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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lehmann HI, Chugh A. Alcohol ablation of the vein of Marshall in a patient with persistent atrial fibrillation and prior surgical ligation of the ligament of Marshall. HeartRhythm Case Rep 2024; 10:151-154. [PMID: 38404976 PMCID: PMC10885713 DOI: 10.1016/j.hrcr.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Affiliation(s)
- H. Immo Lehmann
- Jean and Samuel Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Aman Chugh
- Jean and Samuel Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
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Andronache M, Pastorcici A, Amet D, Blendea D, Boudias A, Mazieres G, Rosu R, Cismaru G, Puiu M, Mot S, Serban A, Mottref P, Dauphin C, Moini C, Lellouche N, Massoulié G. Acute mitral isthmus block during catheter ablation with vein of Marshall ethanol infusion: Angiographic considerations. Arch Cardiovasc Dis 2024; 117:119-127. [PMID: 38040560 DOI: 10.1016/j.acvd.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Achieving bidirectional mitral isthmus block is still challenging. Conventional ablation methods involve radiofrequency applications on the endocardial aspect of the lateral mitral isthmus, and often epicardial applications inside the coronary sinus. AIM To evaluate the impact of the systematic use of ethanol infusion in the vein of Marshall on the achievement of acute mitral isthmus block of additional epicardial component lesion. METHODS We evaluated patients referred to two centres for long-standing persistent atrial fibrillation ablation or recurrent peri-mitral flutter. All patients had pulmonary vein isolation and mitral isthmus line using ethanol infusion in the vein of Marshall for the first procedure and additional radiofrequency ablation lesion if necessary. For redo procedures, additional ablations (atrial lines and complex fractionated atrial electrogram ablations, if needed) were also performed. RESULTS We included 149 patients, and ethanol infusion in the vein of Marshall was not performed in 27 patients (18%). Among 122 patients, 115 had long-standing persistent atrial fibrillation (94.2%) and seven had peri-mitral flutter (5.8%). The mean duration of continuous atrial fibrillation was 53 months before ablation. Acute bidirectional mitral isthmus block was obtained in 115 (94.2%) of the 122 patients who received ethanol infusion in the vein of Marshall (77% when considering the total population). The mean radiofrequency delivery time to obtain mitral isthmus block was 2.6minutes for the endocardial mitral isthmus radiofrequency ablation and 2.6minutes for the epicardial mitral isthmus radiofrequency ablation. Failure to obtain mitral isthmus block was associated with increased mitral isthmus length and left atrial dilation. No major complications related to ethanol infusion in the vein of Marshall were observed. CONCLUSION Ethanol infusion in the vein of Marshall, when feasible (82%), was a safe approach to obtaining a high success rate (94%) of acute bidirectional endocardial and epicardial mitral isthmus block.
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Affiliation(s)
- Marius Andronache
- Cardiology Department, CHU Clermont-Ferrand, Clermont University, 63003 Clermont-Ferrand cedex 1, France; Alleray-Labrouste Cardiology Clinics, 75015 Paris, France
| | - Anda Pastorcici
- Cardiology Department, CHU Clermont-Ferrand, Clermont University, 63003 Clermont-Ferrand cedex 1, France
| | - Denis Amet
- Alleray-Labrouste Cardiology Clinics, 75015 Paris, France; Cardiology Department, Georges Pompidou European Hospital, 75015 Paris, France
| | - Dan Blendea
- Cardiology Department, University of Medicine and Pharmacy "Iuliu Hatieganu", 400394 Cluj-Napoca, Romania
| | - Antoine Boudias
- Cardiology Department, CHU Clermont-Ferrand, Clermont University, 63003 Clermont-Ferrand cedex 1, France
| | - Guillaume Mazieres
- Cardiology Department, CHU Clermont-Ferrand, Clermont University, 63003 Clermont-Ferrand cedex 1, France
| | - Radu Rosu
- Cardiology Department, University of Medicine and Pharmacy "Iuliu Hatieganu", 400394 Cluj-Napoca, Romania
| | - Gabriel Cismaru
- Cardiology Department, University of Medicine and Pharmacy "Iuliu Hatieganu", 400394 Cluj-Napoca, Romania
| | - Mihai Puiu
- Cardiology Department, University of Medicine and Pharmacy "Iuliu Hatieganu", 400394 Cluj-Napoca, Romania
| | - Stefan Mot
- Cardiology Department, University of Medicine and Pharmacy "Iuliu Hatieganu", 400394 Cluj-Napoca, Romania
| | - Adela Serban
- Cardiology Department, University of Medicine and Pharmacy "Iuliu Hatieganu", 400394 Cluj-Napoca, Romania
| | - Pascal Mottref
- Cardiology Department, CHU Clermont-Ferrand, Clermont University, 63003 Clermont-Ferrand cedex 1, France
| | - Claire Dauphin
- Cardiology Department, CHU Clermont-Ferrand, Clermont University, 63003 Clermont-Ferrand cedex 1, France
| | - Cyrus Moini
- Department of Cardiology, GHSIF-Melun, 77000 Melun, France
| | - Nicolas Lellouche
- Department of Cardiology, University Hospital Henri-Mondor, AP-HP, 94000 Créteil, France.
| | - Grégoire Massoulié
- Cardiology Department, CHU Clermont-Ferrand, Clermont University, 63003 Clermont-Ferrand cedex 1, France
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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 2024:10.1007/s10840-023-01732-4. [PMID: 38206450 DOI: 10.1007/s10840-023-01732-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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Baskovski E, Altin AT, Akyurek O, Kuru B, Korkmaz K, Ersoy İ, Kozluca V, Akbulut IM, Tutar E. Electrophysiological characteristics of epicardial atrial tachycardias and endocardial breakthrough site targeting for ablation: a single center experience. J Interv Card Electrophysiol 2023; 66:1901-1910. [PMID: 36811816 DOI: 10.1007/s10840-023-01513-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Despite being increasingly observed in daily practice, epicardial atrial tachycardias (Epi AT) have not been extensively characterized. In the present study, we retrospectively characterize electrophysiological properties, electroanatomic ablation targeting, and outcomes of this ablation strategy. METHODS Patients who underwent scar-based macro-reentrant left atrial tachycardia mapping and ablation patients with at least one Epi AT, which had a complete endocardial map, were selected for the inclusion. Based on current electroanatomical knowledge, Epi ATs were classified based by utilization of following epicardial structures: Bachmann's bundle, septopulmonary bundle, vein of Marshall. Endocardial breakthrough (EB) sites were analyzed as well as entrainment parameters. EB site was targeted for initial ablation. RESULTS Among seventy-eight patients undergoing scar-based macro-reentrant left atrial tachycardia ablation, fourteen (17.8%) patients met the inclusion criteria for Epi AT and were included in the study. Sixteen Epi ATs were mapped, four utilizing Bachmann's bundle, five utilizing septopulmonary bundle, and seven utilizing vein of Marshall. Fractionated, low amplitude signals were present at EB sites. Rf terminated the tachycardia in ten patients; activation changed in five patients and in one patient atrial fibrillation ensued. During the follow-up, there were three recurrences. CONCLUSIONS Epicardial left atrial tachycardias are a distinct type of macro-reentrant tachycardias that can be characterized by activation and entrainment mapping, without need for epicardial access. Endocardial breakthrough site ablation reliably terminates these tachycardias with good long-term success.
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Affiliation(s)
- Emir Baskovski
- Cardiology Department, Ankara University, Ankara, Turkey.
| | | | - Omer Akyurek
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Busra Kuru
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Kubra Korkmaz
- Cardiology Department, Ankara University, Ankara, Turkey
| | - İbrahim Ersoy
- Faculty of Medicine, Afyonkarahisar Science of Health University, Afyonkarahisar, Turkey
| | - Volkan Kozluca
- Cardiology Department, Ankara University, Ankara, Turkey
| | | | - Eralp Tutar
- Cardiology Department, Ankara University, Ankara, Turkey
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Cerantola M, Hanumanthu BKJ, Hyman MC. Ablation of perimitral flutter in a patient with a partially inaccessible left atrium. HeartRhythm Case Rep 2023; 9:704-708. [PMID: 38047205 PMCID: PMC10691951 DOI: 10.1016/j.hrcr.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Maxime Cerantola
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Balaram Krishna J. Hanumanthu
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C. Hyman
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Okabe T, Bhuta S, Afzal MR, Savona SJ, Kalbfleisch SJ, Houmsse M, Augostini RS, Daoud EG, Hummel JD. Delayed bipolar voltage changes in the left atrium after vein of Marshall ethanol infusion. Pacing Clin Electrophysiol 2023; 46:948-950. [PMID: 37436707 DOI: 10.1111/pace.14786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/28/2023] [Accepted: 07/01/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Toshimasa Okabe
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sapan Bhuta
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Muhammad R Afzal
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Salvatore J Savona
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Kalbfleisch
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ralph S Augostini
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John D Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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8
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Zhang W, Li X, Su G, Gao X, Kong Q. A specific notation for contrast medium and dehydrated ethanol injection into the vein of Marshall during mitral isthmus ablation-A case report. Pacing Clin Electrophysiol 2023; 46:34-38. [PMID: 35962617 DOI: 10.1111/pace.14577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/08/2022] [Accepted: 07/28/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Ablation of the vein of Marshall (VOM) by dehydrated ethanol (DE) is an important method for completely blocking the mitral isthmus (MI). Before DE ablation of the VOM, Marshall angiography should be performed so that the contrast medium is inevitably exposed to DE. METHOD We present a case of DE ablation of the VOM. When iodixanol was exposed to DE, some floccule embolized the lumen of the over-the-wire (OTW) balloon dilatation catheter and led to the impossibility of DE ablation. Then, we performed in vitro experiments: iodixanol, not iomeprol, produced many stable white floccules when it encountered DE. CONCLUSION Iodixanol is not an appropriate contrast for DE ablation of the VOM. However, if there is no other alternative contrast, the following methods might be used to address the problem: ⑴ diluted iodixanol (iodixanol:normal saline 1:1) could be used for VOM ablation; or ⑵ the lumen of the OTW could be flushed by NS after VOM angiography, and then DE injection could be performed.
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Affiliation(s)
- Wei Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, People's Republic of China
| | - Xinyun Li
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University (Previous Name: Jinan Central Hospital Affiliated to Shandong University), Jinan, Shandong, People's Republic of China
| | - Guoying Su
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University (Previous Name: Jinan Central Hospital Affiliated to Shandong University), Jinan, Shandong, People's Republic of China
| | - Xiaoyuan Gao
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University (Previous Name: Jinan Central Hospital Affiliated to Shandong University), Jinan, Shandong, People's Republic of China
| | - Qingzan Kong
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University (Previous Name: Jinan Central Hospital Affiliated to Shandong University), Jinan, Shandong, People's Republic of China
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9
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Huang L, Gao M, Lai Y, Guo Q, Li S, Li C, Liu N, Wang W, Liu X, Zuo S, Guo X, Zhao X, Jiang C, Sang C, Tang R, Long D, Du X, Dong J, Ma CS. The adjunctive effect for left pulmonary vein isolation of vein of Marshall ethanol infusion in persistent atrial fibrillation. Europace 2022; 25:441-449. [PMID: 36504017 PMCID: PMC9935035 DOI: 10.1093/europace/euac219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/23/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This study sought to assess the effect of ethanol infusion into the vein of Marshall (EIVOM) on the acute success of left pulmonary vein (LPV) isolation in persistent atrial fibrillation (PeAF). METHODS AND RESULTS A total of 313 patients with drug-resistant PeAF were enrolled (135 in Group 1 and 178 in Group 2). In Group 1, EIVOM was firstly performed, followed by radiofrequency ablation (RFA) including bilateral pulmonary vein isolation (PVI) and linear ablation at roofline, cavotricuspid isthmus, and mitral isthmus (MI). In Group 2, PVI and linear ablations were completed with RFA. First-pass isolation of the LPV was achieved in 119 (88.1%) and 132 (74.2%) patients in Groups 1 and 2, respectively (P = 0.002). The rate of acute pulmonary vein reconnection (PVR) was significantly lower in Group 1 (9.6% vs. 22.5%, P = 0.003). About half of acute PVR occurred in the carina with or without EIVOM. CONCLUSION EIVOM is effective in achieving a higher first-pass isolation and a lower acute PVR of LPV in PeAF.
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Affiliation(s)
- Lihong Huang
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Mingyang Gao
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Yiwei Lai
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Qi Guo
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Songnan Li
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Changyi Li
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Nian Liu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Wei Wang
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Xiaoxia Liu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Song Zuo
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Xueyuan Guo
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Xin Zhao
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Chenxi Jiang
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Caihua Sang
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Ribo Tang
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Deyong Long
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Xin Du
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Beijing Anzhen Hospital, Capital Medical University, No 2, Anzhen Rd, Chaoyang District, 100029 Beijing, China
| | - Chang-sheng Ma
- Corresponding author. Fax: 86-10-84005361. E-mail address:
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10
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Li X, Li M, Zhang Y, Zhang H, Wu W, Ran B, Li X, Tang Q, Fu B. Simplified stepwise anatomical ablation strategy for mitral isthmus: efficacy, efficiency, safety, and outcome. Europace 2022; 25:610-618. [PMID: 36353823 PMCID: PMC9934997 DOI: 10.1093/europace/euac204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS Bidirectional and durable block of mitral isthmus (MI) is essential for catheter ablation of persistent atrial fibrillation (PeAF) and perimitral flutter (PMF), but it remains a challenge. The aim of this study was to create a simple anatomical ablation strategy with minimal fluoroscopy that would yield a high success rate for MI block. METHODS AND RESULTS Patients with PeAF or PMF were included. Mitral isthmus was ablated in a stepwise strategy. In Step 1, endocardial MI linear ablation was performed; in Step 2, ablation was targeted to the posterolateral portion of the left atrium along the MI line; in Step 3, epicardial ablation within the coronary sinus (CS) was performed across the MI line to the ostium of the vein of Marshall (VOM) or performed within the VOM if available; in Step 4, the catheter was rotated and ablated in the CS to isolate the CS; and in Step 5, the early activation site with complex component potential above the MI line during distal CS pacing was considered as the ablation target. All patients were followed up. A total of 178 (17 patients with mechanical prosthetic mitral valve) were included. One hundred and sixty-six patients achieved a confirmed MI bidirectional conduction block (93%). One patient had cardiac tamponade. Four patients showed re-conduction across the MI line during a repeated ablation. In the latest follow-up [12 (7, 16) months], 161 of 178 (90%) patients maintained their sinus rhythm. CONCLUSION A simple stepwise anatomical ablation strategy for MI shows a high success rate with low fluoroscopy exposure.
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Affiliation(s)
- Xiaoqin Li
- Department of Cardiology, Chongqing General Hospital, University of Chinese Academy of Sciences, 118 Xingguang Road, Yubei District, 401120 Chongqing, China
| | - Mengmeng Li
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Yuan Zhang
- Department of Cardiology, Chongqing General Hospital, University of Chinese Academy of Sciences, 118 Xingguang Road, Yubei District, 401120 Chongqing, China
| | - Hao Zhang
- Department of Cardiology, Chongqing General Hospital, University of Chinese Academy of Sciences, 118 Xingguang Road, Yubei District, 401120 Chongqing, China
| | - Wenli Wu
- Department of Cardiology, Chongqing General Hospital, University of Chinese Academy of Sciences, 118 Xingguang Road, Yubei District, 401120 Chongqing, China
| | - Boli Ran
- Department of Cardiology, Chongqing General Hospital, University of Chinese Academy of Sciences, 118 Xingguang Road, Yubei District, 401120 Chongqing, China
| | - Xiaoli Li
- Department of Cardiology, Chongqing General Hospital, University of Chinese Academy of Sciences, 118 Xingguang Road, Yubei District, 401120 Chongqing, China
| | - Qianmei Tang
- Department of Cardiology, Chongqing General Hospital, University of Chinese Academy of Sciences, 118 Xingguang Road, Yubei District, 401120 Chongqing, China
| | - Biao Fu
- Corresponding author. Tel: +86 2363390551. E-mail address:
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11
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Yokoyama M, Yamashita S, Yoshimura M, Yamane T. A case of pseudo-endocardial gap during mitral flutter: Pitfalls of the auto-annotation algorithm on the ultra-high-resolution mapping system. HeartRhythm Case Rep 2022; 9:126-128. [PMID: 36860751 PMCID: PMC9968914 DOI: 10.1016/j.hrcr.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Seigo Yamashita
- Address reprint requests and correspondence: Dr Seigo Yamashita, Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan.
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12
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Leyton-Mange JS, Tandon K, Sze EY, Carpenter CM, Sesselberg HW. The Maine vein of Marshall ethanol experience: learning curve and safety. J Interv Card Electrophysiol 2022. [PMID: 36181632 DOI: 10.1007/s10840-022-01378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Borgquist R, Wang L. Anatomy of the coronary sinus with regard to cardiac resynchronization therapy implantation. Herzschrittmacherther Elektrophysiol 2022; 33:186-194. [PMID: 35648250 PMCID: PMC9177481 DOI: 10.1007/s00399-022-00863-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/04/2022] [Indexed: 11/29/2022]
Abstract
Knowledge of the coronary sinus (CS) anatomy is crucial for implantation of cardiac resynchronization therapy (CRT). Obstacles to CS entry, such as the Eustachian ridge and Thebesian valve, as well as within the CS, such as Vieussen’s valve and the vein of Marshall, are important to understand and differentiate during implantation or to identify earlier by imaging. Anatomic knowledge is mandatory to select the most suitable side branch for lead implantation. Modern tools and techniques almost always enable other anatomic problems, such as tortuous, small, short, or overly straight side branches, to also be overcome.
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Affiliation(s)
- Rasmus Borgquist
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden. .,Department of Arrhythmias, Skane University Hospital, 221 85, Lund, Sweden.
| | - Lingwei Wang
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden.,Department of Arrhythmias, Skane University Hospital, 221 85, Lund, Sweden
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Pambrun T, Derval N, Duchateau J, Denis A, Chauvel R, Tixier R, Welte N, André C, Nakashima T, Nakatani Y, Kamakura T, Takagi T, Ramirez FD, Krisai P, Goujeau C, Cheniti G, Vlachos K, Bourier F, Takigawa M, Kitamura T, Frontera A, Sacher F, Hocini M, Haïssaguerre M, Jaïs P. Epicardial course of the musculature related to the great cardiac vein: Anatomical considerations and clinical implications for mitral isthmus block after vein of Marshall ethanol infusion. Heart Rhythm 2021; 18:1951-1958. [PMID: 34217842 DOI: 10.1016/j.hrthm.2021.06.1202] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/20/2021] [Accepted: 06/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mitral isthmus gaps have been ascribed to an epicardial musculature anatomically related to the great cardiac vein (GCV) and the vein of Marshall (VOM). Their lumen offers an access for radiofrequency application or ethanol infusion, respectively. OBJECTIVE The purpose of this study was to evaluate the frequency of mitral isthmus gaps accessible via the GCV lumen, to assess their location around the GCV circumference, and to propose an efficient ablation strategy when present. METHODS One hundred consecutive patients underwent VOM ethanol infusion (step 1) and endocardial linear ablation from the mitral annulus to the left inferior pulmonary vein (step 2). In cases of mitral isthmus gap, endovascular ablation of the GCV anchored wall facing the left atrium was systematically performed (step 3), while the opposite GCV free wall was targeted in case of block failure only (step 4). RESULTS After VOM ethanol infusion and endocardial ablation, mitral isthmus block occurred in 51 patients (51%). Pacing maneuvers and activation sequences demonstrated an epicardial gap via the VOM in 2 patients (2%) and via the GCV in 47 patients (47%). In the latter case, block was achieved at the GCV anchored wall in 42 patients (89%) and the GCV free wall in 5 patients (11%). Global success rate of mitral isthmus block was 98%. No tamponade occurred. CONCLUSION With the advent of VOM ethanol infusion, residual mitral isthmus gaps are mostly eliminated within the first centimeter of the GCV. Thorough mapping of the entire circumference of the GCV wall can help identify these epicardial gaps.
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Affiliation(s)
- Thomas Pambrun
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France.
| | - Nicolas Derval
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Arnaud Denis
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Rémi Chauvel
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Romain Tixier
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Nicolas Welte
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Clémentine André
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Takashi Nakashima
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Yosuke Nakatani
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Tsukasa Kamakura
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Takamitsu Takagi
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - F Daniel Ramirez
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Philipp Krisai
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Cyril Goujeau
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Konstantinos Vlachos
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Félix Bourier
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Masateru Takigawa
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Takeshi Kitamura
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Antonio Frontera
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Michel Haïssaguerre
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
| | - Pierre Jaïs
- Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Benjamin J Scherlag
- Division of Cardiovascular Services, Department of Medicine, The Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma.
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Sławek-Szmyt S, Szmyt K, Żaba C, Grygier M, Lesiak M, Araszkiewicz A. Peculiarities in coronary sinus anatomy: implications for successful cannulation from an autoptic study. Europace 2021; 23:1787-1794. [PMID: 33864081 PMCID: PMC8576278 DOI: 10.1093/europace/euab108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 04/02/2021] [Indexed: 11/23/2022] Open
Abstract
Aims The number of cardiovascular procedures using the coronary sinus (CS) as a gateway is constantly increasing. The present study aimed to define specific structures within CS, which could potentially complicate CS cannulation and to develop a new Thebesian valve (TV) classification system. Methods and results The study was performed on 560 consecutive unfixed cadaveric hearts during routine autopsy examination (1–3 days post-mortem). Basic CS dimensions were measured and the presence and dimensions of the TV and the Vieussens valve (VV) were assessed. Thebesian valves were classified according to their morphology into six main types: remnant fold, semilunar, fenestrated, chord, fused strands, and mixed shaped. The median age of hearts was 48 years (range 16–95 years), and 38.9% were female. Thebesian valve was present in 79.5%. The most common TV type was semilunar (54%) followed by fenestrated (8.2%), remnant fold (5.5%), fused strands (4.8%), chord (4.0%), and mixed shaped (3.0%). In 1.1% of hearts, TV totally covered the coronary sinus ostium (CSO). The VV was detected in 67.9%. Potentially occlusive VV was found in 1.1% hearts and in all of which it coexisted with obstructive TV. The median CSO area was 87.9 mm2 [interquartile range (IQR): 56.5–127.1 mm2] and median CS length was 38 mm (IQR: 29.5–45 mm). The CSO area and CS length correlated with each other and with the right atrium’s dimensions. Conclusion We identified six types of TVs, among which only 1.1% TVs caused total occlusion of CSO. The obstructive TV co-existed with potentially occlusive VV what might hinder CS cannulation.
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Affiliation(s)
- Sylwia Sławek-Szmyt
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848 Poznan, Poland
| | - Krzysztof Szmyt
- Department of General, Endocrine and Gastrointestinal Oncology Surgery, Poznan University of Medical Sciences, Przybyszewski Street 49, 60-355 Poznan, Poland
| | - Czesław Żaba
- Department of Forensic Medicine, Poznan University of Medical Sciences, Swiecicki Street 6, 60-789 Poznan, Poland
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848 Poznan, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848 Poznan, Poland
| | - Aleksander Araszkiewicz
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848 Poznan, Poland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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20
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Takagi T, Pambrun T, Nakashima T, Vlachos K, André C, Krisai P, Ramirez FD, Kamakura T, Nakatani Y, Cheniti G, Tixier R, Chauvel R, Duchateau J, Sacher F, Cochet H, Hocini M, Haïssaguerre M, Jaïs P, Derval N. Significance of manifest localized staining during ethanol infusion into the vein of Marshall. Heart Rhythm 2021; 18:1057-1063. [PMID: 33741483 DOI: 10.1016/j.hrthm.2021.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Localized staining due to venule injury is attributable to ethanol infusion into the vein of Marshall (Et-VOM). OBJECTIVE The purpose of this study was to investigate adverse outcomes of localized staining during Et-VOM in patients undergoing ablation for atrial fibrillation. METHODS Two hundred four patients (age 64 ± 10 years; 153 male) were sorted based on the aspect of localized staining. Staining of atrial myocardium that spread uniformly along the VOM vascular tree following selective VOM venography was considered normal, in contrast to predominantly localized staining that spread concentrically from a focal point due to vascular injury. Outcomes between the 2 groups were compared. RESULTS Localized staining was observed in 27% of patients. No patients developed clinically significant pericardial effusions during Et-VOM; however, 7 patients developed pericardial effusions on the first postprocedural day (3.6% in patients with vs 3.4% in patients without localized staining). No significant difference was found in achievement of acute mitral isthmus (MI) block (96% vs 98%) and size of the endocardial low-voltage area (8.5 ± 4.1 cm2 vs 9.3 ± 5.3 cm2) in patients with and without localized staining, respectively. Long-term follow-up was not impacted by localized staining. Freedom from recurrent atrial tachyarrhythmias (66% vs 76%) and durability of MI block (57% vs 54%) were not significantly different with and without localized staining. There were no cases of rehospitalization for pericarditis, chronic pericardial effusion, or heart failure. CONCLUSION In our study, localized staining was frequent but was not associated with clinically relevant impact or disadvantages.
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Affiliation(s)
- Takamitsu Takagi
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France.
| | - Thomas Pambrun
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Takashi Nakashima
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Konstantinos Vlachos
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Clémentine André
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Philipp Krisai
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - F Daniel Ramirez
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Tsukasa Kamakura
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Yosuke Nakatani
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Romain Tixier
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Remi Chauvel
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Hubert Cochet
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Michel Haïssaguerre
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Pierre Jaïs
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Nicolas Derval
- Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
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21
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Krisai P, Pambrun T, Nakatani Y, Nakashima T, Takagi T, Kamakura T, André C, Cheniti G, Tixier R, Chauvel R, Duchateau J, Sacher F, Haïssaguerre M, Cochet H, Jaïs P, Derval N, Hocini M. How to perform ethanol ablation of the vein of Marshall for treatment of atrial fibrillation. Heart Rhythm 2021; 18:1083-1087. [PMID: 33601037 DOI: 10.1016/j.hrthm.2021.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/03/2021] [Accepted: 02/06/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Philipp Krisai
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France.
| | - Thomas Pambrun
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Yosuke Nakatani
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Takashi Nakashima
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Takamitsu Takagi
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Tsukasa Kamakura
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Clémentine André
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Ghassen Cheniti
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Romain Tixier
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Rémi Chauvel
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Josselin Duchateau
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Frédéric Sacher
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Michel Haïssaguerre
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Hubert Cochet
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Pierre Jaïs
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Nicolas Derval
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Mélèze Hocini
- Electrophysiology and Ablation Unit and LIRYC, CHU de Bordeaux, Bordeaux-Pessac, France
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22
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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: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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23
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Derval N, Duchateau J, Denis A, Ramirez FD, Mahida S, André C, Krisai P, Nakatani Y, Kitamura T, Takigawa M, Chauvel R, Tixier R, Pillois X, Sacher F, Hocini M, Haïssaguerre M, Jaïs P, Pambrun T. Marshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation (Marshall-PLAN): Prospective, single-center study. Heart Rhythm 2020; 18:529-537. [PMID: 33383226 DOI: 10.1016/j.hrthm.2020.12.023] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Beyond pulmonary vein isolation (PVI), the optimal ablation strategy for persistent atrial fibrillation (AF) remains poorly defined. OBJECTIVE The purpose of this study was to examine a novel comprehensive ablation strategy (Marshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation [Marshall-PLAN]) strictly based on anatomical considerations. METHODS Left atrial (LA) sites were sequentially targeted as follows: (1) coronary sinus and vein of Marshall (CS-VOM) musculature; (2) PVI; and (3) anatomical isthmuses (mitral, roof, and cavotricuspid isthmus [CTI]). The primary endpoint was 12-month freedom from AF/atrial tachycardia (AT). RESULTS Seventy-five consecutive patients were included (age 61 ± 9 years; 10 women; AF duration 9 ± 11 months; mean LA volume 197 ± 43 mL). VOM ethanol infusion was completed in 69 patients (92%). The full Marshall-PLAN lesion set (VOM, PVI, mitral, roof, and CTI with block) was successfully completed in 68 patients (91%). At 12 months, 54 of 75 patients (72%) were free from AF/AT after a single procedure (no antiarrhythmic drugs) in the overall cohort. In the subset of patients with a complete Marshall-PLAN lesion set (n = 68), the single procedure success rate was 79%. After 1 or 2 procedures, 67 of 75 patients (89%) remained free from AF/AT (no antiarrhythmic drugs). After 1 or 2 procedures, VOM ethanol infusion was complete in 72 of 75 patients (96%). CONCLUSION A novel ablation strategy that systematically targets anatomical atrial structures (VOM ethanol infusion, PVI, and prespecified linear lesions) is feasible, safe, and associated with a high rate of freedom from arrhythmia recurrence at 12 months in patients with persistent AF.
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Affiliation(s)
- Nicolas Derval
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France.
| | - Josselin Duchateau
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Arnaud Denis
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - F Daniel Ramirez
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - Saagar Mahida
- Liverpool Centre for Cardiovascular Science and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Clémentine André
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - Philipp Krisai
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - Yosuke Nakatani
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - Takeshi Kitamura
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - Masateru Takigawa
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - Remi Chauvel
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - Romain Tixier
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
| | - Xavier Pillois
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Michel Haïssaguerre
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Pierre Jaïs
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France
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Margato R, Tampakis K, Albenque JP, Combes S. Illuminating the Marshall: novel techniques highlighted in an atrial tachycardia case report. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 32974439 DOI: 10.1093/ehjcr/ytaa229] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/17/2020] [Accepted: 06/25/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Electroanatomic mapping is usually required in order to obtain a precise diagnosis and guide the ablation of atrial tachycardias (ATs) after ablation for atrial fibrillation (AF). However, epicardial connections may limit the interpretation of the endocardial activation sequence as well as the efficacy of endocardial radiofrequency ablation. CASE SUMMARY A 53-year-old man with history of AF ablation 2 years ago was admitted for ablation of a recurrent AT (cycle length 275 ms). Ultra-high-density mapping with the Rhythmia™ system revealed a challenging activation map with two focal points of early activation in the left atrium. The use of an advanced mapping software allowed the rapid reanalysis and reannotation of the activation map and suggested epicardial involvement of the Marshall bundle (MB). Subsequent ethanol infusion in the vein of Marshall (VOM) immediately terminated the tachycardia. Six months post-ablation, the patient had no recurrence of arrhythmias. DISCUSSION This case highlights the role of novel diagnostic and treatment methods in the management of a post-AF ablation AT. By developments in cardiac mapping systems, the rapid editing of a high-density activation map and clarification of the arrhythmia origin can be facilitated overcoming the limitations of conventional techniques. Moreover, ethanol infusion in the VOM was shown to be an effective alternative method in the management of MB-related tachycardias.
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Affiliation(s)
- Renato Margato
- Rhythmology Department, Clinique Pasteur, 45, avenue de Lombez BP 27617, 31076 Toulouse, France
| | - Konstantinos Tampakis
- Rhythmology Department, Clinique Pasteur, 45, avenue de Lombez BP 27617, 31076 Toulouse, France
| | - Jean Paul Albenque
- Rhythmology Department, Clinique Pasteur, 45, avenue de Lombez BP 27617, 31076 Toulouse, France
| | - Stephane Combes
- Rhythmology Department, Clinique Pasteur, 45, avenue de Lombez BP 27617, 31076 Toulouse, France
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25
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Affiliation(s)
- Tadashi Hoshiyama
- Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan
| | - Keiichi Ashikaga
- Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan
| | - Kana Nakashima
- Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoshisato Shibata
- Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan
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26
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Chugh A, Gurm HS, Krishnasamy K, Saeed M, Lohawijarn W, Hornsby K, Cunnane R, Ghanbari H, Latchamsetty R, Crawford T, Jongnarangsin K, Bogun F, Oral H, Morady F. Spectrum of atrial arrhythmias using the ligament of Marshall in patients with atrial fibrillation. Heart Rhythm 2018; 15:17-24. [PMID: 28765086 DOI: 10.1016/j.hrthm.2017.07.033] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The role of the ligament of Marshall (LOM) in patients with atrial fibrillation (AF) has not been well defined. OBJECTIVE The purpose of this study was to describe the role of the LOM in patients with AF and related arrhythmias. METHODS Fifty-six patients (mean age 63 ± 11 years; persistent AF in 48 [86%]; ejection fraction 0.49 ± 0.13; left atrial diameter 4.7 ± 0.6 cm) with LOM-mediated arrhythmias were included. RESULTS A LOM-pulmonary vein (PV) connection was present in 18 patients (32%) and was eliminated with radiofrequency (RF) ablation at the left lateral ridge or crux (n = 12), at the mitral annulus (n = 3), or with alcohol/ethanol (EtOH) ablation of the vein of Marshall (VOM; n = 3). A LOM-mediated atrial tachycardia (AT) was present in 13 patients (23%). Thirty-one patients with refractory mitral isthmus conduction were referred for potential EtOH ablation. In the 6 patients in whom VOM was injected during perimitral reentry, EtOH resulted in slowing in 3 patients and termination in 1 patient. In others, EtOH infusion resulted in complete isolation of the left-sided PVs and left atrial appendage. Repeat RF and adjunctive EtOH ablation of the VOM tended to be more effective in creating conduction block across the mitral isthmus than RF ablation alone (P = .057). CONCLUSION The LOM is responsible for a variety of arrhythmia mechanisms in patients with AF and atrial tachycardia. It may be ablated at any point along its course, at the mitral annulus, at the lateral ridge/PV antrum, and epicardially in the coronary sinus and the VOM itself. EtOH ablation of the VOM may be an adjunctive strategy in patients with refractory perimitral reentry.
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27
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Kashimura S, Nishiyama T, Kimura T, Nishiyama N, Aizawa Y, Takatsuki S. Vein of Marshall partially isolated with radiofrequency ablation from the endocardium. HeartRhythm Case Rep 2017; 3:120-123. [PMID: 28491784 PMCID: PMC5420049 DOI: 10.1016/j.hrcr.2016.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Shin Kashimura
- Department of Cardiology, Keio University Hospital, Tokyo, Japan
| | | | - Takehiro Kimura
- Department of Cardiology, Keio University Hospital, Tokyo, Japan
| | | | - Yoshiyasu Aizawa
- Department of Cardiology, Keio University Hospital, Tokyo, Japan
| | - Seiji Takatsuki
- Department of Cardiology, Keio University Hospital, Tokyo, Japan
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28
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Affiliation(s)
- Moisés Rodríguez-Mañero
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Paul Schurmann
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas.
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29
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Hojo R, Fukamizu S, Kitamura T, Maeno K, Hiraoka M, Sakurada H. Pseudo-conduction block at the mitral isthmus in a patient with epicardial impulse propagation through the vein of Marshall. HeartRhythm Case Rep 2015; 1:232-237. [PMID: 28491556 PMCID: PMC5419419 DOI: 10.1016/j.hrcr.2015.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Key Words
- AT, atrial tachycardia
- Atrial tachycardia
- CS, coronary sinus
- Differential pacing
- ECG, electrocardiogram
- LA, left atrium
- LAA, left atrial appendage
- LPV, left pulmonary vein
- MI, mitral isthmus
- PPI, post-pacing interval
- PVI, pulmonary vein isolation
- Ridge-related reentry
- TCL, tachycardia cycle length
- VOM, vein of Marshall
- Vein of Marshall
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Affiliation(s)
- Rintaro Hojo
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Takeshi Kitamura
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Kenichi Maeno
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Masayasu Hiraoka
- Department of Health Examination, Toride Kitasohma Medical Center Hospital, Ibaraki, Japan
| | - Harumizu Sakurada
- Ohkubo Hospital, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
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30
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Affiliation(s)
- Takehiko Keida
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan.
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