Optimized Computed Tomography Acquisition Protocol for Ethanol Infusion Into the Vein of Marshall

Angiographic assessment of vein of Marshall in atrial fibrillation: Implications for identification and cannulation

Background

The vein of Marshall (VOM) ethanol infusion improves rhythm control in atrial fibrillation (AF). The identification and cannulation of the VOM can be technically challenging. This study aimed to assess the angiographic morphology of the VOM and investigate its value in the VOM ethanol infusion.

Methods

Patients with AF (n = 162) scheduled for combined catheter ablation and VOM ethanol infusion were enrolled. The VOM morphologic features in the right anterior oblique (RAO), the left anterior oblique (LAO), and the LAO cranial views were analyzed. The impact of morphology on the identification and cannulation of the VOM was investigated.

Results

The VOM was identified in 159 (98.1 %) and cannulated in 150 (92.6 %) patients. The VOM identification rate in the RAO and LAO/LAO cranial view was 97.3 % and 89.3 %, respectively. Of 134 patients with VOM identification in the LAO/LAO cranial view, 104 (77.6 %) had a VOM ostium clock location (VOMoClock) of ≤3 and 3-4 o'clock. The VOM cannulation success rate in the ≤3, 3-4, 4-5, and 5-6 o'clock groups was 100 %, 92.6 %, 88.5 %, and 77.8 %, respectively (p = 0.032). The median (interquartile range) cannulation time in the four groups was 10.5 (6.3), 12.0 (9.0), 13.0 (23.0), and 34.0 (30.0) minutes, respectively (p < 0.001). The diameter of the coronary sinus ostium in the RAO view and the VOMoClock were independent predictors for difficult cannulation.

Conclusions

The VOM morphologic features in different angiographic views provide valuable information which could facilitate the identification and cannulation of the VOM.

Double-wire technique to facilitate vein of Marshall cannulation and ethanol infusion in atrial fibrillation: a case series

BACKGROUND

The vein of Marshall (VOM) ethanol infusion is increasingly performed in combination with catheter ablation in atrial fibrillation (AF). The cannulation of the VOM can sometimes be challenging. This study aimed to evaluate the double-wire technique in cases of difficult cannulation of the VOM.

CASE PRESENTATION

Patients with AF scheduled for combined catheter ablation and VOM ethanol infusion were consecutively enrolled. The procedure was performed via the femoral vein. If the regular cannulation technique with one angioplasty wire failed or took more than 20 min, the double-wire technique using a stabilizing wire and a cannulation wire was performed. The unique technique was used mainly in two scenarios, when the Eustachian ridge was too prominent as a barrier for catheter manipulation or when the VOM ostium was close to the coronary sinus ostium. Of 162 patients scheduled for VOM ethanol infusion, the double-wire technique was applied in 6 (3.7%) patients and led to a 100% successful cannulation rate of the VOM. Of the six patients, two had a prominent Eustachian ridge, and four had a VOM ostium close to the coronary sinus ostium. The mean cannulation time was 33.3 ± 7.3 min. The ethanol infusion was successfully performed in 5 patients. One patient had a collateral circulation in the distal VOM, and ethanol infusion was not performed.

CONCLUSIONS

The double-wire technique can facilitate VOM cannulation and ethanol infusion in challenging cases.

WORD COUNT

231.

Vein of Marshall Collateralization during Ethanol Infusion in Atrial Fibrillation: Solution for Effective Myocardium Staining

BACKGROUND

The vein of Marshall (VOM) ethanol infusion improves sinus rhythm maintenance in patients with atrial fibrillation (AF). Distal collateral circulation of VOM can be a challenge to effective ethanol infusion.

OBJECTIVE

This study aimed to evaluate the feasibility and efficacy of ethanol infusion in VOM with distal collateral circulation.

METHODS

Patients with AF scheduled for catheter ablation and VOM ethanol infusion were consecutively enrolled. During the procedure, non-occluded coronary sinus angiography was first performed for VOM identification. After VOM identification, an over-the-wire angioplasty balloon was used for cannulation and occluded angiography of the VOM. Those with distal VOM collateral circulation were included in this study. A method of slower ethanol injection (2 mL over 5 min) plus additional balloon occlusion time for 3 min after each injection was used.

RESULTS

Of 162 patients scheduled for VOM ethanol infusion, apparent distal VOM collateral circulation was revealed in seven (4.3%) patients. Five patients had collateral circulation to the left atrium, one to the right superior vena cava, and one to the great cardiac vein. Two patients did not undergo further ethanol infusion because of our inadequate experience during the early stage of the project. Five patients had successful VOM ethanol infusion with manifest localized myocardium staining.

CONCLUSIONS

Ethanol infusion in VOM with distal collateral circulation can be solved by slow injection of ethanol and enough balloon occlusion time between multiple injections.

Angiographic Characteristics of the Vein of Marshall in Patients with and without Atrial Fibrillation

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