Atrial Tachycardias Utilizing the Ligament of Marshall Region Following Single Ring Pulmonary Vein Isolation for Atrial Fibrillation

Abstract

We identified a pattern of arrhythmias involving a concealed presystolic component and a broad endocardial breakout site related to the LOM region. Successful ablation site involved careful identification of small diastolic potentials in the LAA/ridge region or adjacent to the coronary sinus.

Ligament and vein of Marshall: A therapeutic opportunity in atrial fibrillation

“…Chik et al 24 described 5 patients with tachycardia involving the LOM region in a sample of 240 patients who underwent a “single ring” PV isolation ablation. Of note, both focal non-reentrant mechanisms 8, 17 and also macro-reentry electrical connections between the LOM/VOM and left atrial myocardium could underlie these arrhythmias 25 .…”

Sequential Percutaneous LAA Ligation and Pulmonary Vein Isolation in Patients with Persistent AF: Initial Results of a Feasibility Study

“…LAA ligation has been shown to result in an ischemic necrosis that leads to a transmural lesion and fibrosis around orifice of LAA and LA . The combination of LAA ligation and more extensive ablation of the left lateral ridge may affect epicardial structures, including the ligament of Marshall and autonomic ganglia plexi that lie between the LUPV and LAA within 3 mm from the endocardial surface . Disruption of the ligament of Marshall and autonomic nerve bundles may contribute to improved AF ablation outcomes …”

Preferential properties with decremental conduction of the Marshall vein between the coronary sinus and left superior pulmonary vein

“…Conduction delay may be caused by a complex fiber arrangement, abrupt changes in fiber directions, and anisotropic conduction 7 . In addition to these preexisting pathologic conditions, the anatomic boundaries and secondary slow conduction due to the extensive lines are likely to further promote circumstances that can maintain the development of a microreentrant and macroreentrant AT 3, 8, 9, 10…”