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

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

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Impact of Vein of Marshall Ethanol Infusion on Mitral Isthmus Block

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.120.008884 ◽

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.

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Atrial Fibrillation Ablation Using Vein of Marshall Ethanol Infusion

Methodist DeBakey Cardiovascular Journal ◽

10.14797/zqme8581 ◽

2021 ◽

pp. 52-55

Author(s):

Adi Lador ◽

Miguel Valderrábano

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Left Atrium ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Left Atrial ◽

Atrial Fibrillation Ablation ◽

Autonomic Nerves ◽

Ethanol Infusion ◽

Mitral Isthmus

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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Long‐term efficacy and safety of adjunctive ethanol infusion into the vein of Marshall during catheter ablation for nonparoxysmal atrial fibrillation

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.13969 ◽

2019 ◽

Vol 30 (8) ◽

pp. 1215-1228 ◽

Cited By ~ 6

Author(s):

Chih‐Min Liu ◽

Li‐Wei Lo ◽

Yenn‐Jiang Lin ◽

Chin‐Yu Lin ◽

Shih‐Lin Chang ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Efficacy And Safety ◽

Term Efficacy ◽

Ethanol Infusion

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

EP Europace ◽

10.1093/europace/euab116.177 ◽

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;

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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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Durability of mitral isthmus ablation with and without ethanol infusion in the vein of Marshall

10.22541/au.161611427.74224109/v1 ◽

2021 ◽

Author(s):

Masayuki Ishimura ◽

Masashi Yamamoto ◽

Toshiharu Himi ◽

Yoshio Kobayashi

Keyword(s):

Atrial Tachycardia ◽

Ablation Lesion ◽

Success Rates ◽

Ablation Process ◽

Rf Pulses ◽

Reconnection Rate ◽

Ethanol Infusion ◽

Linear Ablation ◽

Mitral Isthmus

Background: It is established that ethanol infusion in the vein of Marshall (EIVOM) effectively creates a linear ablation lesion in the mitral isthmus (MI). However, data on the long-term success rates of MI ablation remains limited. Methods and Results: Our cohort consisted of 560 patients with non-paroxysmal atrial fibrillation (AF) who underwent an initial MI ablation. Ablations were performed by only radiofrequency (RF) in 384 patients (RF group) or by RF and EIVOM in 176 patients (EIVOM/RF group). Ethanol of 5 mL was used to perform EIVOM in advance of RF. Following EIVOM, RF pulses were delivered to the lateral MI line. Bidirectional MI block was fully achieved in 353 (first 318, re-do 35) patients of the RF group and 171 (first 128, re-do 43) patients of the EIVOM/RF group (p = 0.09 in the first, 0.10 in the re-do ablation cases). In cases with complete MI line block, recurrent AF or atrial tachycardia (AT) was observed in 130 (37%) patients of the RF group and in 64 (37%) patients of the EIVOM/RF group (log-rank p = 0.12 in the first, 0.30 in the re-do ablation cases). Of the total 194 patients, 112 with drug refractory AF or AT proceeded to the subsequent ablation process. Reconnection of MI block line was observed in 39 (49%) patients in the RF group and 25 (58%) patients in the EIVOM/RF group (p = 0.32). Conclusion: EIVOM effectively ensures MI line block; however, the reconnection rate was similar between the two groups.

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