Ethanol infusion for Marshall bundle epicardial connections in Marshall bundle‐related atrial tachycardias following atrial fibrillation ablation: The accessibility and success rate of ethanol infusion by using a femoral approach

Abstract

Background Ethanol infusion of the vein of Marshall (VOM) may be effective to treat Marshall bundle‐related atrial tachycardia (MB‐AT). However, methods and clinical results of ethanol infusion for MB‐AT have been not established. Objective To assess the accessibility of the VOM and the success rate of ethanol infusion using a femoral approach for MB‐AT. Methods A single‐center observational study included consecutive patients who had MB‐AT and in whom we attempted to treat MB‐AT during AT by ethanol infusion. When the VOM was able to be cannulated following VOM venogram using a femoral approach, we systematically performed ethanol infusion with selective balloon occlusion of the VOM. We analyzed in detail the efficacy of ethanol infusion of VOM in patients who were in MB‐AT during ethanol infusion. Results We enrolled 54 consecutive patients in whom we attempted to treat MB‐AT by ethanol infusion. Of those, the VOM was accessible in 92.5% of patients (50 of 54). Of the 50 patients treated by ethanol infusion during MB‐AT, AT was successfully terminated in 56% percent of the patients (28 of 50) by solo treatment of ethanol infusion without RF ablation. The remainder required additional RF application to terminate the MB‐AT. A mean of 6.2 ± 2.8 mL of ethanol was infused resulting in the low‐voltage area significantly larger than that before ethanol infusion (12.7 ± 8.3 vs 6.6 ± 5.3 cm2, P < .001). Conclusion The present study demonstrated that the VOM was highly accessible and MB‐AT was amenable to treatment by ethanol infusion by using a femoral approach.

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

“…Reported complications of VOM-EI include vascular access complications, pericardial effusion, pericarditis, VOM dissection and volume overload. 10,11,13 In our population of patients with intended VOM-EI, we observed pericardial effusion/pericarditis in four patients (18%) and VOM dissection in two (9%), all of which resolved without additional interventions. We performed echocardiography the day after VOM-EI in 86% of patients, irrespective of symptom status.…”

“…7 Kitamura et al adapted the technique for femoral access using a LIMA guiding catheter introduced into a steerable sheath, with successful injection of ethanol in 92.6% of cases. 10 Other groups reported successful VOM-EI rates of 73.4-92%. 11,13,14 .…”

“…The technique of VOM-EI has been described elsewhere. 10 In brief, we cannulated the CS with an 8.5 Fr steerable sheath (Agilis NXT, Abbott Inc, St. Paul, MN) and placed a 6-Fr left internal mammary artery (LIMA) guiding catheter into the great cardiac vein. In a right anterior oblique view, we performed angiography to localize the ostium of the VOM.…”

“…8,9 Subsequently, other groups adopted and refined the technique of VOM-EI for mitral isthmus ablation with high success rates. 10 Linear ablation of the mitral isthmus is an additional target of ablation of persistent atrial fibrillation, and VOM-EI may be used in these patients. The recent VENUS-trial, a prospective multicentre randomized study, showed improved arrhythmia-free outcome in patients with persistent atrial fibrillation treated with catheter ablation with supplement ethanol infusion into the vein of Marshall.…”

A bumped atrial tachycardia due to guidewire manipulation in the vein of Marshall before ethanol infusion

“…Only then, alcohol was injected as previously described (3 injections of 3 mL of 98% ethanol). 5 After 20 minutes of waiting time, the bilateral MI block remained, and no AT could be induced using atrial stimulation.…”