Term Scar Characterization of Venous Ethanol Ablation in the Left Ventricular Summit

    2023, JACC: Clinical Electrophysiology
    Citation 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.

View all citing articles on Scopus

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.

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