Catheter Ablation of an Accessory Pathway within the Marshall Vein in a Patient with Mechanical Mitral Valve

Abstract

A 37-year-old man, known case of mitral valve replacement, was referred for ablation. Meticulous mapping showed the earliest signal in the distal coronary sinus (CS). Endocardial ablation via transseptal approach failed to permanently ablate the accessory pathway. Similarly, ablation within the CS was unsuccessful. Finally, the mapping catheter was introduced into the vein of Marshall (VoM) and a very early signal was obtained. In the first 3 seconds of the radiofrequency energy application within the VoM, delta wave disappeared. During 1-year follow-up, the patient had no recurrence of the palpitations and electrocardiogram showed no delta wave.

Radiofrequency catheter ablation of accessory pathways at the site of prior valve surgery

“…The registry‐VS subgroup included four patients (prevalence, 0.1%; age, 37.0 [25.8‐47.5] years; men, 3/4) who underwent RFCA for APs at the site of prior VS and were listed in the RFCA registry. The historical‐VS subgroup included five patients (age, 32.0 [20.5‐44.5] years; men, 1/5) who underwent RFCA for APs at the site of prior VS and were described in previously published case reports . The no‐VS group included 196 patients (age, 40.5 [23.0‐54.0] years; men, 114/196) without a history of VS who underwent RFCA for APs during the year leading up to the study at the same electrophysiological laboratory as the patients in the RFCA registry.…”

“…A 37‐year‐old male patient (No. 4) who had undergone MVR was referred for WPW syndrome . In an electrophysiological study, AVRT using manifest AP at the distal CS was induced.…”

“…To select suitable patients, we retrospectively reviewed the RFCA registry data of patients (age ≥ 15 years) with APs treated between January 2004 and June 2018 at Severance Hospital or Asan Medical Center, which are large‐volume university hospitals in Seoul, Korea; patients who received RFCA for APs at the site of previous VS were included in the registry‐VS subgroup. In addition, we searched the literature for case reports describing patients who received RFCA for APs at the site of previous VS, and included such patients in the historical‐VS group of the total‐VS group. The no‐VS group included patients with structurally normal heart and without a history of VS, who underwent RFCA for APs during the year leading up to the study in the same electrophysiological laboratory as the patients in the registry‐VS subgroup.…”

“…The medical records, operation records, echocardiographic reports, electrophysiological reports, intracardiac electrograms and fluoroscopic images stored in the RFCA registry were reviewed. For patients in the historical‐VS group, we carefully reviewed all information included in the published case reports . Major complications were defined as atrioventricular block; cardiac perforation or tamponade; stroke or transient ischemic attack; and vascular access complications such as hematoma, pseudoaneurysm, and arteriovenous fistula that required transfusion or surgical procedures.…”

“…However, in patients with valvular heart disease, RFCA of APs is challenging, especially if the AP is located at a valve annulus that has undergone replacement or repair. The optimal strategy for RFCA of APs at the site of prior valve surgery (VS) remains unclear, as very few case reports on this have been published to date . We aimed to clarify the factors associated with successful RFCA for such APs.…”