Purpose: Ventricular arrhythmias with preserved myocardial function pose an especially challenging dilemma. We describe a successful treatment and follow up of a patient with scar related ventricular tachycardia, in the absence of coronary artery disease, probably post-myocarditis, using intracoronary instillation of ethanol after failed endocardial and epicardial RF-Ablation.

Method: 52-year-old patient with a history over 5 years of palpitations, presyncope and known PVCs, with preserved LV function and a small inferior localised hypokinesia without CAD, was referred to our center for PVC Ablation.

The EPS induced a sustained VT CL 250ms (fig. 1). We performed an endocardial VT ablation from an inferolateral scar with VT termination during ablation, PVC & LP elimination and VT non-inducibility (CARTO System) (fig.2). An ILR (Medtronic) was implanted. 4 weeks later the patient was referred again for invasive EPS. At this procedure a stable VT with almost similar morphology, but this time with an epicardial exit was induced (fig. 3).  An epicardial ablation was performed at a collaborating heart center and temporarily successful, but after a period of 4 weeks the same epicardial VT was inducible (fig.4).

 Therefore, a new approach was taken into consideration. 

Coronary angiography was performed to identify the tachycardia related coronary artery, which was presumptive the RPLD of the RCA. After wiring the RCA, the intracoronary instillation of iced saline into a small branch of the RPLD could achieve temporary modification (longer CL and broader morphology) without termination of the arrhythmia (fig. 5&6). Inflation of the balloon in another side branch made the VT non-sustained.

Finally, an instillation of 1cc ethanol using an OTW- balloon with inflation to prevent a "backwash" permanently made the VT non-inducible (fig. 7). The LV ejection function remained preserved, the maximum postprocedural CK was 370 U/L.  After 6 weeks, the VT remained non-inducible.

Conclusions: A selective intracoronary alcohol instillation may be an effective and reliable procedure for repetitive scar related VT after failed RF ablation without concomitant depression of LV-function.