- The arrhythmogenicity of the vein of Marshall (VoM) in atrial fibrillation (AF) has been known for more than 20 years.1 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.2 The VoM is involved in 30% of ATs after AF ablation, and VoM ablation significantly improves the freedom from recurrent arrhythmia.
- Since its introduction, percutaneous epicardial access is increasingly being performed to facilitate catheter ablation of ventricular tachycardias (VTs) with epicardial circuits, difficult cases of idiopathic VTs, focal atrial tachycardia, and accessory pathways that cannot be successfully targeted endocardially.1 A thorough understanding of the clinical anatomy and potential complications is vital in order to perform a safe procedure.2 In this article, we present the clinical anatomy related to epicardial access, the technique of performing a subxiphoid epicardial puncture, and various measures to prevent complications.
- Curative catheter ablation of atrial fibrillation (AF) began with the recognition of ectopic impulses triggering AF, originating dominantly from the pulmonary veins (PV). Electrical isolation of the PV from the LA was proposed to eliminate these triggers from the PV and is now performed with the aid of a circumferential PV mapping (lasso) catheter. In addition to the initiating role of the PV, this structure is also critical as a substrate maintaining AF.1 The importance of PV isolation in AF ablative therapy therefore remains unchanged since the development of this technique whether it is for paroxysmal, persistent or permanent AF.