Search Results (10)

Background: Ethanol infusion into the vein of Marshall (EI-VOM) is widely used to facilitate atrial fibrillation ablation and block of the mitral isthmus. However, it cannot be completed in some anatomically challenging cases. This study aimed to introduce and evaluate a novel reversed U curve method of EI-VOM. Methods: This case-series study enrolled consecutive patients with atrial fibrillation or atrial flutter who were scheduled for EI-VOM. When VOM venography was successfully performed, the conventional EI-VOM method was attempted first. If this approach failed or took ≥20 min, the novel method was applied. The success rate, complications, and applicable anatomical conditions of the new method were summarized. Results: Of the 205 patients enrolled in this study, the novel method was applied to 45 patients, and technical success was achieved in 42 patients (93.3%). Among the patients who underwent the novel method, twenty-four (53.3%) had a long cavotricuspid isthmus, nineteen (42.2%) had a VOM ostium close to the coronary sinus ostium, and sixteen (35.6%) had a prominent Eustachian ridge. The total mean procedure time of EI-VOM using the novel method was 30.00 ± 4.5 min. Acute bidirectional mitral isthmus block was achieved in 40 cases (88.9%), and the mean ethanol volume injected was 8.21 ± 1.5 mL. No serious in-hospital complications were documented in patients treated with the novel method. Conclusions: In this single-center case series, the reversed U curve method appeared feasible as a femoral bailout strategy for EI-VOM in selected anatomically challenging cases. Further prospective, multicenter studies involving multiple operators are required to confirm its reproducibility, efficacy, and safety over conventional approaches. Full article

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and is associated with significant morbidity, mortality, and health care expenditure. Catheter ablation is the most effective treatment strategy to decrease AF burden, a measure strongly correlated with significant clinical outcomes. For the last two decades, pulmonary vein isolation (PVI) has remained the cornerstone of the ablation procedure, with single procedure success rates as high as 90% in patients with paroxysmal AF. These favorable outcomes have not translated to patients with persistent AF, who harbor more atrial remodeling and who may require ablation beyond PVI. While most PVI-adjunctive ablation strategies have not survived the rigor of randomized control trials, in 2020, VENUS showed that adjunctive ethanol instillation into the vein of Marshall (EIVOM) improved clinical outcomes in patients with persistent AF. Since VENUS, three other randomized trials have consistently shown a benefit of adjunctive EIVOM, though utilization of this technique remains low due to a multitude of factors. In parallel to the mounting evidence supporting EIVOM, pulsed-field ablation (PFA) has revolutionized the landscape and has called into question the ongoing role of EIVOM. This review examines the electrophysiologic significance of the VOM and summarizes the clinical evidence supporting adjunctive EIVOM in the era of PFA. Full article

The vein and ligament of Marshall (VOM and LOM) are embryological remnants that have gained increasing recognition due to their anatomical complexity, arrhythmogenic potential, and relevance during catheter ablation and structural heart interventions. This review summarizes current evidence on their embryology, morphology, anatomical variability, imaging characteristics, and clinical implications. A structured literature search across PubMed, Embase, and Scopus identified anatomical, histological, electrophysiological, and interventional studies. The VOM is present in most hearts, but its topographic variants and ostial positions show substantial interindividual diversity. The LOM displays a segmental architecture with distinct muscular and fibrotic components that interface with the atrial myocardium and the coronary sinus, providing a substrate for atrial fibrillation. Advances in cardiac imaging have improved delineation of the VOM–LOM region, enhancing pre-procedural assessment and guidance for ethanol infusion and ablation strategies. Recognition of the variability and functional significance of these structures is essential for optimizing procedural outcomes and avoiding complications. Taken together, the VOM and LOM represent key atrial venous remnants whose detailed characterization contributes to a deeper understanding of atrial arrhythmogenesis and contemporary interventional electrophysiology. Full article

Background: Atypical atrial flutter (AFL) is a complex clinical challenge, particularly in patients with prior atrial fibrillation (AF) treated with pulmonary vein isolation (PVI). Arrhythmias involving the vein of Marshall (VOM) often require extensive lesion sets, including ethanol infusion, to effectively target the epicardial substrate. To minimize tissue damage, an alternative strategy has been proposed, emphasizing advanced electroanatomical mapping, entrainment maneuvers, and highly targeted ablation techniques. Case Presentation: We describe a 72-year-old woman with recurrent atrial arrhythmias following pulmonary vein isolation (PVI), who presented with palpitations as her primary symptom. After ineffective pharmacological therapy, she underwent a catheter ablation procedure. Electroanatomical mapping revealed significant left atrial scarring and suggested a macroreentrant circuit involving the VOM. Entrainment maneuvers confirmed the VOM’s involvement. A single targeted endocardial ablation guided by the ablation index terminated the arrhythmia within 12 s, without the need for ethanol infusion or extensive lesion sets. Discussion: This case underscores the VOM’s role in sustaining atypical AFL post-PVI and highlights the effectiveness of precise electroanatomical mapping combined with targeted endocardial ablation. Unlike broader ablation or ethanol infusion strategies, a focused lesion at the critical isthmus achieved arrhythmia termination with minimal tissue damage. Conclusions: Endocardial ablation at the site of entrainment can safely and effectively treat VOM-related AFL, offering symptom relief and restoration of sinus rhythm. This approach may reduce procedural risks and expand the feasibility of VOM-related arrhythmia management in centers without access to ethanol infusion. Full article

Currently, pulmonary vein isolation (PVI) is the gold standard in catheter ablation for atrial fibrillation (AF). However, PVI alone may be insufficient in the management of persistent AF, and complementary methods are being explored. One such method takes an anatomical approach—improving both its success rate and lesion durability may lead to improved treatment outcomes. An additional approach complementary to the anatomical one is also attracting attention, one that focuses on epicardial conduction. This involves ethanol ablation of the vein of Marshall (VOM) and can be very effective in blocking epicardial conduction related to Marshall structure; it is becoming incorporated into standard treatment. However, the pitfall of this “Marshall-PLAN”, a method that combines an anatomical approach with ethanol infusion within the VOM (Et-VOM), is that Et-VOM and other line creations are not always successfully completed. This has led to cases of AF and/or atrial tachycardia (AT) recurrence even after completing this lesion set. Investigating effective adjunctive methods will enable us to complete the lesion set with the aim to lower the rates of recurrence of AF and/or AT in the future. Full article

Background: The best ablation treatment for persistent atrial fibrillation (PeAF) patients is still debated. The vein of Marshall (VOM) seems to be a promising target for ablation and could be combined with a linear set of ablation lesions. The aim of our study is to evaluate the incidence of AF recurrences in a PeAF population treated with a comprehensive ablation approach consisting of VOM ethanol infusion (EI), pulmonary vein isolation (PVI), a left atrial (LA) roofline, a mitral line (guided by the newly formed lesion after alcohol infusion into the VOM and validated by pacing), and a cavotricuspid isthmus line. Methods: Consecutive patients undergoing the first ablation procedure of catheter ablation (CA) for PeAF were enrolled. All patients underwent VOM-EI, PVI, and ablation lines along the roof of the LA, mitral, and cavotricuspid isthmus. LA voltage mapping before and after VOM-EI was also performed. An implantable loop recorder (ILR) was implanted at the end of the ablation in each patient. Results: Thirty-one consecutive patients (66 ± 8 years and 71% male) affected by PeAF were included in this study. The VOM-EI procedural phase lasted 21.4 ± 10.1 min. PV isolation and lines were validated in all subjects. The ML block was achieved within 10.8 ± 8.7 min. At a mean follow-up of 12 ± 7 months, 27 out of 31 (87%) patients remained free from AT/AF recurrences. Among the patients with recurrences, two (50%) had incomplete ablation lesions and three (75%) had “suboptimal” VOM-EI. In 23/31 patients (74%), antiarrhythmic drugs (AADs) were discontinued after 1 month of follow-up. No significant complications were reported during the follow-up. Conclusions: this single-center experience demonstrates that VOM-EI systematically combined with an anatomical ablation set in patients with PeAF resulted in feasible, safe, and effective freedom from AF/AT recurrences in 87% of the population after a 1-year follow-up period according to an ILR. Full article

Background: Ethanol infusion in the vein of Marshall (EI-VOM) has the advantages of reducing the burden of atrial fibrillation (AF), decreasing AF recurrence, and facilitating left pulmonary vein isolation and mitral isthmus bidirectional conduction block. Moreover, it can lead to prominent edema of the coumadin ridge and atrial infarction. Whether these lesions will affect the efficacy and safety of left atrial appendage occlusion (LAAO) has not yet been reported. Objectives: To explore the clinical outcome of EI-VOM on LAAO during implantation and after 60 days of follow-up. Methods: A total of 100 consecutive patients who underwent radiofrequency catheter ablation combined with LAAO were enrolled in this study. Patients who also underwent EI-VOM at the same period of LAAO were assigned to group 1 (n = 26), and those who did not undergo EI-VOM were assigned to group 2 (n = 74). The feasibility outcomes included intra-procedural LAAO parameters and follow-up LAAO results involving device-related thrombus, a peri-device leak (PDL), and adequate occlusion (defined as a PDL ≤ 5 mm). Safety outcomes were defined as the composites of severe adverse events and cardiac function. Outpatient follow-up was performed 60 days post-procedure. Results: Intra-procedural LAAO parameters, including the rate of device reselection, rate of device redeployment, rate of intra-procedural PDLs, and total LAAO time, were comparable between groups. Furthermore, intra-procedural adequate occlusion was achieved in all patients. After a median of 68 days, 94 (94.0%) patients received their first radiographic examination. Device-related thrombus was not detected in the follow-up populations. The incidence of follow-up PDLs was similar between the two groups (28.0% vs. 33.3%, p = 0.803). The incidence of adequate occlusion was comparable between groups (96.0% vs. 98.6%, p = 0.463). In group 1, none of the patients experienced severe adverse events. Ethanol infusion significantly reduced the right atrial diameter. Conclusions: The present study showed that undergoing an EI-VOM procedure did not impact the operation or effectiveness of LAAO. Combining EI-VOM with LAAO was safe and effective. Full article

Background: The vein of Marshall (VOM) ethanol infusion improves sinus rhythm maintenance in patients with atrial fibrillation (AF). Distal collateral circulation of VOM can be a challenge to effective ethanol infusion. Objective: This study aimed to evaluate the feasibility and efficacy of ethanol infusion in VOM with distal collateral circulation. Methods: Patients with AF scheduled for catheter ablation and VOM ethanol infusion were consecutively enrolled. During the procedure, non-occluded coronary sinus angiography was first performed for VOM identification. After VOM identification, an over-the-wire angioplasty balloon was used for cannulation and occluded angiography of the VOM. Those with distal VOM collateral circulation were included in this study. A method of slower ethanol injection (2 mL over 5 min) plus additional balloon occlusion time for 3 min after each injection was used. Results: Of 162 patients scheduled for VOM ethanol infusion, apparent distal VOM collateral circulation was revealed in seven (4.3%) patients. Five patients had collateral circulation to the left atrium, one to the right superior vena cava, and one to the great cardiac vein. Two patients did not undergo further ethanol infusion because of our inadequate experience during the early stage of the project. Five patients had successful VOM ethanol infusion with manifest localized myocardium staining. Conclusions: Ethanol infusion in VOM with distal collateral circulation can be solved by slow injection of ethanol and enough balloon occlusion time between multiple injections. Full article

Background: Ethanol infusion into the vein of Marshall (Et-VOM) is a novel therapeutic treatment for atrial fibrillation (AF). However, few studies have focused on the difference between AF and non-AF patients (presented other types of arrhythmias) regarding the characteristics of the vein of Marshall (VOM). Objective: This study sought to investigate the incidence, morphology, and angiographic characteristics of the VOM. Methods: Coronary sinus (CS) angiography was performed in all patients. The baseline, angiographic characteristics and measurements of VOM dimensions were compared between the AF and non-AF group. Results: CS angiography was performed in 290 patients. The VOM detection rate was higher in the AF group than in the non-AF group (91.8% vs. 84.1%, p = 0.044). In the right anterior oblique (RAO) projection, AF patients had significant larger VOM ostium, CS ostium, and CS diameter at VOM ostium than non-AF patients (1.9 ± 0.9 vs. 1.7 ± 0.7 mm, p = 0.015; 12.8 ± 4.1 vs. 11.4 ± 3.7 mm, p = 0.016; 9.1 ± 3.1 vs. 8.2 ± 2.9 mm, p = 0.028, respectively). There was a slight linear correlation between the VOM ostium and the CS ostium diameter as well as left atrial volume (LAV). Conclusion: AF patients seem to have a higher incidence of the VOM, larger VOM ostium, CS ostium, and CS lumen in RAO view. Meanwhile, the VOM ostium may correlate with the CS ostium and LAV. Full article

Catheter ablation for persistent atrial fibrillation (PeAF) is particularly challenging, as the clinical outcomes are modest. Pulmonary vein isolation (PVI) plus linear ablation is one of the main strategies for PeAF ablation. Completely durable transmural lesions are difficult to achieve by catheter ablation during mitral isthmus ablation. The ligament of Marshall contains the vein of Marshall (VOM), myocardial tracts and innervation, and serves as arrhythmogenic foci that make it an attractive target in catheter ablation of atrial fibrillation. Additionally, it co-localizes with the mitral isthmus, and may serve as a part of the perimitral isthmus reentrant circuit. Ethanol infusion into the VOM results in rapid ablation of the neighboring myocardium and its innervation. Its incorporation into PVI significantly increases the success rate of mitral isthmus block and the clinical outcome of PeAF ablation. Full article