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How and when to ablate the ligament of Marshall

Published:September 18, 2006DOI:https://doi.org/10.1016/j.hrthm.2006.09.014
      The ligament of Marshall is an epicardial vestigial fold that marks the location of the embryologic left superior vena cava. It contains the nerve, vein (vein of Marshall), and muscle tracts.
      • Marshall J.
      On the development of the great anterior veins in man and mammalia: including an account of certain remnants of foetal structure found in the adult, a comparative view of these great veins in the different mammalia, and an analysis of their occasional peculiarities in the human subject.
      • Scherlag B.J.
      • Yeh B.K.
      • Robinson M.J.
      Inferior interatrial pathway in the dog.
      The proximal portions of the muscle tracts connect directly to the coronary sinus myocardial sleeves. The distal portions of the muscle tracts extend upward into the pulmonary vein region. Figure 1 shows a postmortem human heart with the ligament of Marshall located between the left atrial (LA) appendage and left pulmonary vein.
      • Kim D.T.
      • Lai A.C.
      • Hwang C.
      • Fan L.T.
      • Karagueuzian H.S.
      • Chen P.-S.
      • Fishbein M.C.
      The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias.
      Histologic study showed that the mid and distal portions of the ligament of Marshall had large numbers of connecting muscle fibers. These fibers may insert into the epicardium of the LA and left pulmonary vein. These complex myocardial connections between the structures can form the substrates for reentry that maintain atrial fibrillation (AF).
      • Tan A.Y.
      • Chou C.C.
      • Zhou S.
      • Nihei M.
      • Hwang C.
      • Peter C.T.
      • Fishbein M.C.
      • Chen P.S.
      Electrical connections between left superior pulmonary vein, left atrium, and ligament of Marshall: implications for mechanisms of atrial fibrillation.
      • Doshi R.N.
      • Wu T.-J.
      • Yashima M.
      • Kim Y.-H.
      • Ong J.J.C.
      • Cao J.-M.
      • Hwang C.
      • Yashar P.
      • Fishbein M.C.
      • Karagueuzian H.S.
      • Chen P.-S.
      Relation between ligament of Marshall and adrenergic atrial tachyarrhythmia.
      The ligament of Marshall contains sympathetic nerve trunks as well as sympathetic ganglia.
      • Kim D.T.
      • Lai A.C.
      • Hwang C.
      • Fan L.T.
      • Karagueuzian H.S.
      • Chen P.-S.
      • Fishbein M.C.
      The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias.
      It also is richly innervated by parasympathetic nerves.
      • Ulphani J.S.
      • Cain J.H.
      • Arora R.
      • Gordon D.
      • Shen S.
      • Goldberger J.J.
      • Kadish A.H.
      Role of the ligament of Marshall in vagal control of the posterior left atrium.
      Figure thumbnail gr1
      Figure 1Anatomy of the ligament of Marshall (LOM). A: Location of LOM between left atrial appendage (LAA) and left pulmonary vein (LPV). B: Immunohistochemical staining for tyrosine hydroxylase showing positive staining in nerve (brown staining, arrow). M = myocardium. C–E: Serial sections showing the LOM isolated from the left atrial wall (C), with three tracts (arrows) emerging from it (D), and eventually inserting into the atrial wall (E) (hematoxylin and eosin stain magnification ×10). F: Serial section from lower end of LOM showing muscle tracts inserting into the left atrial wall (arrow) and coronary sinus (CS) (hematoxylin and eosin stain, magnification ×10). (Reproduced with permission from Kim et al.
      • Kim D.T.
      • Lai A.C.
      • Hwang C.
      • Fan L.T.
      • Karagueuzian H.S.
      • Chen P.-S.
      • Fishbein M.C.
      The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias.
      )
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      References

        • Marshall J.
        On the development of the great anterior veins in man and mammalia: including an account of certain remnants of foetal structure found in the adult, a comparative view of these great veins in the different mammalia, and an analysis of their occasional peculiarities in the human subject.
        Phil Trans R Soc Lond. 1850; 140: 133-169
        • Scherlag B.J.
        • Yeh B.K.
        • Robinson M.J.
        Inferior interatrial pathway in the dog.
        Circ Res. 1972; 31: 18-35
        • Kim D.T.
        • Lai A.C.
        • Hwang C.
        • Fan L.T.
        • Karagueuzian H.S.
        • Chen P.-S.
        • Fishbein M.C.
        The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias.
        J Am Coll Cardiol. 2000; 36: 1324-1327
        • Tan A.Y.
        • Chou C.C.
        • Zhou S.
        • Nihei M.
        • Hwang C.
        • Peter C.T.
        • Fishbein M.C.
        • Chen P.S.
        Electrical connections between left superior pulmonary vein, left atrium, and ligament of Marshall: implications for mechanisms of atrial fibrillation.
        Am J Physiol Heart Circ Physiol. 2006; 290: H312-H322
        • Doshi R.N.
        • Wu T.-J.
        • Yashima M.
        • Kim Y.-H.
        • Ong J.J.C.
        • Cao J.-M.
        • Hwang C.
        • Yashar P.
        • Fishbein M.C.
        • Karagueuzian H.S.
        • Chen P.-S.
        Relation between ligament of Marshall and adrenergic atrial tachyarrhythmia.
        Circulation. 1999; 100: 876-883
        • Ulphani J.S.
        • Cain J.H.
        • Arora R.
        • Gordon D.
        • Shen S.
        • Goldberger J.J.
        • Kadish A.H.
        Role of the ligament of Marshall in vagal control of the posterior left atrium.
        Heart Rhythm. 2006; 3: S224-S225
        • Hwang C.
        • Wu T.-J.
        • Doshi R.N.
        • Peter C.T.
        • Chen P.-S.
        Vein of Marshall cannulation for the analysis of electrical activity in patients with focal atrial fibrillation.
        Circulation. 2000; 101: 1503-1505
        • Hsu L.F.
        • Jais P.
        • Keane D.
        • Wharton J.M.
        • Deisenhofer I.
        • Hocini M.
        • Shah D.C.
        • Sanders P.
        • Scavee C.
        • Weerasooriya R.
        • Clementy J.
        • Haissaguerre M.
        Atrial fibrillation originating from persistent left superior vena cava.
        Circulation. 2004; 109: 828-832
        • Katritsis D.
        • Ioannidis J.P.
        • Anagnostopoulos C.E.
        • Sarris G.E.
        • Giazitzoglou E.
        • Korovesis S.
        • Camm A.J.
        Identification and catheter ablation of extracardiac and intracardiac components of ligament of Marshall tissue for treatment of paroxysmal atrial fibrillation.
        J Cardiovasc Electrophysiol. 2001; 12: 750-758
        • Kamanu S.
        • Tan A.Y.
        • Peter C.T.
        • Hwang C.
        • Chen P.-S.
        Vein of Marshall activity during sustained atrial fibrillation.
        J Cardiovasc Electrophysiol. 2006; 17: 839-846