Durability of Left Atrial Lesions After Ethanol Infusion in the Vein of Marshall

Catheter ablation has become a cornerstone treatment for atrial fibrillation (AF). Pulmonary vein isolation is the accepted approach for paroxysmal AF ablation, but it is less effective for persistent AF. The vein of Marshall (VOM) is located in the epicardial left atrium and can be a source of AF triggers as well as a tract for autonomic nerves. It directly communicates with the underlying myocardium, including the left atrial ridge and the posterior mitral isthmus. This review discusses the latest evidence regarding the mechanisms, procedural aspects, and outcomes of VOM ethanol infusion when used as an adjunct to pulmonary vein isolation in patients with persistent AF.

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Durability of Left Atrial Lesions after Ethanol Infusion in the Vein of Marshall

10.22541/au.161022000.09684919/v1 ◽

2021 ◽

Author(s):

Mikael Laredo ◽

Virginie Ferchaud ◽

Olivier Thomas ◽

Ghassan Moubarak ◽

Bruno Cauchemez ◽

...

Keyword(s):

Coronary Sinus ◽

Left Atrial ◽

Mitral Annulus ◽

Acute Effect ◽

High Definition ◽

Bipolar Voltage ◽

Ethanol Infusion ◽

Mitral Isthmus ◽

Efficacy Profile

Background Ethanol infusion in the vein of Marshall (EIVM) has shown to be effective for treating atrial fibrillation (AF) and perimitral left atrial (LA) flutter (PMLAF). Aims To assess the persistence of LA lesions created by EIVM by electro-anatomical mapping (EAM) at repeated procedure for recurrent atrial tachycardia (AT) or AF. Methods We included consecutive patients who underwent EIVM then repeated CA for recurrent AT or AF with high-definition EAM in a single center. Acute and long term EIVM effect was assessed at the index and redo procedures by comparing the area of bipolar voltage <0.05 mV in the vein of Marshall (VOM) region before, immediately after and late after EIVM. Results 24 consecutive patients (mean age 68.6±6.1 years, 58% men) underwent redo procedure after previous successful EIVM for persistent AF (n=21; 88%) or PMLAF (n=5; 21%). In each case, EIVM had an acute effect, with a post-EIVM scar in the VOM (median 12.4 cm2 [interquartile range (IQR) 7.6–15.7]). Mitral isthmus (MI) bidirectional block was obtained in 20/24 patients (83%). In each patient, the EIVM-related lesion persisted, with a chronic scar in the VOM region (median 13.1 cm2 [IQR 8.1–15.9]). One quarter of patients (5/20) had late MI reconnection, which was located at the mitral annulus edge or in the coronary sinus. Conclusions Atrial lesions created by EIVM are durable, which reinforces the efficacy profile of EIVM. Reconduction sites in the MI are located at the edge of the mitral annulus and in the coronary sinus.

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Abstract 4655: Retrograde Ethanol Infusion in the Vein of Marshall for Ablation of Atrial Fibrillation: Tissue Ablation, Effects on Regional Vagal Innervation and First Human Experience

Circulation ◽

10.1161/circ.118.suppl_18.s_925-d ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Miguel Valderrábano ◽

Harvey R Chen ◽

Jasvinder S Sidhu ◽

Liyun Rao ◽

Yuesheng Ling ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Coronary Sinus ◽

Left Atrial ◽

Vagal Stimulation ◽

Pulmonary Veins ◽

Posterior Wall ◽

Tissue Ablation ◽

Ethanol Infusion ◽

Before And After

The vein of Marshall (VOM) is an attractive target during ablation of atrial fibrillation due to its autonomic innervation and its location anterior to the left pulmonary veins and drainage in the coronary sinus. We studied 14 dogs. A coronary sinus venogram showed a VOM in 10, which was successfully cannulated with an angioplasty wire and a 2 mm balloon. In 5 dogs, electroanatomical (Carto) maps of the left atrium were performed at baseline and after ethanol (100%, 4 – 8 cc) was infused in the VOM, which demonstrated the creation of a new crescent-shaped scar in the left atrium, extending from the annular left atrium towards the posterior wall and left pulmonary veins. In 4 dogs, both cervical vagal trunks were isolated in the carotid sheath and cuff stimulation electrodes were attached to them. Effective refractory periods (ERP) were measured in 3 sites of the left atrium, before and after high-frequency bilateral vagal stimulation. The baseline ERP was 113.6±35.0 ms, and decreased to 82.2±25.4 ms (p<0.05) after vagal stimulation. After alcohol infusion in VOM, vagally-mediated ERP decrease was eliminated (from 108±27.2 ms to 95.6 ±16.7ms, p=NS). This elimination of vagal effects was not uniform and was limited in sites in proximity with the VOM (baseline ERP 105±18.7ms vs post vagal 98.±37.6ms, p=NS, as opposed to 106.7±27.1ms vs post vagal 73.3±19.7ms, p<0.05, in sites remote to VOM). We also tested feasibility of VOM alcohol infusion in humans: 2 patients undergoing pulmonary vein antral isolation had successful VOM cannulation: left atrial voltage maps demonstrated new scar involving the infero-posterior left atrial wall extending towards the left pulmonary veins. Retrograde alcohol infusion in the VOM achieves significant left atrial tissue ablation, abolishes local vagal responses and is feasible in humans.

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