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Buck B, Houmsse M. Beyond pulmonary vein isolation: approaches to treat patients with persistent atrial fibrillation. Expert Rev Cardiovasc Ther 2024:1-11. [PMID: 39243124 DOI: 10.1080/14779072.2024.2401876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 08/14/2024] [Accepted: 09/04/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common arrhythmia. Catheter ablation is a successful rhythm control strategy in paroxysmal AF, but it has demonstrated dramatically lower AF-free survival rates in patients with persistent AF. In recent years, myriad novel rhythm control strategies have been developed, each with the promise of improved persistent AF ablation success. AREAS COVERED This review discusses multiple novel techniques and approaches to persistent AF. Authors identified relevant papers by searching PubMed and Google Scholar databases and considered all papers identified, regardless of publication date. It begins by discussing recent advances in electrogram analysis that yielded improved AF-free survival following persistent AF catheter ablation. Next, it discusses several trials revealing the shortcomings of MRI in guiding persistent AF ablation. Finally, it discusses one nascent technique (Vein of Marshall ablation) and technology (AI-assisted electrogram analysis) who have shown promise in improving persistent AF ablation. EXPERT OPINION In the authors' expert opinions, upcoming persistent AF ablations will utilize a stepwise approach of (1) ensuring PV isolation, (2) Vein of Marshall ablation and (3) AI-assisted ablation to optimize future persistent AF ablation outcomes. This approach systematically addresses arrhythmogenic sources beyond the pulmonary veins, the historical treatment target.
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Affiliation(s)
- Benjamin Buck
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024; 21:e31-e149. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024; 67:921-1072. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Landra F, Nesti M, Garibaldi S, Mirizzi G, Startari U, Panchetti L, Piacenti M, Taddeucci S, Formichi BA, Stefani M, Galiberti S, Lionetti V, Solinas P, Levantesi BM, Italia C, Rossi A. A proposed index of myocardial staining for vein of Marshall ethanol infusion: an Italian single-center experience. J Interv Card Electrophysiol 2024; 67:1267-1277. [PMID: 38206450 PMCID: PMC11288988 DOI: 10.1007/s10840-023-01732-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Mitral isthmus (MI) conduction block is a fundamental step in anatomical approach treatment for persistent atrial fibrillation (PeAF). However, MI block is hardly achievable with endocardial ablation only. Retrograde ethanol infusion (EI) into the vein of Marshall (VOM) facilitates MI block. Fluorographic myocardial staining (MS) during VOM-EI could be helpful in predicting procedural alcoholization outcome even if its role is qualitatively assessed in the routine. The aim was to quantitatively assess MS during VOM-EI and to evaluate its association with MI block achievement. METHODS Consecutive patients undergoing catheter ablation for PeAF at Fondazione Toscana Gabriele Monasterio (Pisa, Italy) from February 2022 to May 2023 were considered. Patients with identifiable VOM were included. A proposed index of MS (MSI) was retrospectively calculated in each included patient. Correlation of MSI with low-voltage zones (LVZ) extension after VOM-EI and its association with MI block achievement were assessed. RESULTS In total, 42 patients out of 49 (85.8%) had an identifiable VOM. MI block was successfully achieved in 35 patients out of 42 (83.3%). MSI was significantly associated with the occurrence of MI block (OR 1.24 (1.03-1.48); p = 0.022). A higher MSI resulted in reduced ablation time (p = 0.014) and reduced radiofrequency applications (p = 0.002) to obtain MI block. MSI was also associated with MI block obtained by endocardial ablation only (OR 1.07 (1.02-1.13); p = 0.002). MSI was highly correlated with newly formed LVZ extension (r = 0.776; p = 0.001). CONCLUSIONS In our study cohort, optimal MSI predicts MI block and facilitates its achievement with endocardial ablation only.
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Affiliation(s)
- Federico Landra
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, Italy.
| | | | | | | | | | | | | | - Simone Taddeucci
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, Italy
| | | | | | | | | | | | | | | | - Andrea Rossi
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Hasebe H, Furuyashiki Y, Yoshida K. Vein of Marshall chemical ablation decreases atrial fibrillation drivers detected by CARTOFINDER. J Cardiovasc Electrophysiol 2024; 35:1461-1470. [PMID: 38769635 DOI: 10.1111/jce.16311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/25/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION This study sought to elucidate the impact of vein of Marshall (VOM) chemical ablation on atrial fibrillation (AF) drivers by investigating the changes in CARTOFINDER mappings before and after VOM chemical ablation in patients with persistent AF. METHODS This study included 23 consecutive patients undergoing catheter ablation for long-persistent AF (>18 months). VOM chemical ablation was performed following pulmonary vein isolation. CARTOFINDER and AF cycle length (AFCL) maps were created in the left atrium (LA) before and after VOM chemical ablation. The LA was divided into 8 segments, and the number of focal activation points with 6 or more repetitions was counted in each segment. RESULTS The number of focal activation points was largest in the LA appendage (LAA). After VOM chemical ablation, the number of focal activation points in the LA decreased significantly (37 [interquartile range, IQR: 19-55] vs. 15 [IQR: 7-21], p < .001), and median AFCL was significantly prolonged (159 [147-168] vs. 164 [150-173] ms, p < .001). In the assessment of each segment, significant decreases in focal activation points were observed in the inferior, lateral, and anterior segments and LAA. Among the focal activation points disappearing after chemical ablation, the number in the non-ethanol-affected area was significantly larger than that in the affected area (13 [8-25] vs. 4 [1-10], p < .001). CONCLUSIONS VOM chemical ablation decreases AF drivers detected by CARTOFINDER. Mechanisms other than direct myocardial damage are considered to contribute the attenuation of AF drivers.
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Affiliation(s)
- Hideyuki Hasebe
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Arrhythmology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | | | - Kentaro Yoshida
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Cardiology, Ibaraki Prefectural Central Hospital, Kasama, Japan
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Takigawa M, Miyazaki S, Sasano T. Impact of Ethanol Infusion to the Vein of Marshall in Atrial Fibrillation and Atrial Tachycardia. J Cardiovasc Dev Dis 2024; 11:183. [PMID: 39057606 PMCID: PMC11277033 DOI: 10.3390/jcdd11070183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 07/28/2024] Open
Abstract
The ligament of Marshall is an epicardial structure characterized by its composition of fat, fibrous tissue, blood vessels, muscle bundles, nerve fibers, and ganglia. Its intricate network forms muscular connections with the coronary sinus and left atrium, alongside adjacent autonomic nerves and ganglion cells. This complexity plays a pivotal role in initiating focal electrical activities and sustaining micro- and macro-reentrant circuits, thereby contributing to the onset of atrial fibrillation and atrial tachycardia. However, endocardial ablation in this area may encounter challenges due to anatomical variations and insulation by fibrofatty tissue. Combining ethanol infusion into the vein of Marshall with radiofrequency ablation presents a promising strategy for effectively and safely eliminating this arrhythmogenic structure and terminating associated tachycardias.
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Affiliation(s)
- Masateru Takigawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Department of Advanced Arrhythmia Research, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Department of Advanced Arrhythmia Research, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
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Depes D, Mennander A, Immonen P, Mäkinen A, Huhtala H, Paavonen T, Kholová I. The autonomic nerves around the vein of Marshall: a postmortem study with clinical implications. APMIS 2024; 132:430-443. [PMID: 38468591 DOI: 10.1111/apm.13400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 01/31/2024] [Indexed: 03/13/2024]
Abstract
This study aims to analyze the vein of Marshall (VOM) in human autopsy hearts and its correlation with clinical data to elucidate the morphological substrates of atrial fibrillation (AF) and other cardiac diseases. Twenty-three adult autopsy hearts were studied, assessing autonomic nerves by immunohistochemistry with tyrosine hydroxylase (sympathetic nerves), choline acetyltransferase (parasympathetic nerves), growth-associated protein 43 (neural growth), and S100 (general neural marker) antibodies. Interstitial fibrosis was assessed by Masson trichrome staining. Measurements were conducted via morphometric software. The results were correlated with clinical data. Sympathetic innervation was abundant in all VOM-adjacent regions. Subjects with a history of AF, cardiovascular cause of death, and histologically verified myocardial infarction had increased sympathetic innervation and neural growth around the VOM at the mitral isthmus. Interstitial fibrosis increased with age and heart weight was associated with AF and cardiovascular cause of death. This study increases our understanding of the cardiac autonomic innervation in the VOM area in various diseases, offering implications for the development of new therapeutic approaches targeting the autonomic nervous system.
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Affiliation(s)
- Denis Depes
- Department of Pathology, Fimlab Laboratories, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ari Mennander
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Division of Cardiothoracic Surgery, Tampere University Heart Hospital, Tampere, Finland
| | - Paavo Immonen
- Department of Pathology, Fimlab Laboratories, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Artturi Mäkinen
- Department of Pathology, Fimlab Laboratories, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Timo Paavonen
- Department of Pathology, Fimlab Laboratories, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ivana Kholová
- Department of Pathology, Fimlab Laboratories, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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O’Neill L, De Becker B, De Smet M, Francois C, Tavernier R, Duytschaever M, Le Polain De Waroux JB, Knecht S. Vein of Marshall Ethanol Infusion for AF Ablation; A Review. J Clin Med 2024; 13:2438. [PMID: 38673710 PMCID: PMC11050818 DOI: 10.3390/jcm13082438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
The outcomes of persistent atrial fibrillation (AF) ablation are modest with various adjunctive strategies beyond pulmonary vein isolation (PVI) yielding largely disappointing results in randomised controlled trials. Linear ablation is a commonly employed adjunct strategy but is limited by difficulty in achieving durable bidirectional block, particularly at the mitral isthmus. Epicardial connections play a role in AF initiation and perpetuation. The ligament of Marshall has been implicated as a source of AF triggers and is known to harbour sympathetic and parasympathetic nerve fibres that contribute to AF perpetuation. Ethanol infusion into the Vein of Marshall, a remnant of the superior vena cava and key component of the ligament of Marshall, may eliminate these AF triggers and can facilitate the ease of obtaining durable mitral isthmus block. While early trials have demonstrated the potential of Vein of Marshall 'ethanolisation' to reduce arrhythmia recurrence after persistent AF ablation, further randomised trials are needed to fully determine the potential long-term outcome benefits afforded by this technique.
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Affiliation(s)
- Louisa O’Neill
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
- Department of Cardiology, Blackrock Clinic, A94 E4X7 Dublin, Ireland
- King’s College London, St. Thomas’ Hospital, London SE1 9NH, UK
| | - Benjamin De Becker
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | - Maarten De Smet
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | - Clara Francois
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | - Rene Tavernier
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | - Mattias Duytschaever
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
| | | | - Sebastien Knecht
- Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium; (B.D.B.); (S.K.)
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Ding X, Wang L, Liu Q, Chen S, Jiang R, Yu L, Zhang P, Lin J, Sun Y, Sheng X, Fu G, Zei PC, Jiang C. Use of intracardiac echocardiography in vein of Marshall ethanol infusion for ablation of persistent atrial fibrillation. Heart Rhythm 2024; 21:274-281. [PMID: 38103707 DOI: 10.1016/j.hrthm.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/25/2023] [Accepted: 11/28/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Few methods have been reported to demonstrate real-time effects during vein of Marshall (VOM) ethanol infusion in persistent atrial fibrillation (PeAF). OBJECTIVE This study was to evaluate the impact of left atrial (LA) monitoring using intracardiac echocardiography (ICE) during VOM ethanol infusion. METHODS Seventy-four consecutive patients with PeAF who underwent VOM ethanol infusion followed by radiofrequency (RF) ablation were included. Patients with findings on ICE consistent with echogenic streaming in the LA and with increased myocardial local echogenicity along the VOM area were placed into one group (group A) and those without into the other group (group B). Outcomes between the 2 groups were compared. RESULTS Forty-six patients (62%) were placed into group A. A new ethanol-induced low-voltage area in group A was larger than that in group B (8.5 cm2 [5.5-10.2 cm2] and 4.0 cm2 (2.4-6.3 cm2]; P < .001). The RF ablation time required to achieve MI block was reduced in group A patients (263.0 seconds [196.0-351.0 seconds] vs 417.0 seconds [315.0-709.5 seconds] in group B patients; P < .001). MI block was achieved in 46 patients (100%) via an endocardial approach in group A and 27 patients (96.4%) in group B (extra coronary sinus ablation in 4 patients). One patient developed clinically significant pericardial effusions and required pericardiocentesis in group B. CONCLUSION Presence of increased myocardial local echogenicity at the ridge and consistent echogenic streaming in the LA detected by ICE-based imaging during VOM ethanol infusion suggests increased ablated tissue in that region and lower RF ablation time during ablation for PeAF.
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Affiliation(s)
- Xueyan Ding
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Li Wang
- Department of Cardiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Shiquan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Jianwei Lin
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Yaxun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Paul C Zei
- Department of Cardiac Electrophysiology and Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China.
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Shimizu Y, Yoshitani K, Kuriyama T, Mori K, Kujira K, Imai M, Fukuhara R, Taniguchi R, Toma M, Miyamoto T, Sato Y. The effect of an initial catheter ablation with an adjunctive ethanol infusion into the vein of Marshall on persistent atrial fibrillation. J Cardiovasc Electrophysiol 2024; 35:453-460. [PMID: 38282242 DOI: 10.1111/jce.16191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Some previous studies have reported that a first-step ethanol infusion into the vein of Marshall (EIVOM) with touch-up radiofrequency (RF) ablation can facilitate mitral isthmus (MI) block and improves the ablation outcomes in persistent atrial fibrillation (PeAF) patients. However, the effect of an initial RF ablation with an adjunctive EIVOM has not been fully investigated. METHODS This study enrolled 233 PeAF patients undergoing pulmonary vein isolation and linear ablation including an MI, roof line, and cavotricuspid isthmus ablation. An EIVOM was performed when endocardial ablation with or without coronary sinus ablation failed to create MI block. RESULTS Bidirectional MI block was achieved in 224 patients (96.1%). Among them, MI block was obtained by only RF ablation in 174/224 patients (77.7%) (RF group) and an adjunctive EIVOM was needed in 50/224 (22.3%) (EIVOM group). During the follow-up, 113 (64.9%) RF group patients were free from AF/atrial tachycardia compared to 41 (82.0%) EIVOM group patients (log-rank p = .045). In a multivariate Cox regression analysis, an adjunctive EIVOM was associated with a lower recurrence rate (hazard ratio = 0.39, 95% confidence interval = 0.17-0.78, p = .006). CONCLUSION An initial RF ablation with an adjunctive EIVOM strategy improved MI ablation's acute success rate and was associated with better clinical outcomes.
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Affiliation(s)
- Yukiko Shimizu
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | | | - Tomoari Kuriyama
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Kazuki Mori
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Kazuto Kujira
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Masao Imai
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Rei Fukuhara
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Ryoji Taniguchi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tadashi Miyamoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
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Ge W, Li T, Lu Y, Jiang J, Tung T, Yan S. Efficacy and feasibility of vein of Marshall ethanol infusion during persistent atrial fibrillation ablation: A systematic review and meta-analysis. Clin Cardiol 2024; 47:e24178. [PMID: 37933170 PMCID: PMC10766122 DOI: 10.1002/clc.24178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/30/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Catheter ablation (CA) is currently used to treat persistent atrial fibrillation (PeAF). However, its effectiveness is limited. This study aimed to estimate the effectiveness of the vein of Marshall absolute ethanol injection (VOM-EI) for PeAF ablation. HYPOTHESIS Adjunctive vein of Marshall ethanol injection (VOM-EI) strategies are more effective than conventional catheter ablation (CA) and have similar safety outcomes. METHODS We extensively searched the literature for studies evaluating the effectiveness and safety of VOM-EI + CA compared with CA alone. The primary endpoint was the rate of acute bidirectional block of the isthmus of the mitral annulus (MIBB). The secondary endpoints were atrial fibrillation (AF) or atrial tachycardia (AT) recurrence over 30 seconds after a 3-month blanking period. Weighted pooled risk ratios (RRs) and corresponding 95% confidence intervals (CIs) were calculated using a random effects model. RESULTS Based on the selection criteria, nine studies were included in this systematic review, including patients with AF (n = 2508), persistent AF (n = 1829), perimitral flutter (n = 103), and perimitral AT (n = 165). There were 1028 patients in the VOM-EI + CA group and 1605 in the CA alone group. The VOM-EI + CA group showed a lower rate of AF/AT relapse (RR = 0.70; 95% CI = 0.53-0.91; p = .008) and a higher rate of acute MIBB (RR = 1.29; 95% CI = 1.11-1.50; p = .0007) than the CA alone group. CONCLUSION Our meta-analysis revealed that adjunctive VOM-EI strategies are more effective than conventional CA and have similar safety outcomes.
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Affiliation(s)
- Wei‐Li Ge
- Department of CardiologyShandong Provincial Qianfoshan HospitalShandong UniversityJinanShandongChina
- Department of CardiologyTaizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical UniversityZhejiangChina
| | - Tao Li
- Department of CardiologyTaizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical UniversityZhejiangChina
| | - Yi‐Fei Lu
- Department of CardiologyTaizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical UniversityZhejiangChina
| | - Jian‐Jun Jiang
- Department of CardiologyTaizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical UniversityZhejiangChina
| | - Tao‐Hsin Tung
- Evidence‐Based Medicine Center, Taizhou Hospital of Zhejiang ProvinceWenzhou Medical UniversityLinhaiChina
- Department of UrologyTaizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Affilitated to Hangzhou Medical CollegeTaizhouZhejiangChina
- Key Laboratory of Evidence‐Based Radiology of TaizhouLinhaiZhejiangChina
| | - Su‐Hua Yan
- Department of CardiologyShandong Provincial Qianfoshan HospitalShandong UniversityJinanShandongChina
- Department of CardiologyShandong Provincial Qianfoshan HospitalJinanChina
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13
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Ishimura M, Yamamoto M, Himi T, Kobayashi Y. Comparison of the effect of ethanol infusion into the vein of Marshall between with and without collateral veins. J Cardiovasc Electrophysiol 2024; 35:25-34. [PMID: 37890043 DOI: 10.1111/jce.16115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/30/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Despite the potential benefits of ethanol infusion into the vein of Marshall (EIVOM) for atrial fibrillation (AF) ablation, concerns about its reversible and unpredictable effects persist. OBJECTIVE To assess the effectiveness of EIVOM in the vein of Marshall (VOM) with collateral veins (CVs) during mitral isthmus and AF ablation. METHODS We included 142 AF patients. EIVOM was performed before radiofrequency ablation, and low-voltage areas (<0.5 mV) were measured before, immediately after, and 1 h after EIVOM. RESULTS Among the 142 patients, 93 (65%) underwent EIVOM, and among these, 35 (37%) were found to have CVs. In the VOM with CVs group, areas with low voltage measured 0 (0-1.85) cm2 before EIVOM, 6.9 (4.1-11.2) cm2 immediately after EIVOM, and 5.7 (3.5-10.6) cm2 1 h after EIVOM. Conversely, in the group designated as VOM without CVs-from which the nine leakage cases were excluded-the areas measured 0 (0-1.35) cm2 , 5.5 (2.6-11.8) cm2 , and 4.7 (1.8-13.5) cm2 at the respective time points. MI line block was fully achieved in 89% (31/35) of cases in the VOM with CVs group and 88% (44/49) in the VOM without CVs groups (p = .94). There was no significant difference in the outcome of AF ablation between these groups (log-rank p = .73). Additionally, no significant difference was observed between EIVOM (+) and EIVOM (-) groups (log-rank p = .59). CONCLUSION EIVOM effectively creates MI line block, and its beneficial effects are sustained for at least 1 h after the procedure despite the low-voltage areas showing a slight reduction in size.
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Affiliation(s)
| | - Masashi Yamamoto
- Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Toshiharu Himi
- Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Yoshio Kobayashi
- Department of Cardiology, Chiba University Hospital, Chiba, Japan
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Nesti M, Luca F, Panchetti L, Garibaldi S, Startari U, Mirizzi G, Landra F, Giannoni A, Piacenti M, Rossi A. Impact of Vein of Marshall Ethanol Infusion Combined with Anatomical Ablation for the Treatment of Persistent Atrial Fibrillation: A Long-Term Follow-Up Based on Implantable Loop Recorders. J Clin Med 2023; 12:6916. [PMID: 37959380 PMCID: PMC10648095 DOI: 10.3390/jcm12216916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
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.
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Affiliation(s)
- Martina Nesti
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy; (M.N.); (S.G.); (U.S.); (G.M.); (A.G.); (A.R.)
| | - Fabiana Luca
- Cardiology Department, Grande Ospedale Metropolitano, 89124 Reggio Calabria, Italy
| | - Luca Panchetti
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy; (M.N.); (S.G.); (U.S.); (G.M.); (A.G.); (A.R.)
| | - Silvia Garibaldi
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy; (M.N.); (S.G.); (U.S.); (G.M.); (A.G.); (A.R.)
| | - Umberto Startari
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy; (M.N.); (S.G.); (U.S.); (G.M.); (A.G.); (A.R.)
| | - Gianluca Mirizzi
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy; (M.N.); (S.G.); (U.S.); (G.M.); (A.G.); (A.R.)
| | - Federico Landra
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy;
| | - Alberto Giannoni
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy; (M.N.); (S.G.); (U.S.); (G.M.); (A.G.); (A.R.)
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
| | - Marcello Piacenti
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy; (M.N.); (S.G.); (U.S.); (G.M.); (A.G.); (A.R.)
| | - Andrea Rossi
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy; (M.N.); (S.G.); (U.S.); (G.M.); (A.G.); (A.R.)
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Calvert P, Lip GYH, Gupta D. Radiofrequency catheter ablation of atrial fibrillation: A review of techniques. Trends Cardiovasc Med 2023; 33:405-415. [PMID: 35421538 DOI: 10.1016/j.tcm.2022.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/21/2022] [Accepted: 04/04/2022] [Indexed: 11/24/2022]
Abstract
Ablation of atrial fibrillation is a key area of current research. A multitude of techniques have been tested, some of which are poorly evidenced and not recommended in routine clinical practice whilst others are more promising. Additionally, a plethora of issues exist when researching ablation techniques, from control arm ablation strategy to the relevance of outcome measures. In this review article, we discuss these issues in the context of the current evidence base.
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Affiliation(s)
- Peter Calvert
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Gregory Y H Lip
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Clinical Medicine, Aalborg University, Denmark
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK.
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Luo T, Liu T, Cui B, Li X, Zhang J, Wu G. Efficacy of Vein of Marshall Ethanol Infusion Added to Left Atrial Anatomical Ablation for Treatment of Persistent Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy. Rev Cardiovasc Med 2023; 24:302. [PMID: 39077581 PMCID: PMC11273153 DOI: 10.31083/j.rcm2410302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/16/2023] [Accepted: 07/04/2023] [Indexed: 07/31/2024] Open
Abstract
Background Radiofrequency catheter ablation (RFCA) has been shown to have low efficacy for the treatment of persistent atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM). We conducted this study to evaluate the benefit of adjunctive vein of Marshall (VOM) ethanol infusion during RFCA for persistent AF (PsAF) in patients with non-obstructive HCM. Methods This multicenter retrospective observational study included 102 consecutive non-obstructive HCM patients with PsAF who underwent RFCA plus VOM ethanol infusion (VOM-EI) (RFCA + VOM, n = 56) or RFCA alone (RFCA, n = 46) for the first time. The efficacy endpoint was survival without AF or atrial tachycardia (AT) after the blanking period. Results We completed the VOM-EI in 92.9% (52/56) patients. The left pulmonary vein antrum ablation time (RFCA + VOM: 19.9 ± 6.1 min vs. RFCA: 27.2 ± 9.3 min), mitral isthmus (MI) ablation time (RFCA + VOM: 16.9 ± 3.7 min vs. RFCA: 28.4 ± 7.8 min), and rate of coronary sinus (CS) vein ablation (RFCA + VOM: 57.69% vs. RFCA: 80.43%) were lower but the acute success rate of MI block (RFCA + VOM: 98.1% vs. RFCA: 84.8%) were higher in the RFCA + VOM group than those in the RFCA group (all p < 0.05). After twelve months follow-up, 84.6% of patients (44/52) survived without AF/AT in the RFCA + VOM group, compared to 65.2% of patients (30/46) in the RFCA group (p = 0.03; odds ratio = 2.93, 95% CI: 1.18-7.79). Conclusions VOM-EI combined with RFCA decreased the recurrence rate of AF/AT at 12 months in HCM patients with PsAF. VOM-EI simplified the ablation of the left pulmonary vein antrum and MI and increased the success rate of MI bidirectional block.
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Affiliation(s)
- Tao Luo
- Department of Cardiology, Renmin Hospital of Wuhan University, 430060 Wuhan, Hubei, China
- Cardiovascular Research Institute, Wuhan University, 430060 Wuhan, Hubei, China
- Hubei Key Laboratory of Cardiology, 430060 Wuhan, Hubei, China
| | - Tao Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, 430060 Wuhan, Hubei, China
- Cardiovascular Research Institute, Wuhan University, 430060 Wuhan, Hubei, China
- Hubei Key Laboratory of Cardiology, 430060 Wuhan, Hubei, China
| | - Bo Cui
- Department of Cardiology, Renmin Hospital of Wuhan University, 430060 Wuhan, Hubei, China
- Cardiovascular Research Institute, Wuhan University, 430060 Wuhan, Hubei, China
- Hubei Key Laboratory of Cardiology, 430060 Wuhan, Hubei, China
| | - Xi Li
- Department of Cardiology, Wuhan Asian Heart Hospital, 430060 Wuhan, Hubei, China
| | - Jinlin Zhang
- Department of Cardiology, Wuhan Asian Heart Hospital, 430060 Wuhan, Hubei, China
| | - Gang Wu
- Department of Cardiology, Renmin Hospital of Wuhan University, 430060 Wuhan, Hubei, China
- Cardiovascular Research Institute, Wuhan University, 430060 Wuhan, Hubei, China
- Hubei Key Laboratory of Cardiology, 430060 Wuhan, Hubei, China
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Du X, Luo C, Shen C, Xu Y, Feng M, Jin H, Fu G, Wang B, Liu J, Gao F, Chu H. The impact of empirical Marshall vein ethanol infusion as a first-choice intraoperative strategy on the long-term outcomes in patients with persistent atrial fibrillation undergoing mitral isthmus ablation. Front Cardiovasc Med 2023; 10:1223064. [PMID: 37649670 PMCID: PMC10464908 DOI: 10.3389/fcvm.2023.1223064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023] Open
Abstract
Background Marshall vein ethanol infusion (MVEI) as an additional therapy to conventional catheter ablation (CA) has been proved to be efficacious in patients with persistent atrial fibrillation (PeAF). However, whether empirical MVEI could be the first-line strategy in mitral isthmus (MI) ablation has seldom been investigated. Here, we aim to compare the efficacy, safety, and long-term outcomes between provisional and empirical MVEI in PeAF patients undergoing the index MI ablation procedure. Methods We enrolled 133 patients with PeAF either in the provisional group (n = 38, MVEI was performed when conventional endocardial and/or epicardial ablation procedures were inadequate to achieve bidirectional MI block) or in the empirical group (n = 95, MVEI was performed empirically before MI CA). Results All of the baseline characteristics were comparable. Less spontaneous or inducible atrial tachycardias (ATs) were encountered in the empirical group of patients (P < 0.001). More epicardial ablations were applied (26.3% vs. 9.5%, P = 0.016) and a higher incidence of CA-facilitated restoration of sinus rhythm was recorded (86.8% vs. 11.7%, P < 0.001) in the provisional group of patients. Although more fluoroscopy time (6.4[4.2, 9.3] vs. 9.5[5.9, 11.6] min, P = 0.019) and radiation exposure (69.0[25.3, 160.2] vs. 122.0[62.5, 234.1] mGy, P = 0.010) were documented in the empirical group with comparable procedure time, less time (455.9 ± 192.2 vs. 366.5 ± 161.3 s, P = 0.038) was consumed to achieve bidirectional MI block during endocardial ablation in the provisional group. Incidences of procedure-related complications were similar between the two groups. During a 16.5 ± 4.4-month follow-up, the empirical group of patients showed a significantly higher rate of freedom from AT recurrence (95.8% vs. 81.6%, log-rank P = 0.003), while the rate of freedom from AF or atrial tachyarrhythmias (combining AF and AT) was similar. Both univariate (HR 0.19, 95% CI 0.05-0.64, P = 0.008) and multivariate (HR 0.25, 95% CI 0.07-0.92, P = 0.037) Cox regression analyses indicated that empirical MVEI was independently associated with lower long-term AT recurrence. Conclusion Among patients with PeAF who underwent the index MI ablation procedure, empirical MVEI could reduce endocardial MI ablation time and provide greater long-term freedom from AT recurrence.
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Affiliation(s)
- Xianfeng Du
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Chenxu Luo
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- School of Medicine, Ningbo University, Ningbo, China
| | - Caijie Shen
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Yao Xu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo City, China
| | - Mingjun Feng
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - He Jin
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Guohua Fu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Binhao Wang
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Jin Liu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Fang Gao
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Huimin Chu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
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18
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Ishimura M, Yamamoto M, Himi T, Kobayashi Y. Efficacy and durability of posterior wall isolation with ethanol infusion into the vein of Marshall. J Cardiovasc Electrophysiol 2023; 34:1630-1639. [PMID: 37337457 DOI: 10.1111/jce.15977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/02/2023] [Accepted: 06/11/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Ethanol infusion into the vein of Marshall (EIVOM) is expected to be an adjunctive therapy for mitral isthmus (MI) ablation. Additionally, EIVOM can widely ablate the epicardium via the branches that extend to the left atrial posterior wall (LAPW) and facilitate LAPW isolation. This study aimed to investigate the efficacy and durability of LAPW isolation with EIVOM. METHODS Our cohort consisted of 413 patients with atrial fibrillation (AF) who underwent both LAPW and MI ablations. EIVOM was first attempted in 177 (35%) patients with adequate VOMs. The VOM was infused with 5 mL of ethanol with a double coaxial guiding catheter technique. Both ablations were performed only by radiofrequency ablation (the RF group) in the remaining 236 (57%) patients. RESULTS EIVOM with 5 mL of ethanol was completely achieved in 106 patients (the EIVOM group). The application duration of LAPW isolation did not differ significantly between the two groups (718 ± 276 vs. 709 ± 288 s; p = .78). LAPW debulking ablation was required in 64/106 (60%) and 176/236 (75%) patients in the EIVOM and RF groups, respectively (p < .05). However, AF- or atrial tachycardia-free survival analyses revealed no significant differences between the two groups (log-rank p = .70). Among the cases of recurrence, 17 and 38 patients underwent subsequent ablation sessions; LAPW was reconnected in 9/17 (53%) and 25/38 (53%) patients (p = .36) in the EIVOM and RF groups, respectively. CONCLUSION EIVOM reduced the number of cases that required LAPW debulking ablation but did not improve the durability of LAPW isolation or clinical outcomes.
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Affiliation(s)
| | - Masashi Yamamoto
- Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Toshiharu Himi
- Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Yoshio Kobayashi
- Department of Cardiology, Chiba University Hospital, Chiba, Japan
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19
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Lai Y, Ge W, Sang C, Macle L, Tang R, Long D, Dong J, Ma C. Epicardial connections and bi-atrial tachycardias: From anatomy to clinical practice. Pacing Clin Electrophysiol 2023; 46:895-903. [PMID: 37433176 DOI: 10.1111/pace.14778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/14/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
Bi-atrial tachycardia (BiAT) is not rare after extensive atrial ablation or cardiac surgery. The complexity of bi-atrial reentrant circuits poses a great challenge for clinical practice. With recent advances in mapping technologies, we are now able to characterize atrial activation in detail. However, given the involvement of both atria and multiple epicardial conductions, endocardial mapping for BiATs is not easy to understand. Knowledge of the atrial myocardial architecture is the foundation for the clinical management of BiATs; as it is required to understand the possible mechanism of the tachycardia and identify the optimal target of ablation. In this review we summarize current knowledge about the anatomy of interatrial connections as well as other epicardial fibers and discuss the interpretation of electrophysiological findings and ablation strategies for BiATs.
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Affiliation(s)
- Yiwei Lai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Weili Ge
- Department of Cardiology, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Zhejiang, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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20
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Smith JEG, Ashton JL, Argent LP, Cheyne JE, Montgomery JM. Recording plasticity in neuronal activity in the rodent intrinsic cardiac nervous system using calcium imaging techniques. Front Synaptic Neurosci 2023; 15:1104736. [PMID: 37082542 PMCID: PMC10110955 DOI: 10.3389/fnsyn.2023.1104736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/20/2023] [Indexed: 04/22/2023] Open
Abstract
The intrinsic cardiac nervous system (ICNS) is composed of interconnected clusters of neurons called ganglionated plexi (GP) which play a major role in controlling heart rate and rhythm. The function of these neurons is particularly important due to their involvement in cardiac arrhythmias such as atrial fibrillation (AF), and previous work has shown that plasticity in GP neural networks could underpin aberrant activity patterns that drive AF. As research in this field increases, developing new techniques to visualize the complex interactions and plasticity in this GP network is essential. In this study we have developed a calcium imaging method enabling the simultaneous recording of plasticity in neuronal activity from multiple neurons in intact atrial GP networks. Calcium imaging was performed with Cal-520 AM labeling in aged spontaneously hypertensive rats (SHRs), which display both spontaneous and induced AF, and age-matched Wistar Kyoto (WKY) controls to determine the relationship between chronic hypertension, arrhythmia and GP calcium dynamics. Our data show that SHR GPs have significantly larger calcium responses to cholinergic stimulation compared to WKY controls, as determined by both higher amplitude and longer duration calcium responses. Responses were significantly but not fully blocked by hexamethonium, indicating multiple cholinergic receptor subtypes are involved in the calcium response. Given that SHRs are susceptible to cardiac arrhythmias, our data provide evidence for a potential link between arrhythmia and plasticity in calcium dynamics that occur not only in cardiomyocytes but also in the GP neurons of the heart.
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Affiliation(s)
- Joscelin E. G. Smith
- Department of Physiology, University of Auckland, Auckland, New Zealand
- Pūtahi Manawa, Centre for Heart Research, Auckland, New Zealand
| | - Jesse L. Ashton
- Department of Physiology, University of Auckland, Auckland, New Zealand
- Pūtahi Manawa, Centre for Heart Research, Auckland, New Zealand
| | - Liam P. Argent
- Department of Physiology, University of Auckland, Auckland, New Zealand
- Pūtahi Manawa, Centre for Heart Research, Auckland, New Zealand
| | | | - Johanna M. Montgomery
- Department of Physiology, University of Auckland, Auckland, New Zealand
- Pūtahi Manawa, Centre for Heart Research, Auckland, New Zealand
- *Correspondence: Johanna M. Montgomery,
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21
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Aksu T, Skeete JR, Huang HH. Ganglionic Plexus Ablation: A Step-by-step Guide for Electrophysiologists and Review of Modalities for Neuromodulation for the Management of Atrial Fibrillation. Arrhythm Electrophysiol Rev 2023; 12:e02. [PMID: 36845167 PMCID: PMC9945432 DOI: 10.15420/aer.2022.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/29/2022] [Indexed: 02/01/2023] Open
Abstract
As the most common sustained arrhythmia, AF is a complex clinical entity which remains a difficult condition to durably treat in the majority of patients. Over the past few decades, the management of AF has focused mainly on pulmonary vein triggers for its initiation and perpetuation. It is well known that the autonomic nervous system (ANS) has a significant role in the milieu predisposing to the triggers, perpetuators and substrate for AF. Neuromodulation of ANS - ganglionated plexus ablation, vein of Marshall ethanol infusion, transcutaneous tragal stimulation, renal nerve denervation, stellate ganglion block and baroreceptor stimulation - constitute an emerging therapeutic approach for AF. The purpose of this review is to summarise and critically appraise the currently available evidence for neuromodulation modalities in AF.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | | | - Henry H Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, US
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22
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The Maine vein of Marshall ethanol experience: learning curve and safety. J Interv Card Electrophysiol 2022; 66:661-671. [PMID: 36181632 DOI: 10.1007/s10840-022-01378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/19/2022] [Indexed: 10/06/2022]
Abstract
BACKGROUND The marginal benefit of ethanol infusion into the vein of Marshall (VOM) as an adjunct to atrial fibrillation ablation has shown promise in a single randomized study and case series from very experienced centers. However, adoption has not been widespread and the impact on real-world outcomes outside of leading centers is not established. The objective in this study is to understand the learning curve, and explore procedural outcomes and safety with VOM ethanol infusion from a large single medical center. METHODS One hundred twenty nine atrial ablation cases wherein VOM ethanol infusion was attempted were identified from the time of the program's inception in 2019 at Maine Medical Center (Portland, ME). Our technical approach, procedural success, and complications were adjudicated from the medical record. RESULTS The overall VOM ethanol infusion success was 90%. Infusion success rates improved and fluoroscopy utilization decreased with experience. Arrhythmia recurrence was 14% after a mean follow-up of 9.5 months. Complications occurred in 5.4% of patients, including a 3.1% risk of delayed tamponade. CONCLUSION In our single center experience, VOM ethanol infusion was feasible with a high technical success rate. These positive results are balanced against a concerning rate of delayed tamponade.
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23
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Rodríguez-Mañero M, Minguito C, Martínez-Sande JL, González-Melchor L, Elices-Teijeira J, González-Juanatey JR. Ethanol infusion in the vein of Marshall: A potential bail-out strategy in cardioneuromodulation procedures? HeartRhythm Case Rep 2022; 8:807-810. [PMID: 36620367 PMCID: PMC9811014 DOI: 10.1016/j.hrcr.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Moisés Rodríguez-Mañero
- Cardiology Department, Complejo Hospital Universitario de Santiago Santiago de Compostela, Spain,Instituto de Investigación Sanitaria (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, Spain,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain,Address reprint requests and correspondence: Dr Moisés Rodríguez Mañero, Departamento de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Travesía da Choupana s/n, Santiago de Compostela, 15706 A Coruña, España.
| | - Carlos Minguito
- Cardiology Department, Complejo Hospital Universitario de Santiago Santiago de Compostela, Spain
| | - José Luis Martínez-Sande
- Cardiology Department, Complejo Hospital Universitario de Santiago Santiago de Compostela, Spain,Instituto de Investigación Sanitaria (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, Spain,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
| | - Laila González-Melchor
- Cardiology Department, Complejo Hospital Universitario de Santiago Santiago de Compostela, Spain
| | | | - José Ramón González-Juanatey
- Cardiology Department, Complejo Hospital Universitario de Santiago Santiago de Compostela, Spain,Instituto de Investigación Sanitaria (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, Spain,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
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24
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Junarta J, Dikdan SJ, Upadhyay N, Molin A, Bodempudi S, Warner E, Joffe D, Pang Z, Frisch DR. Pulmonary vein isolation alone versus pulmonary vein isolation with additional extensive ablation for paroxysmal and persistent atrial fibrillation. J Arrhythm 2022; 38:589-597. [PMID: 35936038 PMCID: PMC9347196 DOI: 10.1002/joa3.12727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/25/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background The value of additional ablation beyond pulmonary vein isolation for atrial fibrillation (AF) ablation is unclear, especially for persistent AF. It is uncertain whether substrate modification with additional extensive ablation improves outcomes. We reviewed our experience to determine whether pulmonary vein isolation with additional extensive ablation (PVIEA) improves outcomes compared to pulmonary vein isolation alone (PVIA) for AF ablation. Methods Consecutive cases of patients with PVIA versus PVIEA were compared between September 9, 2013 and December 12, 2020. Procedural data collected include radiofrequency ablation delivery time (RADT) and arrhythmia inducibility. Clinical data collected include sinus rhythm maintenance post-procedure. Results A total of 235 patients were studied (67 PVIA and 168 PVIEA). RADT was shorter when comparing ablation with PVIA versus PVIEA (32 vs. 40 min; p = .04). More arrhythmias were inducible with PVIEA (p < .01). There was no difference in sinus rhythm maintenance by Kaplan-Meier survival analysis (log-rank test p = .75), after 3 or 12 months between groups overall, and when stratified by AF type (paroxysmal and persistent), left atrial volume, CHA2DS2-VASc score, left ventricular ejection fraction, or catheter ablation setting (high-power short-duration, standard-power standard-duration, temperature-controlled non-contact-force). Conclusion AF ablation with PVIA or PVIEA produces similar sinus rhythm maintenance overall and when stratified by catheter setting and AF type. PVIA reduced procedure times and less arrhythmias were inducible post-ablation.
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Affiliation(s)
- Joey Junarta
- Department of MedicineThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Sean J. Dikdan
- Jefferson Heart InstituteThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Naman Upadhyay
- Department of MedicineThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Andrea Molin
- Department of MedicineThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Sairamya Bodempudi
- Department of MedicineThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Eric Warner
- Department of MedicineThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Daniel Joffe
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Zachary Pang
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Daniel R. Frisch
- Jefferson Heart InstituteThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
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25
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Innovations in atrial fibrillation ablation. J Interv Card Electrophysiol 2022; 66:737-756. [PMID: 35411440 DOI: 10.1007/s10840-022-01215-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Catheter-based ablation to perform pulmonary vein isolation (PVI) has established itself as a mainstay in the rhythm control strategy of atrial fibrillation. This review article aims to provide an overview of recent advances in atrial fibrillation ablation technology. METHODS We reviewed the available literature and clinical trials of innovations in atrial fibrillation ablation technologies including ablation catheter designs, alternative energy sources, esophageal protection methods, electroanatomical mapping, and novel ablation targets. RESULTS Innovative radiofrequency (RF) catheter designs maximize energy delivery while avoiding overheating associated with conventional catheters. Single-shot balloon catheters in the form of cryoballoons, radiofrequency, and laser balloons have proven effective at producing pulmonary vein isolation and improving procedural efficiency and reproducibility. Pulsed field ablation (PFA) is a highly anticipated novel nonthermal energy source under development, which demonstrates selective ablation of the myocardium, producing durable lesions while also minimizing collateral damage. Innovative devices for esophageal protection including esophageal deviation and cooling devices have been developed to reduce esophageal complications. Improved electroanatomical mapping systems are being developed to help identify additional non-pulmonary triggers, which may benefit from ablation, especially with persistent atrial fibrillation. Lastly, the vein of Marshall alcohol ablation has been recently studied as an adjunct therapy for improving outcomes with catheter ablation for persistent atrial fibrillation. CONCLUSIONS Numerous advances have been made in the field of atrial fibrillation ablation in the past decade. While further long-term data is still needed for these novel technologies, they show potential to improve procedural efficacy and safety.
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26
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Choudhury M, Mahida S. Optimal ablation strategy for arrhythmia recurrence following persistent atrial fibrillation ablation; anatomy or electrophysiology? J Cardiovasc Electrophysiol 2022; 33:1125-1127. [DOI: 10.1111/jce.15474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 11/26/2022]
Affiliation(s)
| | - Saagar Mahida
- Liverpool Heart and Chest Hospital, Thomas DriveLiverpoolL14 3PEUK
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27
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Nakashima T, Pambrun T, Vlachos K, Goujeau C, André C, Krisai P, Daniel Ramirez F, Pintican G, Kamakura T, Takagi T, Nakatani Y, Surget E, Cheniti G, Tixier R, Chauvel R, Duchateau J, Sacher F, Cochet H, Hocini M, Haïssaguerre M, Jaïs P, Derval N. Strategy for Repeat Procedures in Patients with Persistent Atrial Fibrillation: Systematic Linear Ablation with Adjunctive Ethanol Infusion into the Vein of Marshall versus Electrophysiology‐Guided Ablation. J Cardiovasc Electrophysiol 2022; 33:1116-1124. [DOI: 10.1111/jce.15472] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | | | - F. Daniel Ramirez
- CHU Bordeaux, IHU Lyric, Univ. BordeauxFrance
- Division of Cardiology, University of Ottawa Heart InstituteOttawaOntarioCanada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Pierre Jaïs
- CHU Bordeaux, IHU Lyric, Univ. BordeauxFrance
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Ghannam M, Chugh A. Preprocedural Imaging of the Vein of Marshall in Patients Undergoing Alcohol Ablation for Atrial Fibrillation. JACC Clin Electrophysiol 2022; 8:179-181. [PMID: 35210074 DOI: 10.1016/j.jacep.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Michael Ghannam
- Section of Electrophysiology/Division of Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan, USA
| | - Aman Chugh
- Section of Electrophysiology/Division of Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan, USA.
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29
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Suzuki N, Kaneko S, Fujita M, Shinoda M, Kubota R, Ohashi T, Tatami Y, Suzuki J, Hori H, Adachi K, Ito R, Shirai Y, Yanagisawa S, Inden Y, Murohara T. Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis. BMC Cardiovasc Disord 2022; 22:13. [PMID: 35065605 PMCID: PMC8783511 DOI: 10.1186/s12872-022-02460-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/11/2022] [Indexed: 11/15/2022] Open
Abstract
Background The efficacy of pulmonary vein isolation (PVI) alone is not guaranteed for persistent atrial fibrillation (PeAF), and it is unclear which type of ablation approach should be applied in addition to PVI. This study aimed to compare outcomes and prognosis between empirical linear ablation and low-voltage area (LVA) ablation after PVI for PeAF. Methods We enrolled 128 patients with PeAF who were assigned to the linear ablation group (n = 64) and the LVA ablation group (n = 64) using a propensity score-matched model. After PVI and cardioversion, the patients underwent either empirical linear ablation or LVA ablation during sinus rhythm. All patients in the linear ablation group underwent both roof line and mitral valve isthmus (MVI) ablations. An electrical-guided ablation targeting LVA (< 0.5 mV) was performed in the LVA group. When there was no LVA in the LVA group, only PVI was applied. We compared the procedural outcomes and recurrence after ablation between the two groups. Results The baseline characteristics were well-balanced between the two groups. Fifty patients had LVA (22 and 28 patients in the linear and LVA groups). The roof and MVI lines were completed in 100% and 96.9% of the patients. During the mean follow-up of 279.5 ± 161.3 days, the LVA group had significantly lower recurrence than the linear group (15 patients [23%] vs. 29 patients [45%], p = 0.014). Thirty-five patients were prescribed antiarrhythmic drugs during the follow-up period (linear group, n = 17; LVA group, n = 18); amiodarone and bepridil were administered to most of the patients (15 and 17 patients, respectively). The difference in the prognosis was relevant among the patients with LVA, while this trend was not observed in those without LVA. The LVA ablation group demonstrated significantly lower radiofrequency energy and shorter procedural time compared to the linear ablation group. The recurrence of atrial flutter was more likely to occur in the linear group than in the LVA group (14 [22%] vs. 6 [9.4%], p = 0.052). Conclusion The electrophysiological-guided LVA ablation is more effective than empirical linear ablation in PeAF patients with LVA. Unnecessary empirical linear ablation might have a risk of iatrogenic gap and atrial flutter recurrence. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02460-9.
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Rodríguez-Mañero M, Martínez-Sande JL, García-Seara J, González-Ferrero T, González-Juanatey JR, Schurmann P, Tavares L, Valderrábano M. Neuromodulatory Approaches for Atrial Fibrillation Ablation. Eur Cardiol 2022; 16:e53. [PMID: 35024055 PMCID: PMC8728882 DOI: 10.15420/ecr.2021.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/23/2021] [Indexed: 12/01/2022] Open
Abstract
In this review, the authors describe evolving alternative strategies for the management of AF, focusing on non-invasive and percutaneous autonomic modulation. This modulation can be achieved – among other approaches – via tragus stimulation, renal denervation, cardiac afferent denervation, alcohol injection in the vein of Marshall, baroreceptor activation therapy and endocardial ganglionated plexi ablation. Although promising, these therapies are currently under investigation but could play a role in the treatment of AF in combination with conventional pulmonary vein isolation in the near future.
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Affiliation(s)
- Moisés Rodríguez-Mañero
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Institute of Health Research, University of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Spain
| | - Jose Luis Martínez-Sande
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Institute of Health Research, University of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Spain
| | - Javier García-Seara
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Institute of Health Research, University of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Spain
| | - Teba González-Ferrero
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain
| | - José Ramón González-Juanatey
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Institute of Health Research, University of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Spain
| | - Paul Schurmann
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital Houston, TX, US
| | - Liliana Tavares
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital Houston, TX, US
| | - Miguel Valderrábano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital Houston, TX, US
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Mhanna M, Beran A, Al-Abdouh A, Sajdeya O, Altujjar M, Alom M, M Abumoawad A, M Elzanaty A, Chacko P, A Eltahawy E. Adjunctive Vein of Marshall Ethanol Infusion During Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis. J Atr Fibrillation 2021; 14:20200492. [PMID: 34950366 DOI: 10.4022/jafib.20200492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/27/2021] [Accepted: 06/26/2021] [Indexed: 11/10/2022]
Abstract
Introduction Catheter ablation (CA) for atrial fibrillation (AF) can be associated with limited efficacy. Due to its autonomic innervation, the vein of Marshall (VOM) is an attractive target during AF ablation. In this meta-analysis, we aimed to evaluate the efficacy and safety of adjunctive ethanol infusion of VOM (VOM-EI) in AF ablation. Methods We performed a comprehensive literature search for studies that evaluated the efficacy and safety of VOM-EI in AF ablation compared to AF catheter ablation alone. The primary outcome of interest was late (≥3 months) AF or atrial tachycardia (AT) recurrence. The secondary outcomes included acute mitral isthmus bidirectional block (MIBB) and procedural complications (pericardial effusion, stroke, or atrio-esophageal fistula). Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. Results A total of four studies, including 804 AF patients (68.2% with persistent AF, the mean age of 63.5±9.9 years, 401 patients underwent VOM-EI plus CA vs. 403 patients who had CA alone), were included in the final analysis. VOM-EI group was associated with a lower risk of late AF/AT recurrence (RR:0.63; 95% CI:0.46-0.87; P = 0.005), and increased probability to achieve acute MIBB (RR:1.39; 95% CI:1.08-1.79; P = 0.009) without an increase in procedural complications (RR:1.05; 95% CI:0.57-1.94; P = 0.87). Conclusions Our meta-analysis demonstrated that adjunctive VOM-EI strategy is more effective than conventional catheter ablation with similar safety profiles.
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Affiliation(s)
- Mohammed Mhanna
- Department of Internal Medicine, The University of Toledo, Toledo, OH, USA
| | - Azizullah Beran
- Department of Internal Medicine, The University of Toledo, Toledo, OH, USA
| | - Ahmad Al-Abdouh
- Department of Internal Medicine, Saint Agnes Hospital, Baltimore, MD, USA
| | - Omar Sajdeya
- Department of Internal Medicine, The University of Toledo, Toledo, OH, USA
| | - Mohammed Altujjar
- Department of Internal Medicine, Promedica Toledo hospital, Toledo, OH, USA
| | - Modar Alom
- Department of Internal Medicine, Promedica Toledo hospital, Toledo, OH, USA
| | - Abdelrhman M Abumoawad
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Ahmed M Elzanaty
- Department of Cardiovascular Medicine, The University of Toledo, Toledo, OH, USA
| | - Paul Chacko
- Department of Cardiovascular Medicine, The University of Toledo, Toledo, OH, USA
| | - Ehab A Eltahawy
- Department of Cardiovascular Medicine, The University of Toledo, Toledo, OH, USA
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Sasaki W, Nakamura K, Minami K, Sasaki T, Take Y, Naito S. Left atrial roof-dependent atrial tachycardia via the Marshall bundle. HeartRhythm Case Rep 2021; 7:566-570. [PMID: 34434710 PMCID: PMC8377269 DOI: 10.1016/j.hrcr.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Kohki Nakamura
- Address reprint requests and correspondence: Dr Kohki Nakamura, Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma 371-0004, Japan.
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Chatterjee NA, Singh JP. Autonomic modulation and cardiac arrhythmias: old insights and novel strategies. Europace 2021; 23:1708-1721. [PMID: 34050642 DOI: 10.1093/europace/euab118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
The autonomic nervous system (ANS) plays a critical role in both health and states of cardiovascular disease. There has been a long-recognized role of the ANS in the pathogenesis of both atrial and ventricular arrhythmias (VAs). This historical understanding has been expanded in the context of evolving insights into the anatomy and physiology of the ANS, including dysfunction of the ANS in cardiovascular disease such as heart failure and myocardial infarction. An expanding armamentarium of therapeutic strategies-both invasive and non-invasive-have brought the potential of ANS modulation to contemporary clinical practice. Here, we summarize the integrative neuro-cardiac anatomy underlying the ANS, review the physiological rationale for autonomic modulation in atrial and VAs, highlight strategies for autonomic modulation, and finally frame future challenges and opportunities for ANS therapeutics.
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Affiliation(s)
- Neal A Chatterjee
- Electrophysiology Section, Cardiology Division, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Ishimura M, Yamamoto M, Himi T, Kobayashi Y. Durability of mitral isthmus ablation with and without ethanol infusion in the vein of Marshall. J Cardiovasc Electrophysiol 2021; 32:2116-2126. [PMID: 34028116 DOI: 10.1111/jce.15107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION 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 is limited. METHODS AND RESULTS Our cohort consisted of 560 patients with nonparoxysmal atrial fibrillation (AF) who underwent an initial MI ablation. Ablations were performed by only radiofrequency (RF) in 384 (RF group) or by RF and EIVOM in 176 (EIVOM/RF group) patients; 5 ml anhydrous ethanol 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 353/384 (92%) (First 318, Re-do 35) patinents in the RF group and 171/176 (97%) (First 128, Re-do 43) patients in the EIVOM/RF group (p = .09 in the first, p = .10 in the re-do ablation cases). In cases with complete MI line block, recurrent AF or atrial tachycardia was observed in 130/353 (37%) patients in the RF group and in 64/171 (37%) patients in the EIVOM/RF group (log-rank p = .12 in the first, and p = .30 in the re-do ablation cases). Of the total 560 patients, 123 proceeded to the subsequent ablation session. Reconduction across MI line block was observed in 39/80 (49%) patients in the RF group and 25/43 (58%) patients in the EIVOM/RF group (p = .32). CONCLUSION EIVOM effectively ensures MI line block; however, the reconduction rate was similar between the two groups.
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Affiliation(s)
| | - Masashi Yamamoto
- Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Toshiharu Himi
- Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Yoshio Kobayashi
- Department of Cardiology, Chiba University Hospital, Chiba, Japan
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He Z, Yang L, Bai M, Yao Y, Zhang Z. Feasibility, efficacy, and safety of ethanol infusion into the vein of Marshall for atrial fibrillation: A meta-analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1151-1162. [PMID: 33990979 DOI: 10.1111/pace.14263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/24/2021] [Accepted: 05/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Contemporary radiofrequency catheter ablation (RFCA) approaches for atrial fibrillation (AF) have reached an efficacy "ceiling". Ethanol infusion into the vein of Marshall (EI-VOM) has shown potential in preliminary studies. Data on EI-VOM are largely limited to small single-center reports, and clinical benefits and risks have not been systematically examined. Therefore, we performed a meta-analysis to assess the feasibility, efficacy, and safety of EI-VOM for AF. METHODS All studies evaluating EI-VOM for AF were initially searched from four electronic search engines: PubMed, Web of Science, Cochrane Library, and SinoMed. We used RevMan5.4 to calculate pooled outcomes of randomized controlled trial and cohort studies. We also performed single-arm meta-analyses using Open Meta-Analyst. RESULTS We included a total of 10 studies with 1322 patients. Successful EI-VOM was performed in 86.7% (95% CI 81.9-91.4%) of patients. For persistent AF patients, the recurrence of AF and/or atrial tachycardia (AT) was significantly lower in the EI-VOM combined with RFCA group compared with RFCA alone group (RR 0.58, 95% CI 0.35 to 0.96, p = 0.04). EI-VOM combined with RFCA significantly increased the rate of bidirectional mitral isthmus block compared with RFCA alone in AF patients (RR 1.50, 95% CI 1.34 to 1.67, p < 0.001). There were nine cardiac tamponades observed in 644 patients (PR 0.8%, 95% CI 0.1-1.5%) who were performed EI-VOM combined with RFCA. CONCLUSIONS Our meta-analysis brings encouraging evidence that adjuvant EI-VOM reduces AF and/or AT recurrence rate in persistent AF patients and increases the success rate of bidirectional mitral isthmus block.
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Affiliation(s)
- Zhiyu He
- Heart Center, the First Hospital of Lanzhou University, Lanzhou, China.,the First Clinical Medical School, Lanzhou University, Lanzhou, China.,Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.,The Quality Improvement Project for the Diagnosis and Treatment of Complicated Cardiovascular and Cerebrovascular Diseases (2018), The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Lin Yang
- Department of Pathology, the First Hospital of Lanzhou University, Lanzhou, China
| | - Ming Bai
- Heart Center, the First Hospital of Lanzhou University, Lanzhou, China.,Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.,The Quality Improvement Project for the Diagnosis and Treatment of Complicated Cardiovascular and Cerebrovascular Diseases (2018), The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yali Yao
- Heart Center, the First Hospital of Lanzhou University, Lanzhou, China.,Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.,The Quality Improvement Project for the Diagnosis and Treatment of Complicated Cardiovascular and Cerebrovascular Diseases (2018), The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Zheng Zhang
- Heart Center, the First Hospital of Lanzhou University, Lanzhou, China.,the First Clinical Medical School, Lanzhou University, Lanzhou, China.,Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.,The Quality Improvement Project for the Diagnosis and Treatment of Complicated Cardiovascular and Cerebrovascular Diseases (2018), The First Hospital of Lanzhou University, Lanzhou, Gansu, China
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Nakamura K, Takigawa M, Sasaki T, Minami K, Naito S. What are the post-ablation insular residual electrograms in the posterior left pulmonary veins electrically connected to? Indian Pacing Electrophysiol J 2021; 21:241-244. [PMID: 33965551 PMCID: PMC8263333 DOI: 10.1016/j.ipej.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/11/2021] [Accepted: 04/30/2021] [Indexed: 11/29/2022] Open
Abstract
A 67-year-old man underwent a third ablation procedure for a recurrent atrial tachycardia (AT) after an extensive pulmonary vein (PV) isolation, linear ablation along the left atrial (LA) roof and posterolateral mitral isthmus (MI), and defragmentation of persistent atrial fibrillation and an induced perimitral AT. High-resolution mapping during the clinical AT using the Rhythmia system (Boston Scientific) suggested that the AT was a ridge-related reentrant AT and exhibited a reconnection of the left PVs (LPVs). The residual electrograms in the posterior LPVs were surrounded by endocardial scar, which was like an island consisting of residual LPV electrograms. Retrograde venography of the vein of Marshall (VOM) demonstrated that the VOM reached the posterior left superior PV through the ridge between the LA appendage and left inferior PV and then the LPV carina. An ethanol infusion into the VOM resulted in a simultaneous AT termination and complete electrical isolation of the LPVs, that is, the disappearance of the residual LPV electrograms. The insular residual LPV electrograms in the present case did not appear to be endocardially connected to the LA, because the LPV electrograms were surrounded by endocardial scar and there was a large time gap between the earliest activation in the posterior LPVs and activation in the surrounding area. The VOM course on the venography and elimination of the residual LPV electrograms with an ethanol infusion into the VOM suggested that the insular residual LPV electrograms were electrically connected to the posterolateral LA via the VOM and its branches.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan.
| | - Masateru Takigawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo City, Tokyo, 113-8510, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
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Liu F, Sun W, Li Y, Sun Y, Yu X, Yin X, Xia Y. Low-Level Stimulation and Ethanol Ablation of the Vein of Marshall Prevent the Vagal-Mediated AF. Front Cardiovasc Med 2021; 8:675485. [PMID: 34026877 PMCID: PMC8131864 DOI: 10.3389/fcvm.2021.675485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The mechanisms for the vein of Marshall (VOM) mediated atrial fibrillation (AF) are not completely understood. We sought to evaluate the contribution of the intrinsic cardiac autonomic nervous system in VOM mediated AF. Method: Seven mongrel dogs were administered propranolol and continuously exposed to left superior ganglionated plexi (LSGP) stimulation, LSGP + low-level VOM stimulation, LSGP + atropine administration, LSGP + VOM filling with ethanol separately. The effective refractory period (ERP) and window of vulnerability (WOV) at the left superior pulmonary vein (LSPV), left inferior pulmonary vein (LIPV) and left atrial appendage (LAA) were measured. Result: LSGP stimulation significantly shortens the ERP and prolonged the ERP dispersion and WOV in LSPV, LIPV, and LAA. Interestingly, low-level VOM stimulation, atropine administration, or VOM filling with ethanol were able to attenuate the effects of LSGP in all sites. Conclusion: VOM as an inter-communication pathway of ganglionated plexis plays an important role in the development of vagal-related AF.
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Affiliation(s)
- Fei Liu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Wei Sun
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yan Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yuanjun Sun
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaohong Yu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaomeng Yin
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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Vlachos K, Derval N, Pambrun T, Duchateau J, Martin CA, Bazoukis G, Frontera A, Takigawa M, Nakashima T, Efremidis M, Letsas KP, Bourier F, André C, Krisai P, Ramirez FD, Kamakura T, Takagi T, Nakatani Y, Tixier R, Chauvel R, Welte N, Kitamura T, Cheniti G, Sacher F, Jaïs P, Haïssaguerre M, Hocini M. Ligament of Marshall ablation for persistent atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:782-791. [PMID: 33687764 DOI: 10.1111/pace.14208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/09/2021] [Accepted: 02/28/2021] [Indexed: 11/29/2022]
Abstract
Beyond pulmonary vein isolation, the two main additional strategies: Cox-Maze procedure or targeting of electrical signatures (focal bursts, rotational activities, meandering wavelets), remain controversial. High-density mapping of these arrhythmias has demonstrated firstly that a patchy lesion set is highly proarrhythmogenic, favoring macro-re-entry through conduction slowing and providing pivots for localized re-entry. Secondly, discrete anatomical structures such as the Vein or Ligament of Marshall (VOM/LOM) and the coronary sinus (CS) have epicardial muscular bundles that are more frequently involved in re-entry than previously thought. The Marshall Bundle can be ablated at any point along its course from the mid-to-distal coronary sinus to the left atrial appendage. If necessary, the VOM may be directly ablated using ethanol infusion to eliminate PV contributions and produce conduction block across the mistral isthmus. Ethanol ablation of the VOM, supplemented with RF ablation, may be more effective in producing conduction block at the mitral isthmus than repeat RF ablation alone.
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Affiliation(s)
- Konstantinos Vlachos
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Nicolas Derval
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Thomas Pambrun
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Josselin Duchateau
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Claire A Martin
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France.,Cardiology Department, Royal Papworth Hospital, Cambridge, UK
| | - George Bazoukis
- Arrhythmia Unit, Laboratory of Cardiac Electrophysiology, Second Cardiology Department, Evangelismos General Hospital of Athens, Greece
| | - Antonio Frontera
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Masateru Takigawa
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Takashi Nakashima
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Michael Efremidis
- Arrhythmia Unit, Laboratory of Cardiac Electrophysiology, Second Cardiology Department, Evangelismos General Hospital of Athens, Greece.,Onassis Cardiac Surgery Centre, Athens, Greece
| | - Konstantinos P Letsas
- Arrhythmia Unit, Laboratory of Cardiac Electrophysiology, Second Cardiology Department, Evangelismos General Hospital of Athens, Greece
| | - Felix Bourier
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Clémentine André
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Philipp Krisai
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - F Daniel Ramirez
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Tsukasa Kamakura
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Takamitsu Takagi
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Yosuke Nakatani
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Romain Tixier
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Remi Chauvel
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Nicolas Welte
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Takeshi Kitamura
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Ghassen Cheniti
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Frédéric Sacher
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Pierre Jaïs
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Michel Haïssaguerre
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Mélèze Hocini
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
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Valderrábano M. Vein of Marshall ethanol infusion in the treatment of atrial fibrillation: From concept to clinical practice. Heart Rhythm 2021; 18:1074-1082. [PMID: 33781979 DOI: 10.1016/j.hrthm.2021.03.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/18/2021] [Accepted: 03/21/2021] [Indexed: 11/25/2022]
Abstract
The vein of Marshall (VOM) contains innervation, myocardial connections, and arrhythmogenic foci that make it an attractive target in catheter ablation of atrial fibrillation (AF). Additionally, it co-localizes with the mitral isthmus, which is critical to sustain perimitral flutter, and is a true atrial vein that communicates with underlying myocardium. Retrograde balloon cannulation of the VOM from the coronary sinus is feasible and allows for ethanol delivery, which results in rapid ablation of neighboring myocardium and its innervation. Here we review the body of work performed over a span of 13 years, from the inception of the technique, to its preclinical validation, to demonstration of its ablative and denervation effects, and finally to completion of a randomized clinical trial demonstrating favorable outcomes, improving rhythm control in catheter ablation of persistent AF.
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Affiliation(s)
- Miguel Valderrábano
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center and Houston Methodist Research Institute, The Methodist Hospital, Houston, Texas.
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La Rosa G, Quintanilla JG, Salgado R, González-Ferrer JJ, Cañadas-Godoy V, Pérez-Villacastín J, Jalife J, Pérez-Castellano N, Filgueiras-Rama D. Anatomical targets and expected outcomes of catheter-based ablation of atrial fibrillation in 2020. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:341-359. [PMID: 33283883 DOI: 10.1111/pace.14140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/18/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022]
Abstract
Anatomical-based approaches, targeting either pulmonary vein isolation (PVI) or additional extra PV regions, represent the most commonly used ablation treatments in symptomatic patients with atrial fibrillation (AF) recurrences despite antiarrhythmic drug therapy. PVI remains the main anatomical target during catheter-based AF ablation, with the aid of new technological advances as contact force monitoring to increase safety and effective radiofrequency (RF) lesions. Nowadays, cryoballoon ablation has also achieved the same level of scientific evidence in patients with paroxysmal AF undergoing PVI. In parallel, electrical isolation of extra PV targets has progressively increased, which is associated with a steady increase in complex cases undergoing ablation. Several atrial regions as the left atrial posterior wall, the vein of Marshall, the left atrial appendage, or the coronary sinus have been described in different series as locations potentially involved in AF initiation and maintenance. Targeting these regions may be challenging using conventional point-by-point RF delivery, which has opened new opportunities for coadjuvant alternatives as balloon ablation or selective ethanol injection. Although more extensive ablation may increase intraprocedural AF termination and freedom from arrhythmias during the follow-up, some of the targets to achieve such outcomes are not exempt of potential severe complications. Here, we review and discuss current anatomical approaches and the main ablation technologies to target atrial regions associated with AF initiation and maintenance.
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Affiliation(s)
- Giulio La Rosa
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain
| | - Jorge G Quintanilla
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ricardo Salgado
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain
| | - Juan José González-Ferrer
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Victoria Cañadas-Godoy
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Julián Pérez-Villacastín
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - José Jalife
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Nicasio Pérez-Castellano
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - David Filgueiras-Rama
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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Lador A, Peterson LE, Swarup V, Schurmann PA, Makkar A, Doshi RN, DeLurgio D, Athill CA, Ellenbogen KA, Natale A, Koneru J, Dave AS, Giorgberidze I, Afshar H, Guthrie ML, Bunge R, Morillo CA, Kleiman NS, Valderrábano M. Determinants of outcome impact of vein of Marshall ethanol infusion when added to catheter ablation of persistent atrial fibrillation: A secondary analysis of the VENUS randomized clinical trial. Heart Rhythm 2021; 18:1045-1054. [PMID: 33482387 DOI: 10.1016/j.hrthm.2021.01.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Vein of Marshall Ethanol for Untreated Persistent AF (VENUS) trial demonstrated that adding vein of Marshall (VOM) ethanol infusion to catheter ablation (CA) improves ablation outcomes in persistent atrial fibrillation (AF). There was significant heterogeneity in the impact of VOM ethanol infusion on rhythm control. OBJECTIVE The purpose of this study was to assess the association between outcomes and (1) achievement of bidirectional perimitral conduction block and (2) procedural volume. METHODS The VENUS trial randomized patients with persistent AF (N = 343) to CA combined with VOM ethanol or CA alone. The primary outcome (freedom from AF or atrial tachycardia [AT] lasting longer than 30 seconds after a single procedure) was analyzed by 2 categories: (1) successful vs no perimitral block and (2) high- (>20 patients enrolled) vs low-volume centers. RESULTS In patients with perimitral block, the primary outcome was reached 54.3% after VOM-CA and 37% after CA alone (P = .01). Among patients without perimitral block, freedom from AF/AT was 34.0% after VOM-CA and 37.0% after CA (P = .583). In high-volume centers, the primary outcome was reached in 56.4% after VOM-CA and 40.2% after CA (P = .01). In low-volume centers, freedom from AF/AT was 30.77% after VOM-CA and 32.61% after CA (P = .84). In patients with successful perimitral block from high-volume centers, the primary outcome was reached in 59% after VOM-CA and 39.1% after CA (P = .01). Tests for interaction were significant (P = .002 for perimitral block and P = .04 for center volume). CONCLUSION Adding VOM ethanol infusion to CA has a greater impact on outcomes when associated with perimitral block and performed in high-volume centers. Perimitral block should be part of the VOM procedure.
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Affiliation(s)
- Adi Lador
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Leif E Peterson
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | | | - Paul A Schurmann
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Rahul N Doshi
- Division of Cardiology, Keck-USC University Hospital, University of Southern California, Los Angeles, California
| | - David DeLurgio
- Division of Cardiology, Emory St. Joseph's Hospital, Emory University, Atlanta, Georgia
| | - Charles A Athill
- San Diego Cardiac Center, Sharp Memorial Hospital, San Diego, California
| | - Kenneth A Ellenbogen
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas
| | - Jayanthi Koneru
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Amish S Dave
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | | | - Hamid Afshar
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Michelle L Guthrie
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Raquel Bunge
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Carlos A Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Neal S Kleiman
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Miguel Valderrábano
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas.
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Kashimura S, Fujisawa T, Nakajima K, Kunitomi A, Katsumata Y, Nishiyama T, Kimura T, Nishiyama N, Aizawa Y, Fukuda K, Takatsuki S. Electrical Isolation of the Marshall Bundle by Radiofrequency Catheter Ablation. JACC Clin Electrophysiol 2020; 6:1647-1657. [DOI: 10.1016/j.jacep.2020.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/08/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
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Valderrábano M, Peterson LE, Swarup V, Schurmann PA, Makkar A, Doshi RN, DeLurgio D, Athill CA, Ellenbogen KA, Natale A, Koneru J, Dave AS, Giorgberidze I, Afshar H, Guthrie ML, Bunge R, Morillo CA, Kleiman NS. 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. [PMID: 33107945 PMCID: PMC7592031 DOI: 10.1001/jama.2020.16195] [Citation(s) in RCA: 169] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Catheter ablation of persistent atrial fibrillation (AF) has limited success. Procedural strategies beyond pulmonary vein isolation have failed to consistently improve results. The vein of Marshall contains innervation and AF triggers that can be ablated by retrograde ethanol infusion. OBJECTIVE To determine whether vein of Marshall ethanol infusion could improve ablation results in persistent AF when added to catheter ablation. DESIGN, SETTING, AND PARTICIPANTS The Vein of Marshall Ethanol for Untreated Persistent AF (VENUS) trial was an investigator-initiated, National Institutes of Health-funded, randomized, single-blinded trial conducted in 12 centers in the United States. Patients (N = 350) with persistent AF referred for first ablation were enrolled from October 2013 through June 2018. Follow-up concluded in June 2019. INTERVENTIONS Patients were randomly assigned to catheter ablation alone (n = 158) or catheter ablation combined with vein of Marshall ethanol infusion (n = 185) in a 1:1.15 ratio to accommodate for 15% technical vein of Marshall ethanol infusion failures. MAIN OUTCOMES AND MEASURES The primary outcome was freedom from AF or atrial tachycardia for longer than 30 seconds after a single procedure, without antiarrhythmic drugs, at both 6 and 12 months. Outcome assessment was blinded to randomization treatment. There were 12 secondary outcomes, including AF burden, freedom from AF after multiple procedures, perimitral block, and others. RESULTS Of the 343 randomized patients (mean [SD] age, 66.5 [9.7] years; 261 men), 316 (92.1%) completed the trial. Vein of Marshall ethanol was successfully delivered in 155 of 185 patients. At 6 and 12 months, the proportion of patients with freedom from AF/atrial tachycardia after a single procedure was 49.2% (91/185) in the catheter ablation combined with vein of Marshall ethanol infusion group compared with 38% (60/158) in the catheter ablation alone group (difference, 11.2% [95% CI, 0.8%-21.7%]; P = .04). Of the 12 secondary outcomes, 9 were not significantly different, but AF burden (zero burden in 78.3% vs 67.9%; difference, 10.4% [95% CI, 2.9%-17.9%]; P = .01), freedom from AF after multiple procedures (65.2% vs 53.8%; difference, 11.4% [95% CI, 0.6%-22.2%]; P = .04), and success achieving perimitral block (80.6% vs 51.3%; difference, 29.3% [95% CI, 19.3%-39.3%]; P < .001) were significantly improved in vein of Marshall-treated patients. Adverse events were similar between groups. CONCLUSIONS AND RELEVANCE Among patients with persistent AF, addition of vein of Marshall ethanol infusion to catheter ablation, compared with catheter ablation alone, increased the likelihood of remaining free of AF or atrial tachycardia at 6 and 12 months. Further research is needed to assess longer-term efficacy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01898221.
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Affiliation(s)
- Miguel Valderrábano
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Leif E. Peterson
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | | | - Paul A. Schurmann
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Rahul N. Doshi
- Keck-USC University Hospital, University of Southern California, Los Angeles
| | - David DeLurgio
- Emory St Joseph’s Hospital, Emory University, Atlanta, Georgia
| | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin
| | - Jayanthi Koneru
- Virginia Commonwealth University School of Medicine, Richmond
| | - Amish S. Dave
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | | | - Hamid Afshar
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Michelle L. Guthrie
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Raquel Bunge
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Carlos A. Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Neal S. Kleiman
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
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He B, Wang X, Zhao F, Guo T, Po SS, Lu Z. The ligament of Marshall and arrhythmias: A review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:792-799. [PMID: 32914878 DOI: 10.1111/pace.14071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/17/2020] [Accepted: 09/09/2020] [Indexed: 01/27/2023]
Abstract
The ligament of Marshall (LOM) is a remnant of the embryonic sinus venosus and left cardinal vein, and contains fat and fibrous tissues, blood vessels, muscle bundles, nerve fibers, and ganglia. The complexity of LOM's structure makes it as a source of triggers and drivers as well as substrates of re-entry for atrial arrhythmias, especially for atrial fibrillation (AF). LOM also serves as a portion of left atrial macro-re-entrant circuit, especially peri-mitral isthmus re-entrant circuit. Experimental studies demonstrate that the LOM acts as a sympathetic conduit between the left stellate ganglion and the ventricles, and participates in the initiation and maintenance of ventricular arrhythmias. Endocardial or epicardial catheter ablation or ethanol infusion into the vein of Marshall may serve as an important adjunct therapy to pulmonary vein isolation in patients with advanced stage of AF, and may help alleviate ventricular arrhythmias as well.
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Affiliation(s)
- Bo He
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaoying Wang
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Fang Zhao
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Tao Guo
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Sunny S Po
- Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
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47
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Okishige K, Kawaguchi N, Iwai S, Yamauchi Y, Keida T, Sasano T, Hirao K, Valderrabano M. Comparative Study of Cryoballoon versus Radiofrequency for Pulmonary Vein Isolation when Combined with vein of Marshall Ethanol Infusion for Paroxysmal Atrial Fibrillation. J Atr Fibrillation 2020; 12:2253. [PMID: 32435354 DOI: 10.4022/jafib.2253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/12/2019] [Accepted: 01/11/2020] [Indexed: 01/08/2023]
Abstract
Introduction Ethanol infusion (EI) in the vein of Marshall (VOM) has multifactorial effects that could be synergistic to pulmonary vein isolation (PVI) in ablation of atrial fibrillation (AF). The efficacy of radiofrequency (RF) versus cryoablation when combined with a VOM-EI has never been investigated. The aim of this study is to evaluate outcome differences of AF ablation using RF versus cryoablation when combined with a VOM-EI. Materials and Methods Consecutive patients (n=132) underwent catheter ablation of paroxysmal AF with either RF or cryoballoon (CB) for PVI combined with VOM-EI. Bi-directional conduction block at the mitral isthmus was attempted. The end-point was the freedom from any atrial arrhythmias documented after a blanking period of 90 days after the procedure. Results Kaplan-Meier estimates of the arrhythmia-free survival after 1 year were 63.8 (RF + VOM), and 82.7 % (CB + VOM), respectively. Comparison between CB + VOM versus RF + VOM reached a significance (p=0.0292). The periprocedural complication rate was comparable in both groups (5.0 % RF, 5.8 % CB; p=0.14) with a significant difference in the incidence of phrenic nerve palsy (0 % RF, 2.0 % CB; p<0.05). Conclusions PVI with a CB had an increased freedom from AF recurrence compared to RF combined with VOM-EI. The present results suggest a potential additive effect of a VOM-EI to CB application.
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Affiliation(s)
- Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan.,Division of Cardiology, Edogawa Hospital.,Arrhythmia Center, Tokyo Medical and Dental University.,Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center and Houston Methodist Research Institute, Houston, TX
| | - Naohiko Kawaguchi
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan.,Division of Cardiology, Edogawa Hospital.,Arrhythmia Center, Tokyo Medical and Dental University.,Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center and Houston Methodist Research Institute, Houston, TX
| | - Shinsuke Iwai
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan.,Division of Cardiology, Edogawa Hospital.,Arrhythmia Center, Tokyo Medical and Dental University.,Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center and Houston Methodist Research Institute, Houston, TX
| | | | | | - Tetsuo Sasano
- Arrhythmia Center, Tokyo Medical and Dental University
| | - Kenzo Hirao
- Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center and Houston Methodist Research Institute, Houston, TX
| | - Miguel Valderrabano
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan.,Division of Cardiology, Edogawa Hospital.,Arrhythmia Center, Tokyo Medical and Dental University.,Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center and Houston Methodist Research Institute, Houston, TX
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48
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Okishige K, Shigeta T, Nishimura T, Nakamura RA, Hirao T, Yoshida H, Yamauchi Y, Keida T, Sasano T, Hirao K, Valderrábano M. Chemical mapping as a predictor of vein of Marshall ethanol ablative effects. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 43:47-53. [PMID: 31707738 DOI: 10.1111/pace.13839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/28/2019] [Accepted: 11/06/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to test regional pharmacological effects of an antiarrhythmic agents to predict ablative effects. BACKGROUND The vein of Marshall (VOM) providing vascular access to myocardial tissue has been used for ablative purposes using ethanol. METHODS A total of 35 patients (male 21, 63.2 ± 7.8 years old) were included. A balloon-tipped infusion catheter was inserted into the VOM. Endocardial ultrahigh-resolution mapping was performed along the VOM region to record the change in atrial electrograms (AEs) after VOM injection of cibenzoline of 3.5 mg during sustained atrial fibrillation (AF). Subsequently, ethanol was infused into the VOM and ablative region was mapped. RESULTS In 17 patients (49 %), cibenzoline reduced AEs amplitude by >50%, all of which had also complete elimination of AEs following ethanol (Group A). In 18 patients (Group B), cibenzoline failed to eliminate AEs; yet, in 13 of 18 AEs were eliminated by ethanol. In the remaining five patients, ethanol did not eliminate AE. CONCLUSIONS Cibenzoline into the VOM could reliably predicts the results of subsequent ethanol infusion into the VOM using ultrahigh-resolution mapping system, which leads to avoid unnecessary permanent lesion creation by ethanol infusion.
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Affiliation(s)
- Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Takatoshi Shigeta
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Takuro Nishimura
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Rena A Nakamura
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Tatsuhiko Hirao
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Hiroshi Yoshida
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Yasuteru Yamauchi
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Takehiko Keida
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | - Tetsuo Sasano
- Arrhythmia Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenzo Hirao
- Arrhythmia Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center, Houston, Texas.,Division of Cardiac Electrophysiology, Houston Methodist Research Institute, Houston, Texas
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49
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Kato K, Tanaka A, Morimoto SI, Hasegawa S, Ishiguro N, Kametani R, Hattori H, Shibata N. Potential complications in patients undergoing an ethanol injection into the vein of Marshall. J Cardiovasc Electrophysiol 2019; 30:2743-2750. [PMID: 31596017 PMCID: PMC6916342 DOI: 10.1111/jce.14221] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/06/2019] [Accepted: 09/19/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ethanol injections into the vein of Marshall (VOM) (EIM) are considered to be a good therapeutic option for atrial tachyarrhythmias, however, the safety remains to be determined. To elucidate what would affect the safety and potential complications of an EIM, we investigated the anatomical features of the VOM and patient background. METHODS We performed the EIM before the conventional pulmonary vein isolation for drug-resistant atrial fibrillation in 88 patients and evaluated the anatomical features of the VOM and their background. RESULTS All procedures were completed, however, other than myocardial staining, trivial contrast medium leaked out of the VOM into the pericardial space, that is, extravasation of contrast medium with capillary rupture, during the EIM in 20 patients (22.7%) regardless of the features of the VOM. No pericardial effusions requiring further intervention developed after the extravasation, which resolved by the next day on echocardiography in 18 of those patients. However, two patients who had extravasation other than during the initial contrast injection required additional therapeutic intervention for nonnegligible pericardial effusions. Their body weights were significantly lower and the latter two patients were also small lean women with heart failure and a preserved ejection fraction. CONCLUSIONS The physical constitution, regardless of the characteristics of the VOM, could be strongly associated with adverse events during the EIM. We must take extreme care in smaller patients with poor compliant hearts during the EIM.
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Affiliation(s)
- Kazuo Kato
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Akimitsu Tanaka
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Shin-Ichiro Morimoto
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Shin Hasegawa
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Nobuo Ishiguro
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Ryosuke Kametani
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Hideo Hattori
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Norihisa Shibata
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
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50
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Valderrábano M, Peterson LE, Bunge R, Prystash M, Dave AS, Nagueh S, Kleiman NS. Vein of Marshall ethanol infusion for persistent atrial fibrillation: VENUS and MARS clinical trial design. Am Heart J 2019; 215:52-61. [PMID: 31279972 PMCID: PMC6692654 DOI: 10.1016/j.ahj.2019.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although pulmonary vein isolation (PVI) is effective in the treatment of paroxysmal atrial fibrillation (AF), its success rates in persistent AF are suboptimal. Ablation strategies to improve outcomes including additional lesions beyond PVI have not consistently shown benefit. Recurrence as perimitral flutter (PMF) is a common form of ablation failure. The vein of Marshall (VOM) contains myocardial connections and abundant sympathetic and parasympathetic innervation implicated in the genesis and maintenance of AF, and is anatomically co-localized with the mitral isthmus, the ablation target of PMF. VOM ethanol infusion is effective in targeting these arrhythmia substrates. OBJECTIVE To test the safety and efficacy of VOM ethanol infusion when added to PVI in patients undergoing either de novo ablation of persistent AF or after a previous ablation failure. STUDY DESIGN VENUS-AF and MARS-AF are prospective, multicenter, randomized, controlled trials. VENUS-AF will enroll patients undergoing their first catheter ablation of persistent AF. MARS-AF will enroll patients undergoing ablation after previous ablation failure(s). Patients (n = 405) will be randomized to PVI alone or in combination with VOM ethanol infusion. The primary endpoints include procedural safety and freedom from AF or atrial tachycardia (AT) of more than 30 seconds on 30-day continuous event monitors at 6 and 12 months after randomization procedure (single-procedure success), off antiarrhythmic drugs. Key secondary endpoints include AF burden, freedom from AF/AT after repeat procedures and quality of life. CONCLUSIONS The VENUS-AF and MARS-AF will determine the safety and potential rhythm control benefit of VOM ethanol infusion when added to PVI in patients with persistent AF undergoing de novo or repeat ablation, respectively.
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Affiliation(s)
| | - Leif E Peterson
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
| | - Raquel Bunge
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
| | | | - Amish S Dave
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
| | - Sherif Nagueh
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
| | - Neal S Kleiman
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
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