Combined ethanol and radiofrequency ablation for the elimination of focal atrial tachycardia originating from the Marshall bundle.

Introduction and importance: Atrial tachycardias (AT) originating from the Marshall bundle (MB) are rare and present significant challenges in diagnosis and management. The authors present the case of a 29-year-old male with recurrent AT successfully treated with a combined ethanol and radiofrequency ablation approach. This case highlights the effectiveness of this dual ablation strategy in resolving AT originating from the MB, contributing valuable insights into managing complex AT cases. Case presentation: A 29-year-old male with recurrent, symptomatic palpitations was initially suspected of orthodromic atrioventricular reentrant tachycardia, but an initial electrophysiological study (EPS) failed to induce arrhythmia. Subsequent spontaneous episodes led to a detailed EPS, revealing automatic AT originating presumably from an epicardial focus on the posterior wall of the left atrium (LA). Detailed mapping identified the earliest activation at the vein of Marshall (VoM) ostium within the coronary sinus (CS). Suspecting the involvement of MB structures, VoM ethanol ablation was performed. Complete arrhythmia elimination was achieved with radiofrequency ablation (RFA) at the VoM ostium within the CS, with no recurrence. Discussion: Most cases in the literature are associated with atrial fibrillation (AF) or AT within AF, typically involving re-entry mechanisms. The given case is unique as it presents a highly probable VoM origin of automatic AT with no concomitant AF. The VoM's anatomical and electrophysiological properties make it a potential source of refractory AT. In this case, ethanol ablation supplemented by targeted, limited RFA emerged as an effective strategy, highlighting the importance of comprehensive mapping and tailored ablation approaches in managing complex atrial arrhythmias. Conclusion: The potential implications for clinical practice include recognizing the VoM as a critical target in refractory AT cases and adopting a combined ablation strategy to improve patient outcomes in similarly challenging scenarios.

Successful chemical ablation for intraventricular septal ventricular tachycardia-An alternative approach to the septal branch.

Trans-coronary ethanol ablation for ventricular tachycardia originating from the ventricular septum is effective, but there are cases with no septal perforator from left anterior descending artery. CT and angiography can reveal the optimal vessel.

Prevalence and Management of Complications of Percutaneous Ethanol Injection for Cystic Thyroid Nodules: A Systematic Review of Literature and Meta-analysis.

Background: We assessed the prevalence of complications from percutaneous ethanol injection (PEI) for benign and cystic thyroid nodules (CTNs) and their management. Methods: We conducted a systematic review with meta-analysis of data from published observational studies on PEI of CTNs. We also included unpublished retrospectively collected data on complications after PEI from all consecutive patients with cytologically benign CTNs who underwent PEI at the Unit of Endocrinology and Metabolic Diseases, AOU University of Campania Luigi Vanvitelli (Naples, Italy) between June 1, 2021, and March 31, 2024. A random effects meta-analysis was performed on the prevalence rate data. Pooled prevalence data were presented with confidence intervals (CIs). The I2 statistic index was used to quantify the heterogeneity. The details of the complications and the management were qualitatively described. Results: The literature search yielded 1189 studies, of which 48 studies were included in the systematic review and meta-analysis, in addition to our institutional experience (3670 CTNs in total). The overall quality of each included study was judged as fair. The prevalence of "Overall" complications of PEI was 32% ([CI 25-40%], I2 92.7%, 967 of 3195 thyroid nodules [TNs]). The prevalence of "Minor" complications of PEI was 32% ([CI 25-40%], I2 92.7%, 952 of 3195 TNs). The prevalence of "Major" complications of PEI was 2% ([CI 1-2%], I2 0%, 22 of 3670 TNs). Sensitivity analyses did not modify the results. The pooled prevalence rate of local pain was 21% (CI [16-27] I2 90.3). Local pain was typically transient and mild, sometimes moderate, and requiring analgesics for few days. The pooled prevalence rate of dysphonia was 1% (CI [1-2], I2 0). Dysphonia was transient and could last from several hours to 12 months after PEI. Conclusions: Complications of PEI for benign and CTNs are relatively common, but most are minor and usually transient, not requiring treatment. Dysphonia was a major complication, but it was uncommon and transient. PEI for CTNs could be considered a generally safe technique.

Ethanol Ablation of Refractory Premature Ventricular Complex Originating from a Left Ventricular Summit Communicating Vein after Radiofrequency Catheter Ablation Failed in a Dilated Cardiomyopathy Patient.

During follow-up of a 60-year-old patient with dilated cardiomyopathy, a Holter electrocardiogram revealed monomorphic premature ventricular complexes (PVCs) accounting for 21-30% of total beats. Oral beta-blockers led to no improvement in PVC burden. The first radiofrequency catheter ablation attempt identified the PVC arising from the left ventricle summit communicating vein (CV) but failed to eliminate the PVC's origin. The second ablation attempt with selective infusions of 100% ethanol into the summit CV resulted in immediate termination of PVCs. The post-ablation course was uneventful. Echocardiography showed an improved ejection fraction, and a repeated Holter electrocardiogram showed no recurrence of PVCs during follow-up. Ethics The RCVEA procedures were approved by the Takagi Hospital Ethical Committee and were performed under an institutional review board-approved protocol. (Kouhou-kai Ethical Committee, ID: KR168) Fundings This work was supported by the Takagi Hospital Cardiology Research Grant. The authors declare no competing interests. Acknowledgements: We thank the patient, the patient's family, and the medical staff of Takagi Hospital for their valuable cooperation and kind support. Consent Written informed consent was obtained from the patient for the publication of this case report and accompanying images.

Vein of Marshall ethanol infusion for recurrent atrial fibrillation in patients with durably isolated pulmonary veins.

BACKGROUND: Vein of Marshall (VoM) ethanol ablation has a proven benefit in patients with persistent atrial fibrillation (AF) undergoing index procedure; however, its role in repeat ablation is unknown. We sought to evaluate the benefit of empiric VoM ethanol ablation in addition to posterior wall isolation (PWI) during the repeat procedure in patients with durable pulmonary vein (PV) isolation from prior ablation. METHODS: Twenty-three patients (age 67.1 + / - 7.4, 74% males) who received empiric VoM ethanol infusion in addition to PWI were matched for age, gender, ejection fraction, and left atrial size with forty-six patients receiving empiric PWI alone. All patients in the study group underwent additional ablation on mitral isthmus to complete the lateral mitral isthmus line. Additional ablation was based on program and trigger stimulation. Primary outcome was freedom from AF after a blanking period of 3 months by qualification of symptoms, EKG, wearable, or implantable monitor or device. RESULTS: The study group had a higher average BMI (35.07 + / - 8.98 vs. 30.85 + / - 5.65, p = 0.033) and rate of persistent AF (83.0% vs. 54.3%, p = 0.029) versus the control. The 1-year AF-free survival for the study and control groups was 20 (86.96%) and 28 (60.1%) patients (p = 0.027). Cox proportional hazard regression analysis showed a significant reduction in AF recurrence in the study group (HR 0.25, 95% CI 0.073-0.843, p = 0.026). CONCLUSION: Among patients undergoing repeat catheter ablation for recurrent AF with durably isolated PVs, the addition of VoM ethanol infusion increased the likelihood of remaining free from AF at 12 months.

Retrograde coronary venous ethanol ablation for ventricular tachycardia in a patient with inaccessible substrate due to previous surgery.

INTRODUCTION: Catheter-based radiofrequency (RF) ablation is generally regarded as the standard approach for patients with ventricular tachycardia (VT) refractory to antiarrhythmic drug therapy and may be considered as a first-line approach when there is a preference to avoid these agents. Patients with a history of cardiac surgery may have VT substrate inaccessible to catheter ablation due to intervening prosthetic materials or scar. METHODS AND RESULTS: This article describes a 55-year-old patient with a history of surgically repaired subvalvular aortic stenosis and subsequent valve-sparing root replacement who presented with sustained VT. After RF ablation failed due to VT substrate "guarded" by graft material, retrograde coronary venous ethanol ablation (RCVEA) was employed to successfully treat the clinical VT. CONCLUSION: RCVEA ablation can be useful for treating VT when conventional ablation is limited by inaccessible substrate due to prior cardiac surgery.

The Comparison of Efficacy and Safety between Radiofrequency Ablation Alone and Ethanol Ablation Followed by Radiofrequency Ablation in the Treatment of Mixed Cystic and Solid Thyroid Nodule.

Purpose: To compare the efficacy and safety of radiofrequency ablation (RFA) and ethanol ablation (EA) followed by RFA in treating mixed cystic and solid thyroid nodules. Materials and Methods: We included 243 nodules from 243 patients who underwent RFA for mixed cystic and solid benign nodules. The nodules were divided into two groups (RFA alone and EA + RFA). We evaluated volume reduction rate (VRR), therapeutic success rate, improvement in symptomatic and cosmetic issues, complications, and adverse effects. Results: The RFA group included 204 patients, and the EA + RFA group included 39 patients. The long-term success rates in the RFA only and EA + RFA groups were 90.2% and 97.4%, respectively. The mean VRR at the last follow-up in the RFA and EA + RFA groups were 81.6% and 87.2%, respectively. Therapeutic results were similar in both groups at the last follow-up. Cosmetic and symptomatic problems markedly improved in both groups. No major complications were observed. Conclusion: Both RFA alone and EA + RA are safe and effective methods for treating mixed cystic and solid thyroid nodules, although EA + RFA is slightly more effective.

Double-balloon venous ethanol ablation for treatment of repetitive monomorphic ventricular complexes from intramural infero-basal septum: a case report.

Background: Ablation failures are common in case of intramural location of the arrhythmogenic substrate. Case summary: We report the case of a patient with cardiomyopathy contributed by frequent monomorphic ventricular arrhythmias (VAs) from intramural basal interventricular septum treated with double-balloon venous ethanol ablation (VEA) after a previous failed endocardial radiofrequency (RF) ablation. Discussion: Double-balloon VEA represents a safe and effective therapeutic option in case of intramural VAs also in the absence of venous collaterals joining selectively an intramural arrhythmic substrate.

A Solvent Exchange Induced Robust Wet Adhesive Hydrogels to Treat Solid Tumor Through Synchronous Ethanol Ablation and Chemotherapy.

The treatment of tumors in developing countries, especially those with poor medical conditions, remains a significant challenge. Herein, a novel solvent-exchange strategy to prepare adhesive hydrogels for the concurrent treatment of tumors through synchronous ethanol ablation and local chemotherapy is reported. First, a poly (gallic acid-lipoic acid) (PGL) ethanol gel is prepared that can undergo solvent exchange with water to form a hydrogel in situ. PGL ethanol gel deposited on the wet tissue can form a hydrogel in situ to effectively repel interfacial water and establish a tight contact between the hydrogel and tissue. Additionally, the functional groups between the hydrogels and tissues can form covalent and non-covalent bonds, resulting in robust adhesion. Furthermore, this PGL ethanol gel demonstrates exceptional capacity to effectively load antitumor drugs, allowing for controlled and sustained release of the drugs locally and sustainably both in vitro and in vivo. In addition, the PGL ethanol gel can combine ethanol ablation and local chemotherapy to enhance the antitumor efficacy in vitro and in vivo. The PGL ethanol gel-derived hydrogel shows robust wet bioadhesion, drug loading, sustained release, good biocompatibility and biodegradability, easy preparation and usage, and cost-effectiveness, which make it a promising bioadhesive for diverse biomedical applications.

Can Ethanol Ablation Achieve Durable Control of Neck Nodal Recurrences in Adults With Stage I Papillary Thyroid Cancer?

Objective: Results of ethanol ablation (EA) for controlling neck nodal metastases (NNM) in adult patients with papillary thyroid carcinoma (APTC) beyond 6 months have rarely been reported. We now describe outcome results in controlling 71 NNM in 40 node-positive stage I APTC patients followed for 66 to 269 months. Methods: All 40 patients were managed with bilateral thyroidectomy and radioiodine therapy and followed with neck ultrasound (US) for >48 months after EA. Cumulative radioiodine doses ranged from 30 to 550 mCi; pre-EA 27 patients (67%) had 36 additional neck surgeries. Cytologic diagnosis of PTC in 71 NNM selected for EA was confirmed by US-guided biopsy. EA technique and follow-up protocol were as previously described. Results: The 40 patients had 1 to 4 NNM; 67/71 NNM (94%) received 2 to 4 ethanol injections (total median volume 0.8 cc). All ablated 71 NNM shrank (mean volume reduction of 93%); nodal hypervascularity was eliminated. Thirty-eight NNM (54%) with initial volumes of 12-1404 mm3 (median 164) disappeared on neck sonography. Thirty-three hypovascular foci from ablated NNM (pre-EA volume range 31-636 mm3; median 147) were still identifiable with volume reductions of 45% to 97% observed (median 81%). There were no complications and no postprocedure hoarseness. Final results were considered to be ideal or near ideal in 55% and satisfactory in 45%. There was no evidence of tumor regrowth after EA. Conclusion: Our results demonstrate that for patients with American Joint Committee on Cancer stage I APTC, who do not wish further surgery or radioiodine, and are uncomfortable with active surveillance, EA can achieve durable control of recurrent NNM.

A clinical practice review of percutaneous ethanol injection for thyroid nodules: state of the art for benign, cystic lesions.

Percutaneous ethanol injection (PEI) is a widely used treatment option for cystic and predominantly cystic thyroid nodules. It has several advantages over other treatment modalities. Compared to surgery, PEI is less painful, can be performed in the outpatient setting, and carries less risk of transient or permanent side effects. Compared to other minimally invasive techniques such as radiofrequency ablation (RFA), PEI is less expensive and does not require specialized equipment. PEI performs well in the context of cystic nodules. PEI does not perform as well as other techniques in solid nodules, so its use as a primary treatment is limited to cystic and predominantly cystic thyroid nodules. However, PEI is also being explored as an adjunct treatment to improve ablation of solid nodules with other techniques. Here, we provide a clinical review discussing the genesis, mechanism of action, and patient selection with respect to ethanol ablation, as well as the procedure itself. Predictors of operative success, failure, and common adverse events are also summarized. Altogether, PEI allows impressive volume reduction rates with minimal complications. Several recent studies have also evaluated the long-term impact of PEI up to 10 years after treatment and revealed maintenance of robust treatment efficacy with no undesirable long-term sequelae. Thus, PEI remains the treatment of choice for benign but symptomatic cystic and predominantly cystic thyroid nodules.

Thyroid Ethanol and Radiofrequency Ablation: A Call for Patient-Friendly Online Resources.

INTRODUCTION: The multiple treatment options available to patients with thyroid nodules can generate uncertainty and confusion. Radiofrequency ablation (RFA) and ethanol ablation (EA) are two alternative modalities to manage thyroid nodules. As patients more frequently utilize online resources to guide their decision-making, the quality of such resources must be evaluated. The goal of this study was to assess the quality of online patient materials relating to RFA and EA compared to standard thyroidectomy. METHODS: The terms "thyroidectomy," "thyroid radiofrequency ablation," and "thyroid ethanol ablation" were searched on Google. Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Patient Education Materials Assessment Tool (PEMAT) understandability and actionability were calculated for each website. Statistical analysis was conducted on SPSS Statistics. Google trends were used to determine search interest for each term (May 2016 - May 2021). RESULTS: Of the 77 websites that met our inclusion criteria (30 thyroidectomy sites, 30 RFA sites, and 17 EA sites), the average FRE, FKGL, and SMOG scores of the RFA websites were significantly worse than those of the thyroidectomy websites (p < 0.05). The FKGL and SMOG scores of the EA websites were significantly worse than those of the thyroidectomy websites (p < 0.05). The average understandability and actionability scores for thyroidectomy websites were significantly higher than those of RFA and EA websites (p < 0.05). CONCLUSION: Ablation websites have lower search interest, readability, validity, understandability, and actionability scores in comparison to traditional thyroidectomy websites. Our findings emphasize the need to consider readability and PEMAT scores when developing online educational resources for ablative alternatives to thyroidectomy to allow for greater patient accessibility.

Concomitant treatment of sustained ventricular tachycardia and hypertrophic cardiomyopathy with transcoronary ethanol ablation: a case report.

Background: The recommended treatment for recurrent ventricular tachycardia in patients with hypertrophic cardiomyopathy that is not amenable to defibrillator implantation due to shock burden is radiofrequency ablation. In patients with deeply intramural foci of ventricular tachycardia, traditional unipolar ablation has a lower probability of success. Case summary: A 66-year-old Caucasian man was admitted with ventricular tachycardia, which recurred despite antiarrhythmic drugs. On cardiac magnetic resonance imaging, he was discovered to have septal hypertrophic cardiomyopathy, which was not significant on echocardiogram. The focus of ventricular tachycardia was suspected to be buried deeply within the hypertrophic segment as localized by late gadolinium enhancement. The patient underwent transcoronary ethanol ablation, which abated the ventricular tachycardia while also completely decreasing his invasively measured left ventricular outflow tract obstruction gradient from 45 to 17 mmHg. Discussion: Transcoronary ethanol ablation may be successfully applied to simultaneously treat ventricular arrhythmia superimposed within a segment of hypertrophic cardiomyopathy. Further data are needed to evaluate long-term success of this strategy vs. traditional radiofrequency ablation.

Ultrasound-guided ethanol ablation versus the Sistrunk operation as a primary treatment for thyroglossal duct cysts.

PURPOSE: This study compared ethanol ablation (EA) with the Sistrunk operation (SO) with regard to feasibility, treatment efficacy, and cost-effectiveness. The goal was to evaluate whether EA could replace SO as a primary treatment modality for thyroglossal duct cysts (TGDCs). METHODS: This retrospective case-control study included patients with TGDCs who were treated with either EA or SO between 2016 and 2022. The primary outcome variables evaluated were treatment efficacy (as measured by the volume reduction rate [VRR] and treatment success rate), complications, and cost-effectiveness. RESULTS: A total of 72 patients were enrolled, with 33 in the EA group and 39 in the SO group. The procedure or operation times for the EA and SO groups were 9 and 82 minutes, respectively (P<0.001). At the final follow-up appointment, the VRR was 94.1% for the EA group and 100.0% for the SO group (P<0.001). Treatment success was achieved for 32 patients (97.0%) in the EA group and for all 39 patients (100.0%) in the SO group (P=0.458). The overall complication rates were 0.0% and 17.9% in the EA and SO groups, respectively (P=0.013). The total costs, including all treatment procedures and follow-up ultrasound examinations, were $485 and $1,081.7 for the EA and SO groups, respectively (P<0.001). CONCLUSION: EA demonstrates superiority over SO in terms of feasibility, safety, and costeffectiveness, while maintaining comparable treatment efficacy. Despite the need for multiple treatment sessions in approximately one-quarter of patients, EA can serve as a primary treatment modality for selected patients with TGDCs, supplanting SO.

Pro-arrhythmic Effect of the Vein of Marshall Ethanol Ablation: A Case Report of Perimitral Flutter After Vein of Marshall Ethanol Ablation.

The ligament of Marshall is an embryological remnant of the left superior vena cava that contains neural tissues shown to be an arrhythmogenic source of atrial fibrillation (AF). Vein of Marshall (VOM) ethanol ablation is an ablation technique that can potentially treat AF by targeting the ligament of Marshall. We report a case of a patient who developed a pro-arrhythmic effect related to VOM ethanol ablation, which manifested as a perimitral flutter.

Ethanol Ablation of a Thyroglossal Duct Cyst and Review of the Literature.

Ultrasound-guided ethanol ablation (EA) is a less invasive alternative to surgical resection for the management of thyroglossal duct cysts (TGDCs). However, to date, EA is rarely used in the United States to treat TGDCs. We present a case of TGDC successfully treated with EA in the United States. A 66-year-old man presented with a mobile anterior neck mass. Neck ultrasonography revealed a complex cystic mass in the midline directly anterior to the trachea, measuring 52 × 41 × 50 mm. Fine needle aspiration revealed no malignant cells, and pathology was consistent with TGDC. The patient had no contraindications to surgical resection. The patient's pretreatment symptom score was 7 and cosmetic score was 3. One month after EA, volume reduction ratio was 40%, symptom score was 1, and cosmetic score was 3. Four months after EA, the TGDC was resolved without need for an additional procedure. The volume reduction ratio was 96.8%, and symptom score and cosmetic score were both 1. In summary, EA is a viable alternative to surgical resection, even in patients who are surgical candidates. EA is attractive due to its simplicity, cost effectiveness, and tolerable side effect profile. Further studies are needed to evaluate long-term safety and efficacy, particularly in United States patients.

In Vivo Evaluation of Safety and Efficacy of Ethyl Cellulose-Ethanol Tissue Ablation in a Swine Cervix Model.

Current therapies for treating cervical dysplasia are often inaccessible in low and middle-income countries (LMICs), highlighting the need for novel low-cost therapies that can be delivered at the point of care. Ethanol ablation is a low-cost therapy designed to treat locoregional cancers, which we augmented into an ethyl cellulose (EC)-ethanol gel formulation to enhance its efficacy. Here, we evaluated whether EC-ethanol ablation is able to safely achieve an ablation zone comparable to thermocoagulation, a commonly used therapy for cervical dysplasia. The study was performed in 20 female Yorkshire pigs treated with either a single 500 µL injection of EC-ethanol into the 12 o'clock position of the cervix or a single application of thermocoagulation at 100 °C for 20 s. The average temperature, heart rate, respiratory rate, and blood oxygen remained within normal ranges throughout the EC-ethanol procedure and were similar to the thermocoagulation group. No major side effects were observed. The reproductive tracts were excised after 24 h to examine ablation zones. Comparable depths of necrosis were seen for EC-ethanol (18.6 ± 1.6 mm) and thermocoagulation (19.7 ± 4.1 mm). The volumes of necrosis induced by a single injection of EC-ethanol (626.2 ± 122.8 µL) were comparable to the necrotic volumes induced by thermocoagulation in the top half of the cervices (664.6 ± 168.5 µL). This suggests that two EC-ethanol injections could be performed (e.g., at the 12 and 6 o'clock positions) to achieve comparable total necrotic volumes to thermocoagulation and safely and effectively treat women with cervical dysplasia in LMICs. This is the first study to systematically evaluate EC-ethanol ablation in a large animal model and compare its safety and efficacy to thermocoagulation, a commonly used ablative therapy for cervical dysplasia.

Ultrasound-Guided Ethanol Percutaneous Ablation Versus Rescue Surgery in Patients With Locoregional Recurrence of Papillary Thyroid Cancer.

OBJECTIVES: Neck recurrence of papillary thyroid cancer (PTC) is frequently detected after initial surgery. The management of these lesions may include rescue surgery (RS) or minimally invasive techniques in selected patients, but comparative studies evaluating the effectiveness and safety of these techniques are lacking. In this paper, we compared ultrasound-guided ethanol ablation (EA) in selected patients to RS in a matched cohort. METHODS: We retrospectively compared 41 patients and 41 matched PTC patients without known distant metastases, who underwent ultrasound-guided EA or RS (matched reference group), who had 63 and 75 thyroid bed and/or lymph node confirmed PTC recurrences during a median follow-up of 72.8 and 89.6 months, respectively. The primary outcome was time until structural recurrence, compared using Kaplan-Meier survival curves. The secondary outcomes included time until biochemical recurrence, plasma thyroglobulin (Tg) levels, American Thyroid Association (ATA) response-to-therapy categories by the last available observation, and treatment-derived complications in each group. RESULTS: No significant differences were found between the EA and RS groups for time until structural recurrence (log-rank test, P=0.94). The time until biochemical recurrence was also similar (P=0.51); and the plasma Tg concentration reduction and proportions of patients in the ATA reclassification categories were also similar. A significantly higher proportion of patients in the RS group presented treatment-derived complications (29.27% vs. 9.75%, P<0.05). CONCLUSION: In this retrospective analysis, the treatment of PTC neck recurrence with EA in selected patients was comparable to RS in a matched reference group for the long-term risk of structural or biochemical relapse, but with a lower risk of treatment-derived complications. These. RESULTS: support the effectiveness and safety of this minimally invasive technique in the management of selected patients with recurrent PTC.