Feasibility, efficacy, and safety of ethanol infusion into the vein of Marshall for atrial fibrillation: A meta‐analysis

Abstract

Background Contemporary radiofrequency catheter ablation (RFCA) approaches for atrial fibrillation (AF) have reached an efficacy “ceiling”. Ethanol infusion into the vein of Marshall (EI‐VOM) has shown potential in preliminary studies. Data on EI‐VOM are largely limited to small single‐center reports, and clinical benefits and risks have not been systematically examined. Therefore, we performed a meta‐analysis to assess the feasibility, efficacy, and safety of EI‐VOM for AF. Methods All studies evaluating EI‐VOM for AF were initially searched from four electronic search engines: PubMed, Web of Science, Cochrane Library, and SinoMed. We used RevMan5.4 to calculate pooled outcomes of randomized controlled trial and cohort studies. We also performed single‐arm meta‐analyses using Open Meta‐Analyst. Results We included a total of 10 studies with 1322 patients. Successful EI‐VOM was performed in 86.7% (95% CI 81.9–91.4%) of patients. For persistent AF patients, the recurrence of AF and/or atrial tachycardia (AT) was significantly lower in the EI‐VOM combined with RFCA group compared with RFCA alone group (RR 0.58, 95% CI 0.35 to 0.96, p = 0.04). EI‐VOM combined with RFCA significantly increased the rate of bidirectional mitral isthmus block compared with RFCA alone in AF patients (RR 1.50, 95% CI 1.34 to 1.67, p < 0.001). There were nine cardiac tamponades observed in 644 patients (PR 0.8%, 95% CI 0.1–1.5%) who were performed EI‐VOM combined with RFCA. Conclusions Our meta‐analysis brings encouraging evidence that adjuvant EI‐VOM reduces AF and/or AT recurrence rate in persistent AF patients and increases the success rate of bidirectional mitral isthmus block.

The Long-Term Outcomes of Ablation With Vein of Marshall Ethanol Infusion vs. Ablation Alone in Patients With Atrial Fibrillation: A Meta-Analysis

“…For safety, our analysis showed no increased risk of pericardial effusion, stroke/TIA, and all-cause death between the two groups. These results are similar to previous studies (6,7), further suggesting that VOM-ABL had a good performance on efficacy and safety in AF patients with long-term follow-up.…”

“…Recently, a randomized, multiple-center trial (VENUS trial, NCT01898221) had indicated that compared with catheter ablation alone, catheter ablation with VOM ethanol infusion increased the likelihood of freedom from AF/AT for PeAF with one-year follow-up (6). Moreover, a meta-analysis conducted by He et al (7) also revealed that VOM-ABL procedure was feasible, effective, and safe by reducing AF/AT recurrence rate without increasing the risk of cardiac tamponade and pericardial effusion. However, challenges still remained, which included few studies providing reliable conclusion due to short-term follow-up (less than one-year) (24,25), limited to case reports (26,27) and lack of control group (single-arm study) (28)(29)(30).…”

“…VENUS trial had revealed that compared to ablation alone, ablation with VOM ethanol infusion (VOM-ABL) increased the likelihood of freedom from AF/AT for persistent AF (PeAF) with one-year follow-up (6). A recent meta-analysis showed that the VOM-ABL procedure is feasible, effective, and safe for AF patients (7). Interestingly, a recent secondary analysis of the VENUS trial revealed that successful MI block and high-volume center were two important determinants for VOM-ABL procedure (8).…”

Simplified stepwise anatomical ablation strategy for mitral isthmus: efficacy, efficiency, safety, and outcome

“…Ethanol infusion of the VOM exhibited a higher success rate of MI block, from 80 to 100%, and has been widely accepted recently. 4 , 9 , 14 However, because the VOM could not be identified or cannulated in some cases, ethanol infusion of VOM was completed only in 84–92% patients. 4–6 , 10 …”

“…However, ethanol infusion of the VOM might fail in some cases due to variations in VOM anatomy. 4 , 5 , 9 , 10 Based on our experience, we found that endocardial plus epicardial ablation within the CS to isolate the CS has the potential to yield a high success rate for MI block. This represents a simple anatomical ablation strategy with minimal fluoroscopy exposure.…”