Ethanol infusion in the vein of Marshall facilitates mitral isthmus ablation

Baez-Escudero, Jose L.; Morales, Percy Francisco; Dave, Amish S.; Sasaridis, Christine; Kim, Young Hoon; Okishige, Kaoru; Valderrábano, Miguel

doi:10.1016/j.hrthm.2012.03.008

Cited by 141 publications

(165 citation statements)

References 32 publications

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“…12, 26, 41, 43 In our in toto experience of 165 patients has an overall success of VOM cannulation and ethanol delivery in 89% (unpublished data). The initial step includes CS cannulation with a suitably large sheath (usually 7F sheath) preferably via the right internal jugular vein, although femoral or left subclavian vein approaches can be successful.…”

Section: Vom Ethanol Infusionmentioning

confidence: 89%

Ligament and vein of Marshall: A therapeutic opportunity in atrial fibrillation

2016

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Section: Vom Ethanol Infusionmentioning

confidence: 89%

Ligament and vein of Marshall: A therapeutic opportunity in atrial fibrillation

2016

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“…Additionally, the VOM sits on the epicardial aspect of the left atrial ridge and the mitral isthmus – a critical region sustaining perimitral flutter. We showed that VOM ethanol infusion can lead to effective ablation of this region and cure of perimitral flutter [46]. Finally, we demonstrated that the abundant para-sympathetic innervation of the VOM and the neighboring atrial epicardium can be ablated by VOM ethanol infusion [47 ■ ] (see Fig.…”

Section: Using the Venous Route For Ethanol Deliverymentioning

confidence: 99%

Ethanol for the treatment of cardiac arrhythmias

Schürmann

Peñalver

Valderrábano

2015

Current Opinion in Cardiology

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Introduction Ethanol infusion was an early mode of ablative treatment for cardiac arrhythmias. Its initial descriptions involved coronary intra-arterial delivery, targeting arrhythmogenic substrates in drug-refractory ventricular tachycardia or the atrioventricular node. Largely superseded by radiofrequency ablation (RFA) and other contact-based technologies as a routine ablation strategy, intracoronary arterial ethanol infusion remains as an alternative option in the treatment of ventricular tachycardia when conventional ablation fails. Arrhythmic foci that are deep-seated in the myocardium may not be amenable to catheter ablation from either the endocardium or the epicardium by RFA, but they can be targeted by an ethanol infusion. Recent findings Recently, we have explored ethanol injection through cardiac venous systems, in order to avoid the risks of complications and limitations of coronary arterial instrumentation. Vein of Marshall ethanol infusion is being studied as an adjunctive procedure in ablation of atrial fibrillation, and coronary venous ethanol infusion for ventricular tachycardia. Conclusion Ethanol ablation remains useful as a bail-out technique for refractory cases to RFA, or as an adjunctive therapy that may improve the efficacy of catheter ablation procedures.

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“…4 Herein, we report the first proof a mechanistic role of VOM in recurrent PMF, by showing epicardial signals from the VOM in areas endocardially ablated, and the successful treatment by ethanol infusion.…”

Section: Discussionmentioning

confidence: 78%

Recurrent Perimitral Flutter due to Vein of Marshall Epicardial Connections Bypassing the Mitral Isthmus

Briceño

Valderrábano

2014

Circ: Arrhythmia and Electrophysiology

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A 68-year-old man with hypertension, dyslipidemia, obstructive sleep apnea, chronic obstructive pulmonary disease, sick sinus syndrome status post dual chamber pacemaker, and a history of 2 pulmonary vein isolation ablations for persistent atrial fibrillation was evaluated in our institution for recurrent atrial flutter.He underwent a complete electrophysiology study. A duodecapolar catheter was used, so that the distal 10 poles were inside the coronary sinus (CS) and the proximal were in the right atrium. The underlying rhythm was atrial flutter with a cycle length of 350 ms and ostial-to-distal activations in the CS. Responses to entrainment were consistent with a left atrial origin. After a trans-septal puncture, a 3-dimensional map of the left atrium was performed using the NavX system (St Jude Medical, St Paul, MN) and a circular duodecapolar catheter, which was consistent with counterclockwise perimitral flutter (PMF). However, the entire cycle length was not present in the mitral annulus ( Figure A To ascertain the role of the vein of Marshall (VOM) in providing with epicardial connections bypassing the endocardial mitral isthmus scar, we cannulated the VOM via the CS. A sheath was inserted in the CS through the right internal jugular vein. A LIMA (left internal mammary artery) angioplasty guide catheter was inserted in the CS with its tip facing posteriorly and superiorly in the right anterior oblique projection ( Figure E). Contrast injection identified the VOM, which was subsequently cannulated with a 0.014″ angioplasty wire and 2×6 mm angioplasty balloon (Medtronic, Minneapolis, MN; Figure E and F). VOM signals were obtained by connecting the angioplasty wire in a unipolar fashion using alligator clips with the indifferent electrode clamped to the skin. By slightly exposing the wire beyond the balloon, only the exposed wire tip (≈3 mm) would serve as an electrode, which could be located by the NavX system, and from which unipolar signals could be sequentially recorded at different depths of the VOM. Local activation times from different levels of the VOM were added to the NavX map ( Figure C and D) and were shown to complete the reentrant activation sequence with the portion of the cycle length that was missing in the endocardial map.Up to 4 injections of 98% ethanol were injected via the angioplasty balloon at different depths of the VOM. The first injection led to termination of the PMF (Figure G and H). Bidirectional perimitral block was subsequently proven by differential pacing. No radiofrequency ablation was required. DiscussionPMF is a macroreentrant tachycardia that typically occurs after left atrial ablation for atrial fibrillation. PMF is commonly treated by ablation in the so-called mitral isthmus, although this has been consistently reported as suboptimal. Failures can occur due to poor catheter contact, motion, or the thickness of the lateral ridge of the left atrium, as well as epicardial cooling of CS or VOM flow.1,2 It has also been hypothesized to occur due to remaining epicardial co...

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Ethanol infusion in the vein of Marshall facilitates mitral isthmus ablation

Cited by 141 publications

References 32 publications

Ligament and vein of Marshall: A therapeutic opportunity in atrial fibrillation

Ligament and vein of Marshall: A therapeutic opportunity in atrial fibrillation

Ethanol for the treatment of cardiac arrhythmias

Recurrent Perimitral Flutter due to Vein of Marshall Epicardial Connections Bypassing the Mitral Isthmus

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