Achieving acute mitral isthmus block with catheter ablation with vein of marshall ethanol infusion

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
M Andronache ◽  
A Pastorcici ◽  
G Massoulie ◽  
D Blendea ◽  
A Boudias ◽  
...  
Keyword(s):  
Persistent Atrial Fibrillation ◽  
Rf Ablation ◽  
Ablation Procedure ◽  
Funding Sources ◽  
Ethanol Infusion ◽  
Ablation Index ◽  
Mitral Isthmus ◽  
Acute Success ◽  
Isthmus Block ◽  
Safe Approach

Abstract Funding Acknowledgements Type of funding sources: None. Background Achieving bidirectional mitral isthmus block during radiofrequency (RF) ablation for persistent atrial fibrillation (AF) is still challenging. The conventional ablation method involves RF applications on the endocardial aspect of the Mitral Isthmus (MI), and for a majority of patients, in the distal coronary sinus (CS).  Purpose We have evaluated the acute success of obtaining mitral isthmus block by adding another epicardial component using ethanol infusion in the vein of Marshall (EIVOM) in addition to endocardial MI and epicardial CS ablation.  Methods  We studied 121 patients (pts.) with a mean age of 65 years (range 40-83) 73% men; 119 with longstanding persistent AF (98%) and 2 with perimitral flutter (2%). The mean duration of AF was 53 months (12-244 months). In the majority of patients, additional endocardial (on the ventricular aspect of the MI) and/or epicardial (distal CS) (RF) ablation was performed in order to achieve MIB. The ablation procedure was performed under general anesthesia (GA) for 81 pts (67%). EIVOM was perform with a mean 6 ml ethanol (range 2-10ml)  Results  Bidirectional MIB was obtained in 114 pts. (94,2%). The 7 patients without MIB were scheduled for another ablation procedure (4 pts under GA during the first procedure). The average RF delivery time to block was 160 seconds (range 42-480 seconds) for the endocardial MI RF ablation (point-by-point application with a power of 50W and an Ablation Index of 450-500, contact force 10-20g) and 156 seconds (range 55-438) for the epicardial MI RF ablation (applications with a power of 20W). Bidirectional endocardial and epicardial MIB was confirmed by conventional pacing maneuvers performed in sinus rhythm. No major complications were observed. The parameters associated with failure for MIB were AF duration, Left Atrial dilatation >200 ml, MI thickness (epicardial endocardial distance on the CARTO maps >15mm). Conclusion Ethanol infusion in the vein of Marshall is a safe approach and is associated with a higher success rate of obtaining acute bidirectional endocardial and epicardial mitral isthmus block when compared with the conventional method. Abstract Figure. Bloc Mitral Endo; Bloc Mitral Epi;

scholarly journals Acute and mid-term outcome of ethanol infusion of vein of Marshall for the treatment of perimitral flutter

EP Europace ◽  
2020 ◽  
Vol 22 (8) ◽  
pp. 1252-1260
Author(s):  
Masateru Takigawa ◽  
Konstantinos Vlachos ◽  
Claire A Martin ◽  
Felix Bourier ◽  
Arnaud Denis ◽  
...  
Keyword(s):  
Rf Ablation ◽  
Term Outcome ◽  
High Resolution Mapping ◽  
Ethanol Infusion ◽  
Mitral Isthmus ◽  
Resolution Mapping ◽  
Isthmus Block ◽  
Group Contact ◽  
One Year

Abstract Aims  We hypothesized that an epicardial approach using ethanol infusion in the vein of Marshall (EIVOM) may improve the result of ablation for perimitral flutter (PMF). Methods and results  We studied 103 consecutive patients with PMF undergoing high-resolution mapping. The first 71 were treated with radiofrequency (RF) ablation alone (RF-group), and the next 32 underwent EIVOM followed by RF on the endocardial and epicardial mitral isthmus (EIVOM/RF-group). Contact force was not measured during ablation. Acute and 1-year outcomes were compared. Flutter termination rates were similar between the RF-group (63/71, 88.7%) and EIVOM/RF-group (31/32, 96.8%, P = 0.27). Atrial tachycardia (AT) terminated with EIVOM alone in 22/32 (68.6%) in the EIVOM/RF-group. Bidirectional block of mitral isthmus was always achieved in the EIVOM/RF-group, but significantly less frequently achieved in the RF-group (62/71, 87.3%; P = 0.05). Median RF duration for AT termination/conversion was shorter [0 (0–6) s in the EIVOM/RF-group than 312 (55–610) s in the RF-group, P < 0.0001], as well as for mitral isthmus block in the EIVOM/RF-group [246 (0–663) s] than in the RF-group [900 (525–1310) s, P < 0.0001]. Pericardial effusion was observed in 1/32 (3.2%) in EIVOM/RF-group and 5/71 (7.0%) in RF-group (P = 0.66); two in RF-group required drainage and one of them developed subsequent ischaemic stroke. One-year follow-up demonstrated fewer recurrences in the EIVOM/RF-group [6/32 (18.8%)] than in the RF-group [29/71 (40.8%), P = 0.04]. By multivariate analysis, only EIVOM was significantly associated with less AT recurrence (hazard ratio = 0.35, P = 0.018). Conclusion  Ethanol infusion in the vein of Marshall may reduce RF duration required for PMF termination as well as for mitral isthmus block without severe complications, and the mid-term outcome may be improved by this approach.

scholarly journals Impact of Vein of Marshall Ethanol Infusion on Mitral Isthmus Block

2020 ◽  
Vol 13 (12) ◽  
Author(s):  
Takashi Nakashima ◽  
Thomas Pambrun ◽  
Konstantinos Vlachos ◽  
Cyril Goujeau ◽  
Clémentine André ◽  
...  
Keyword(s):  
Index Procedure ◽  
Ethanol Infusion ◽  
Number Of Patients ◽  
Mitral Isthmus ◽  
Acute Mi ◽  
Isthmus Block ◽  
The Impact ◽  
Repeat Procedures

Background: Achieving bidirectional mitral isthmus (MI) block using radiofrequency catheter ablation (RFCA) alone is challenging, and MI reconnection is common. Adjunctive vein of Marshall (VOM) ethanol infusion (VOM-Et) can facilitate acute MI block. However, little is known about its long-term success. This study sought to evaluate the impact of adjunctive VOM-Et on MI block achievement and durability compared with RFCA alone. Methods: Patients undergoing the first attempt of posterior MI ablation were grouped according to their MI block index strategy: adjunctive VOM-Et and RFCA alone. Rates of acute MI block and MI reconnection observed during repeat procedures were compared between the 2 groups. Results: The VOM-Et group consisted of 152 patients (63.8±9.4 years) undergoing adjunctive VOM-Et for MI block. The RFCA group consisted of 110 patients (60.9±9.2 years) undergoing MI ablation using RFCA alone. Acute MI block was more frequently achieved in the VOM-Et group (98.7% [150/152] versus 63.6% [70/110]; P <0.001) with shorter RFCA duration (5.00 [3.00–7.00] versus 19.0 [13.6–22.0] minutes; P <0.001). Of the 220 patients with MI block achieved during the index procedure, 81 underwent a repeat procedure during follow-up (VOM-Et group: 23.3% [35/150] versus RFCA group: 65.7% [46/70], respectively; P <0.001). A significantly greater number of patients exhibited durable MI block in the VOM-Et group (62.9% [22/35] versus 32.6% [15/46], respectively; P =0.008). Conclusions: Beyond facilitating acute MI block, VOM-Et is associated with greater lesion durability as evidenced by higher rates of MI block during repeat procedures.

scholarly journals Efficacy and safety of ethanol infusion into the vein of Marshall for mitral isthmus ablation

2021 ◽  
Author(s):  
Anna Lam ◽  
Thomas Küffer ◽  
Lukas Hunziker ◽  
Nikolas Nozica ◽  
Babken Asatryan ◽  
...  
Keyword(s):  
Low Voltage ◽  
Troponin T ◽  
Efficacy And Safety ◽  
Epicardial Ablation ◽  
Ethanol Infusion ◽  
Mitral Isthmus ◽  
Isthmus Block ◽  
Chemical Ablation ◽  
Small Pericardial Effusion

Introduction: Chemical ablation by retrograde infusion of ethanol into the vein of Marshall (VOM-EI) can facilitate achievement of mitral isthmus block. This study sought to describe efficacy and safety of this technique. Methods and Results: Twenty-two consecutive patients (14 male, median age 71 years) with attempted VOM-EI for mitral isthmus ablation were included in the study. VOM-EI was successfully performed with a median of 4 ml of 96% ethanol in 19 patients (86%) and mitral isthmus was successfully blocked in all (100%). Touch up endocardial and/or epicardial ablation after VOM-EI was necessary in 12 patients (63%). Perimitral flutter was present in 12 patients (63%) during VOM-EI and terminated or slowed by VOM-EI in four and three patients, respectively. Low-voltage area of the mitral isthmus region increased from 3.1 cm2 (IQR 0-7.9) before to 13.2 cm2 (IQR 8.2-15.0) after VOM-EI and correlated significantly with the volume of ethanol injected (P = 0.03). Median high-sensitive cardiac troponin-T increased significantly from 330 ng/L (IQR 221-516) the evening of the procedure to 598 ng/L (IQR 382-769; P=0.02) the following morning. A small pericardial effusion occurred in three patients (16%), mild pericarditis in one (5%) and uneventful VOM dissection in two (11%). After a median follow-up of 3.5 months (IQR 3.0-11.0), 10 of 18 patients (56%) with VOM-EI and available follow-up had arrhythmia recurrence. Repeat ablation was performed in five patients (50%) and peri-mitral flutter diagnosed in three (60%). Conclusion: VOM-EI is feasible, safe and effective to achieve acute mitral isthmus block

scholarly journals Mitral isthmus block is associated with favorable outcomes after reablation for long‐standing persistent atrial fibrillation

2020 ◽  
Vol 43 (10) ◽  
pp. 1119-1125
Author(s):  
Xin‐hua Wang ◽  
Ling‐cong Kong ◽  
Zheng Li ◽  
Peng Nie ◽  
Jun Pu
Keyword(s):  
Atrial Fibrillation ◽  
Persistent Atrial Fibrillation ◽  
Mitral Isthmus ◽  
Isthmus Block

scholarly journals Catheter ablation with ethanol infusion in the vein of marshall for persistent atrial fibrillation: safety and procedure duration

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
G Massoulie ◽  
M Andronache ◽  
A Pastorcici ◽  
C Dauphin ◽  
A Costea ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Learning Curve ◽  
Persistent Atrial Fibrillation ◽  
Efficient Technique ◽  
Ethanol Injection ◽  
Funding Sources ◽  
Ethanol Infusion ◽  
Initial Learning ◽  
Procedure Duration ◽  
Time Required

Abstract Funding Acknowledgements Type of funding sources: None. Background Ethanol Infusion in the Vein of Marshall (EIVOM) has been recently introduced as an efficient technique that helps achieving mitral isthmus block during ablation procedures for persistent atrial fibrillation (PAF) or peri-mitral atrial flutter. Purpose We have evaluated the safety of EIVOM and the duration required to perform this procedure.  Methods  We performed EIVOM in 121 patients for PAF (mean age of 65 years (range 40-83, 73% men; Mean EF 50%. The main steps of the EIVOM were as follows: the procedure commenced with catheterization of the coronary sinus, followed by the subsequent introduction of an angiography catheter that allowed for iodine contrast injection and vein of Marshall (VOM) localization, 1.5-2.5 mm angioplasty balloon over 0.014" guidewire placement and finally the ethanol injection up to 10 ml.  Results No major complications were observed during the ablation procedure or before hospital discharge. In 62 patients in whom procedure duration data was available the mean EIVOM procedure time was 41 min (range from 13 to 105 min). After the first 20 procedures, where the learning curve for the operators has to be taken into consideration, a reduction in the time required to achieve EIVOM was consistently noted, with an average of less than 30 min. and for the last 20 procedures less than 20 min. Factors which increase the time required for successful EIVOM include: difficulty in visualizing the ostium of the VOM, a VOM ostium located proximally, difficulty in advancing the angioplasty wire into the VOM and balloon displacement and repositioning. Conclusions Ethanol infusion in the Vein of Marshall is a safe and efficient technique that can be performed in an acceptable amount of time after an initial learning curve. Abstract Figure. Image 1 VOM

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