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How to perform ethanol ablation of the vein of Marshall for treatment of atrial fibrillation

Published:February 15, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.02.009
      The arrhythmogenicity of the vein of Marshall (VoM) in atrial fibrillation (AF) has been known for more than 20 years.
      • Kim D.T.
      • Lai A.C.
      • Hwang C.
      • et al.
      The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias.
      A recent randomized trial showed a reduced odds ratio (0.63; 95% confidence interval 0.41–0.97; P = .04) for the primary outcome of AF or atrial tachycardia (AT) recurrence in patients with persistent AF by adding VoM ethanol infusion (VoM-Et) to the standard ablation approach.
      • Valderrábano M.
      • Peterson L.E.
      • Swarup V.
      • et al.
      Effect of catheter ablation with vein of Marshall ethanol infusion vs catheter ablation alone on persistent atrial fibrillation: the VENUS randomized clinical trial.
      The VoM is involved in 30% of ATs after AF ablation, and VoM ablation significantly improves the freedom from recurrent arrhythmia.
      • Vlachos K.
      • Denis A.
      • Takigawa M.
      • et al.
      The role of Marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation.
      ,
      • Takigawa M.
      • Derval N.
      • Martin C.A.
      • et al.
      Mechanism of recurrence of atrial tachycardia: comparison between first versus redo procedures in a high-resolution mapping system.
      VoM-Et also improves the success rate for lateral mitral isthmus block, from 64% to nearly 100%.
      • Nakashima T.
      • Pambrun T.
      • Vlachos K.
      • et al.
      Impact of vein of Marshall ethanol infusion on mitral isthmus block: efficacy and durability.
      Based on these findings, we developed the anatomy-based MARSHALL-PLAN (MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation) ablation approach for persistent AF. This protocol includes pulmonary vein (PV) isolation, a left atrial (LA) roof line, a lateral mitral isthmus line facilitated by VoM-Et, and a cavotricuspid isthmus line.
      • Pambrun T.
      • Denis A.
      • Duchateau J.
      • et al.
      MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation: MARSHALL-PLAN case series.
      First results showed promising acute and mid-term success rates, and the protocol is now being investigated in larger populations and in a randomized controlled trial (ClinicalTrials.gov Identifier: NCT04206982).

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      References

        • Kim D.T.
        • Lai A.C.
        • Hwang C.
        • et al.
        The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias.
        J Am Coll Cardiol. 2000; 36: 1324-1327
        • Valderrábano M.
        • Peterson L.E.
        • Swarup V.
        • et al.
        Effect of catheter ablation with vein of Marshall ethanol infusion vs catheter ablation alone on persistent atrial fibrillation: the VENUS randomized clinical trial.
        JAMA. 2020; 324: 1620-1628
        • Vlachos K.
        • Denis A.
        • Takigawa M.
        • et al.
        The role of Marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation.
        Heart Rhythm. 2019; 16: 1341-1347
        • Takigawa M.
        • Derval N.
        • Martin C.A.
        • et al.
        Mechanism of recurrence of atrial tachycardia: comparison between first versus redo procedures in a high-resolution mapping system.
        Circ Arrhythm Electrophysiol. 2020; 13e007273
        • Nakashima T.
        • Pambrun T.
        • Vlachos K.
        • et al.
        Impact of vein of Marshall ethanol infusion on mitral isthmus block: efficacy and durability.
        Circ Arrhythm Electrophysiol. 2020; 13e008884
        • Pambrun T.
        • Denis A.
        • Duchateau J.
        • et al.
        MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation: MARSHALL-PLAN case series.
        J Cardiovasc Electrophysiol. 2019; 30: 7-15
        • Sirajuddin A.
        • Chen M.Y.
        • White C.S.
        • Arai A.E.
        Coronary venous anatomy and anomalies.
        J Cardiovasc Comput Tomogr. 2020; 14: 80-86
        • Cabrera J.A.
        • Ho S.Y.
        • Climent V.
        • Sánchez-Quintana D.
        The architecture of the left lateral atrial wall: a particular anatomic region with implications for ablation of atrial fibrillation.
        Eur Heart J. 2008; 29: 356-362
        • von Lüdinghausen M.
        • Ohmachi N.
        • Besch S.
        • Mettenleiter A.
        Atrial veins of the human heart.
        Clin Anat. 1995; 8: 169-189
        • Di Biase L.
        • Romero J.
        • Briceno D.
        • et al.
        Evidence of relevant electrical connection between the left atrial appendage and the great cardiac vein during catheter ablation of atrial fibrillation.
        Heart Rhythm. 2019; 16: 1039-1046

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