Clinical impact of ethanol infusion into the vein of Marshall on the mitral isthmus area evaluated by atrial electrograms recorded inside the coronary sinus

Kawaguchi, Naohiko; Okishige, Kaoru; Yamauchi, Yasuteru; Kurabayashi, Manabu; Nakamura, Tomofumi; Keida, Takehiko; Sasano, Tetsuo; Hirao, Kazuyuki; Valderrábano, Miguel

doi:10.1016/j.hrthm.2019.01.031

Cited by 24 publications

(35 citation statements)

References 22 publications

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“…Other groups described comparable results of mitral isthmus block in 98.7-100% of cases. 10,13,16 Importantly, ancillary radiofrequency ablation was necessary in 63% of our patients, mainly on the annular side of the mitral isthmus both endocardially and epicardial from within the CS. As previously described and expected for anatomical reasons, the main impact of VOM-EI is on the pulmonary venous side of the mitral isthmus, sparing the annular aspect.…”

Section: Efficacy Of Vom-eimentioning

confidence: 90%

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Efficacy and safety of ethanol infusion into the vein of Marshall for mitral isthmus ablation

Lam

Kueffer

Hunziker

et al. 2021

Preprint

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Introduction: Chemical ablation by retrograde infusion of ethanol into the vein of Marshall (VOM-EI) can facilitate achievement of mitral isthmus block. This study sought to describe efficacy and safety of this technique. Methods and Results: Twenty-two consecutive patients (14 male, median age 71 years) with attempted VOM-EI for mitral isthmus ablation were included in the study. VOM-EI was successfully performed with a median of 4 ml of 96% ethanol in 19 patients (86%) and mitral isthmus was successfully blocked in all (100%). Touch up endocardial and/or epicardial ablation after VOM-EI was necessary in 12 patients (63%). Perimitral flutter was present in 12 patients (63%) during VOM-EI and terminated or slowed by VOM-EI in four and three patients, respectively. Low-voltage area of the mitral isthmus region increased from 3.1 cm2 (IQR 0-7.9) before to 13.2 cm2 (IQR 8.2-15.0) after VOM-EI and correlated significantly with the volume of ethanol injected (P = 0.03). Median high-sensitive cardiac troponin-T increased significantly from 330 ng/L (IQR 221-516) the evening of the procedure to 598 ng/L (IQR 382-769; P=0.02) the following morning. A small pericardial effusion occurred in three patients (16%), mild pericarditis in one (5%) and uneventful VOM dissection in two (11%). After a median follow-up of 3.5 months (IQR 3.0-11.0), 10 of 18 patients (56%) with VOM-EI and available follow-up had arrhythmia recurrence. Repeat ablation was performed in five patients (50%) and peri-mitral flutter diagnosed in three (60%). Conclusion: VOM-EI is feasible, safe and effective to achieve acute mitral isthmus block

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Section: Efficacy Of Vom-eimentioning

confidence: 90%

“…10 Other groups reported successful VOM-EI rates of 73.4-92%. 11,13,14 . Using the same approach, we successfully achieved VOM-EI in comparable 86% of cases.…”

Section: Feasibility and Safety Of Vom-eimentioning

confidence: 99%

Efficacy and safety of ethanol infusion into the vein of Marshall for mitral isthmus ablation

Lam

Kueffer

Hunziker

et al. 2021

Preprint

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“…The procedural steps for retrograde infusion of ethanol in the VOM have been described in detail by Valderrábano et al (Figure 4). 18,19,36–38 Firstly, CS venogram is performed by direct contrast injection or a balloon occlusion to assess the presence or absence of VOM after a successful CS cannulation via the right internal jugular vein, femoral vein, or left subclavian vein. Secondly, subselective cannulation of the VOM is performed using a left internal mammary artery angioplasty guide catheter or a subselective catheter for CS branch cannulation.…”

Section: Targeting the Lom For Ablationmentioning

confidence: 99%

“…In 21 patients undergoing de novo VOM ethanol infusion, five patients had bidirectional MI block achieved solely by VOM ethanol infusion without radiofrequency ablation. A recent study by Kawaguchi et al 38 showed that in 31 patients with successful ethanol infusion into VOM, the connection between left atrial myocardium and CS musculature was successfully ablated in 19 patients. Combined ethanol infusion with radiofrequency ablation created bidirectional conduction block at the MI in 78/84 patients (93%).…”

Section: Targeting the Lom For Ablationmentioning

confidence: 99%

The ligament of Marshall and arrhythmias: A review

Wang

Zhao

et al. 2020

Pacing Clinical Electrophis

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The ligament of Marshall (LOM) is a remnant of the embryonic sinus venosus and left cardinal vein, and contains fat and fibrous tissues, blood vessels, muscle bundles, nerve fibers, and ganglia. The complexity of LOM's structure makes it as a source of triggers and drivers as well as substrates of re‐entry for atrial arrhythmias, especially for atrial fibrillation (AF). LOM also serves as a portion of left atrial macro‐re‐entrant circuit, especially peri‐mitral isthmus re‐entrant circuit. Experimental studies demonstrate that the LOM acts as a sympathetic conduit between the left stellate ganglion and the ventricles, and participates in the initiation and maintenance of ventricular arrhythmias. Endocardial or epicardial catheter ablation or ethanol infusion into the vein of Marshall may serve as an important adjunct therapy to pulmonary vein isolation in patients with advanced stage of AF, and may help alleviate ventricular arrhythmias as well.

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“…It is critical for any technique to have validation beyond its original proponents. Multiple groups have reproduced the VOM ethanol technique safely . Questions remain as to the outcomes when applied to unselected AF patient populations.…”

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confidence: 99%

Improving ablation results in persistent AF: Is ethanol the answer?

Valderrábano

2019

Cardiovasc electrophysiol

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Disclosures: NonePulmonary vein isolation (PVI) has become established as an effective therapy for paroxysmal atrial fibrillation (AF). The mechanistic basis of PVI, as a strategy to isolate ectopic foci that trigger AF paroxysms, is sound. The therapeutic tools to achieve PVI are robust, and the outcomes, albeit imperfect, are satisfactory. Although PVI failures do exist, the majority are due to technical failures, ie, the inability to achieve durable PVI, and only a relative minority can be attributed to nonpulmonary vein triggers. In essence, the mechanistic paradigm of trigger ablation remains unchallenged for paroxysmal AF. Although purely a temporal-pattern characteristic, paroxysmal AF in its prototypical form occurs in structurally normal hearts, and trigger elimination without extensive substrate modification is generally sufficient.On the other hand, the treatment of nonparoxysmal forms of AF remains challenging. Persistent AF most commonly arises in the context of aged atria, and often coexists with hypertensive heart disease, diabetes, sleep apnea, and other comorbidities. Even in the presence of structurally normal hearts with normal left ventricular ejection fraction, high left atrial pressures, left atrial scar, and varying degrees of diastolic dysfunction are common in persistent AF. By definition, persistent AF patients are in continuous AF for at least a week, but some for months or even years. The coexistence of structural atrial disease and the prolonged temporal persistence are inconsistent with an exclusive relevance of triggers initiating AF, and suggest that a substrate maintaining AF is perhaps a more valid therapeutic target. Identifying accurately such substrate-regions mechanistically involved in the maintenance of AF-has proven extremely difficult. It is likely that no single region is solely responsible for the maintenance of AF, and that interindividual and intraindividual variations in AF maintenance mechanisms exist. Strategies to improve ablation outcomes by extending lesion sets beyond PVI have failed in randomized clinical trials. Reasons may be technical; if ablation lesion sets are incomplete, no benefit is to be expected, but also could be because mechanistically the additional lesions fail to impact AF.Although it is likely that no single or fixed anatomical location can be expected to be a universally valid ablation target, the ligament and vein of Marshall (LOM and VOM) appear plausible contributors to AF generation and maintenance. Located in the epicardial aspect of the left atrial ridge, the VOM colocalizes with abundant sympathetic and parasympathetic innervation that can modulate atrial myocyte physiology to create a profibrillatory state. It has associated complex myocardial architecture with discrete LOM-atrial connections. It can be a source of ectopic AF triggers (for review, see Rodríguez-Mañero et al 1 ). In addition, the VOM is a true atrial vein with direct communication with the underlying myocardium, 2,3 which encompasses the left atrial ridge, and most imp...

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Clinical impact of ethanol infusion into the vein of Marshall on the mitral isthmus area evaluated by atrial electrograms recorded inside the coronary sinus

Cited by 24 publications

References 22 publications

Efficacy and safety of ethanol infusion into the vein of Marshall for mitral isthmus ablation

Efficacy and safety of ethanol infusion into the vein of Marshall for mitral isthmus ablation

The ligament of Marshall and arrhythmias: A review

Improving ablation results in persistent AF: Is ethanol the answer?

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