Distribution of atrial low voltage induced by vein of Marshall ethanol infusion

Abstract

Introduction Systematic and quantitative descriptions of vein of Marshall (VOM)‐induced tissue ablation are lacking. We sought to characterize the distribution of low voltage observed in the left atrium (LA) after VOM ethanol infusion. Methods and Results The distribution of ethanol‐induced low voltage was evaluated by comparing high‐density maps performed before and after VOM ethanol infusion in 114 patients referred for atrial fibrillation ablation. The two most frequently impacted segments were the inferior portion of the ridge (82.5%) and the first half of the mitral isthmus (pulmonary vein side) (92.1%). Low‐voltage absence in these typical areas resulted from inadvertent ethanol infusion in the left atrial appendage vein (n = 3), initial VOM dissection (n = 3), or a “no branches” VOM morphology (n = 1). Visible anastomosis of the VOM with roof or posterior veins more frequently resulted in low‐voltage extension beyond typical areas, toward the entire left antrum (19.0% vs. 1.9%, p = .0045) or the posterior LA (39.7% vs. 3.8%, p < .001) but with a limited positive predictive value ranging from 29.4% to 43.5%. Ethanol‐induced low voltage covered a median LA surface of 3.6% (1.9%–5.0%) and did not exceed 8% of the LA surface in 90% of patients. Conclusion VOM ethanol infusion typically locates at the inferior ridge and the adjacent half of the mitral isthmus. Low‐voltage extensions can be anticipated but not guaranteed by the presence of visible anastomosis of the VOM with roof or posterior veins.

The adjunctive effect for left pulmonary vein isolation of vein of Marshall ethanol infusion in persistent atrial fibrillation

“…The regions intervened by ethanol was dependent on the anatomical distribution of the branches of the VOM. 18 (2) The connections between VOM and left PV: There are abundant junctions between VOM and left PV. Some of the branching courses of the VOM insert into the PV directly from epicardial access.…”

Ethanol Infusion of Vein of Marshall for the Treatment of Persistent Atrial Fibrillation: The Basics and Clinical Practice

“…In terms of the limitations of VOM ethanol infusion, we should be cautious about its utility in PeAF ablation. Firstly, the anatomical course of the VOM determines the lesion sites and VOM ethanol infusion areas [ 48 ]. Based on this, the mitral annular side of the MI is usually beyond the lesion region of VOM ethanol infusion ( Figure 4 G,H).…”

The coronary sinus Marshall structure: From an anatomical ligament to an arrhythmogenic vein

“…It is one of the most important findings of this study that successful VOM ethanol infusion in conjunction with radiofrequency ablation within the CS (in all patients) was able to achieve bidirectional block of the mitral isthmus in 97%, a result that virtually promises a guarantee of bidirectional block of the most challenging linear lesion in the human atria. The strength of the presented study by Kamakura et al 9 is that it provides important new data on the distribution of lesion sets specifically induced by VOM ethanol infusion in a large cohort of patients with persistent AF. Moreover, the authors identified a distinct fingerprint lesion pattern of VOM ethanol infusion that is observed in almost all patients undergoing successful VOM ethanol infusion.…”

“…The strength of the presented study by Kamakura et al 9 is that it provides important new data on the distribution of lesion sets specifically induced by VOM ethanol infusion in a large cohort of patients with persistent AF. Moreover, the authors identified a distinct fingerprint lesion pattern of VOM ethanol infusion that is observed in almost all patients undergoing successful VOM ethanol infusion.…”

“…In the current issue of the journal, Kamakura et al 9 provide a comprehensive analysis of the amount and distribution of low voltage atrial tissue induced exclusively by VOM ethanol infusion. In a total number of 114 patients undergoing de novo ablation for persistent AF, a high‐density CARTO map obtained by a multipolar catheter (Pentaray, Biosense Webster) was created before and after the VOM procedure with a mean of more than 1.000 points.…”