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He B, Zhao F, Yu W, Li Y, Wu X, Lu Z. Ethanol Infusion of Vein of Marshall for the Treatment of Persistent Atrial Fibrillation: The Basics and Clinical Practice. J Cardiovasc Dev Dis 2022; 9:jcdd9080270. [PMID: 36005434 PMCID: PMC9409861 DOI: 10.3390/jcdd9080270] [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: 06/08/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 11/21/2022] Open
Abstract
Catheter ablation for persistent atrial fibrillation (PeAF) is particularly challenging, as the clinical outcomes are modest. Pulmonary vein isolation (PVI) plus linear ablation is one of the main strategies for PeAF ablation. Completely durable transmural lesions are difficult to achieve by catheter ablation during mitral isthmus ablation. The ligament of Marshall contains the vein of Marshall (VOM), myocardial tracts and innervation, and serves as arrhythmogenic foci that make it an attractive target in catheter ablation of atrial fibrillation. Additionally, it co-localizes with the mitral isthmus, and may serve as a part of the perimitral isthmus reentrant circuit. Ethanol infusion into the VOM results in rapid ablation of the neighboring myocardium and its innervation. Its incorporation into PVI significantly increases the success rate of mitral isthmus block and the clinical outcome of PeAF ablation.
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Affiliation(s)
- Bo He
- Department of Cardiology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China
- Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Fang Zhao
- Department of Cardiology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China
- Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Wenxi Yu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China
- Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Yi Li
- Department of Cardiology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China
- Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Xiaoyan Wu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China
- Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China
- Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
- Correspondence: ; Tel.: +86-27-67813073
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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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Abstract
Although pulmonary vein isolation is accepted as an established interventional treatment in paroxysmal atrial fibrillation (AF), alternative modalities are being investigated because of the high recurrence rates of nonparoxysmal forms. One of the alternative ablation approaches is ablation or modification of vagal ganglionated plexi (VGP). The technique has not only been used in vagally mediated AF but also investigated in paroxysmal and nonparoxysmal AF. Clinical studies demonstrate significant discrepancy related with detection of VGP sites or ablation targets and definition of procedurel end-points, so far. In this review, we aimed to discuss the current data on the role of VGP in the pathogenesis of AF and potential therapeutic implications of ablation of these ganglia.
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Wang S, Lu Z, He W, He B, Xie J, Yu X, Jiang H. Selective Ablation of the Ligament of Marshall Reduces the Prevalence of Ventricular Arrhythmias Through Autonomic Modulation in a Cesium-Induced Long QT Canine Model. JACC Clin Electrophysiol 2016; 2:97-106. [DOI: 10.1016/j.jacep.2015.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/10/2015] [Accepted: 09/17/2015] [Indexed: 11/30/2022]
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Assessment of atrial fibrillation and vulnerability in patients with Wolff-Parkinson-White syndrome using two-dimensional speckle tracking echocardiography. PLoS One 2014; 9:e108315. [PMID: 25397668 PMCID: PMC4232256 DOI: 10.1371/journal.pone.0108315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 08/28/2014] [Indexed: 12/19/2022] Open
Abstract
Purpose The aim was to assess atrial fibrillation (AF) and vulnerability in Wolff-Parkinson-White (WPW) syndrome patients using two-dimensional speckle tracking echocardiography (2D-STE). Methods All patients were examined via transthoracic echocardiography and 2D-STE in order to assess atrial function 7 days before and 10 days after RF catheter ablation. A postoperative 3-month follow-up was performed via outpatient visit or telephone calls. Results Results showed significant differences in both body mass index (BMI) and supraventricular tachycardia (SVT) duration between WPW patients and DAVNP patients (both P<0.05). Echocardiography revealed that the maximum left atrial volume (LAVmax) and the left ventricular mass index (LVMI) in diastole increased noticeably in patients with WPW compared to patients with DAVNP both before and after ablation (all P<0.05). Before ablation, there were obvious differences in the levels of SRs, SRe, and SRa from the 4-chamber view (LA) in the WPW patients group compared with patients in the DAVNP group (all P<0.05). In the AF group, there were significant differences in the levels of systolic strain rate (SRs), early diastolic strain rate (SRe), and late diastolic strain rate (SRa) from the 4-chamber view (LA) both before and after ablation (all P<0.05). In the non-AF group, there were decreased SRe levels from the 4-chamber view (LA/RA) pre-ablation compared to post-ablation (all P<0.05). Conclusion Our findings provide convincing evidence that WPW syndrome may result in increased atrial vulnerability and contribute to the development of AF. Further, RF catheter ablation of AAV pathway can potentially improve atrial function in WPW syndrome patients. Two-dimensional speckle tracking echocardiography imaging in WPW patients would be necessary in the evaluation and improvement of the overall function of RF catheter ablation in a long-term follow-up period.
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Mao J, Yin X, Zhang Y, Yan Q, Dong J, Ma C, Liu X. Ablation of Epicardial Ganglionated Plexi Increases Atrial Vulnerability to Arrhythmias in Dogs. Circ Arrhythm Electrophysiol 2014; 7:711-7. [PMID: 24860179 DOI: 10.1161/circep.113.000799] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Jun Mao
- From the Department of Cardiology, Center for Atrial Fibrillation, Beijing Anzhen Hospital, Beijing, China (J.M., J.D., C.M.); Center for Atrial Fibrillation, Heart Center, Beijing Chao-Yang Hospital, Beijing, China (X.Y., Q.Y., X.L.); and Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China (Y.Z.)
| | - Xiandong Yin
- From the Department of Cardiology, Center for Atrial Fibrillation, Beijing Anzhen Hospital, Beijing, China (J.M., J.D., C.M.); Center for Atrial Fibrillation, Heart Center, Beijing Chao-Yang Hospital, Beijing, China (X.Y., Q.Y., X.L.); and Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China (Y.Z.)
| | - Ying Zhang
- From the Department of Cardiology, Center for Atrial Fibrillation, Beijing Anzhen Hospital, Beijing, China (J.M., J.D., C.M.); Center for Atrial Fibrillation, Heart Center, Beijing Chao-Yang Hospital, Beijing, China (X.Y., Q.Y., X.L.); and Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China (Y.Z.)
| | - Qian Yan
- From the Department of Cardiology, Center for Atrial Fibrillation, Beijing Anzhen Hospital, Beijing, China (J.M., J.D., C.M.); Center for Atrial Fibrillation, Heart Center, Beijing Chao-Yang Hospital, Beijing, China (X.Y., Q.Y., X.L.); and Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China (Y.Z.)
| | - Jianzeng Dong
- From the Department of Cardiology, Center for Atrial Fibrillation, Beijing Anzhen Hospital, Beijing, China (J.M., J.D., C.M.); Center for Atrial Fibrillation, Heart Center, Beijing Chao-Yang Hospital, Beijing, China (X.Y., Q.Y., X.L.); and Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China (Y.Z.)
| | - Changsheng Ma
- From the Department of Cardiology, Center for Atrial Fibrillation, Beijing Anzhen Hospital, Beijing, China (J.M., J.D., C.M.); Center for Atrial Fibrillation, Heart Center, Beijing Chao-Yang Hospital, Beijing, China (X.Y., Q.Y., X.L.); and Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China (Y.Z.)
| | - Xingpeng Liu
- From the Department of Cardiology, Center for Atrial Fibrillation, Beijing Anzhen Hospital, Beijing, China (J.M., J.D., C.M.); Center for Atrial Fibrillation, Heart Center, Beijing Chao-Yang Hospital, Beijing, China (X.Y., Q.Y., X.L.); and Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China (Y.Z.).
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Zhang S, Lin N. Another step forward: Journal of Cardiovascular Electrophysiology special issue for electrophysiology research from China. J Cardiovasc Electrophysiol 2013; 23 Suppl 1:S2-4. [PMID: 23140345 DOI: 10.1111/jce.12011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Shu Zhang
- National Center for Cardiovascular Diseases, Beijing, China
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Lim PB, Malcolme-Lawes LC, Stuber T, Wright I, Francis DP, Davies DW, Peters NS, Kanagaratnam P. Intrinsic cardiac autonomic stimulation induces pulmonary vein ectopy and triggers atrial fibrillation in humans. J Cardiovasc Electrophysiol 2011; 22:638-46. [PMID: 21235671 DOI: 10.1111/j.1540-8167.2010.01992.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The induction of atrial fibrillation (AF) by pulmonary vein (PV) ectopy is well described. The triggers for these PV ectopy are not so well understood. The intrinsic cardiac autonomic nervous system (ANS) has been suggested as a potential upstream regulator that may cause PV ectopy and atrial fibrillation (AF). We hypothesized that activation of the ANS by high frequency stimulation (HFS) of atrial ganglionated plexi (GP) can initiate PV ectopy. METHODS AND RESULTS During sinus rhythm in 12 patients undergoing ablation for paroxysmal AF, short bursts of HFS, synchronized to the local atrial refractory period, were delivered at presumed GP sites. Electrograms were recorded from catheters placed in the PV, coronary sinus (CS) and high right atrium (HRA). A total of 112 episodes of HFS were recorded, producing ectopic activity in 91 of 112 (81%) episodes. Of these 91 episodes, there were 46 episodes of isolated single ectopic beats, 5 episodes of double ectopic responses, 24 episodes of ectopy/tachycardia lasting <30 s, and 16 episodes of AF lasting >30 s. In 63 of 91 episodes, the PV catheter was placed adjacent to the stimulated GP, resulting in ectopy recorded earliest in the PV catheter in 48 of 63 (76%) episodes. In one patient, reproducible ectopy was shown to occur following AV nodal conduction delay in response to HFS. Without HFS, neither AV nodal conduction delay nor ectopy occurred. CONCLUSIONS This study has demonstrated a direct link between activation of the intrinsic cardiac autonomic nervous system and pulmonary vein ectopy in humans.
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Affiliation(s)
- Phang Boon Lim
- Cardiology Department, Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed Street, London, UK.
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