Identification and Endocardial Ablation of the Ligament of Marshall for Pulmonary Vein Isolation

Chee, Jennifer; Kalogeropoulos, Andreas P.; Almasry, Ibrahim; Singh, Abhijeet; Rashba, Eric J.; Fan, Roger

doi:10.1016/j.jacep.2020.08.027

Cited by 9 publications

(6 citation statements)

References 14 publications

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“…The requirement of carina ablation is associated with reduced effectiveness of PVI Ablation between ipsilateral PVs, at the intervenous carina can be required to achieve PVI after creating a WACA line in up to 50 % of the cases 3,4 . Although recent advances in technology likely decreased this percentage, it is nevertheless still reported in some contemporary series in more than 10% of cases 6,9 .…”

Section: Discussionmentioning

confidence: 98%

Persistent Carina Conduction after Wide Area Circumferential Ablation is Associated with Inadequate Lesion Creation During Pulmonary Vein Isolation

Robert¹

2022

Journal of Atrial Fibrillation and Electrophysiology

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We selected consecutive patients undergoing their first PVI for AF at a time when the Ablation Index (AI) was measured during the procedures, but specific target values were not established, resulting in greater variation of AI of individual lesions. Exclusion criteria were: presence of a common PV trunk (lack of a carina) and any gap in the WACA line (interlesion distance > 6 mm anywhere along the line).The ablation strategy was to create antral WACA lines around

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Section: Discussionmentioning

confidence: 98%

Persistent Carina Conduction after Wide Area Circumferential Ablation is Associated with Inadequate Lesion Creation During Pulmonary Vein Isolation

Robert¹

2022

Journal of Atrial Fibrillation and Electrophysiology

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“…Retrograde ethanol infusion into the MV has been recognized as a therapeutic tool in AF ablation ( 4 , 13 – 15 , 20 , 22 ). Adjunctive MVEI can facilitate the efficacy of PVI ( 14 , 23 ). Anatomical ablation strategies such as MB elimination, PVI, and line completion can also improve the success rate in patients with PeAF ( 6 – 8 , 24 ).…”

Section: Discussionmentioning

confidence: 99%

The impact of empirical Marshall vein ethanol infusion as a first-choice intraoperative strategy on the long-term outcomes in patients with persistent atrial fibrillation undergoing mitral isthmus ablation

Luo

Shen

et al. 2023

Front. Cardiovasc. Med.

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BackgroundMarshall vein ethanol infusion (MVEI) as an additional therapy to conventional catheter ablation (CA) has been proved to be efficacious in patients with persistent atrial fibrillation (PeAF). However, whether empirical MVEI could be the first-line strategy in mitral isthmus (MI) ablation has seldom been investigated. Here, we aim to compare the efficacy, safety, and long-term outcomes between provisional and empirical MVEI in PeAF patients undergoing the index MI ablation procedure.MethodsWe enrolled 133 patients with PeAF either in the provisional group (n = 38, MVEI was performed when conventional endocardial and/or epicardial ablation procedures were inadequate to achieve bidirectional MI block) or in the empirical group (n = 95, MVEI was performed empirically before MI CA).ResultsAll of the baseline characteristics were comparable. Less spontaneous or inducible atrial tachycardias (ATs) were encountered in the empirical group of patients (P < 0.001). More epicardial ablations were applied (26.3% vs. 9.5%, P = 0.016) and a higher incidence of CA-facilitated restoration of sinus rhythm was recorded (86.8% vs. 11.7%, P < 0.001) in the provisional group of patients. Although more fluoroscopy time (6.4[4.2, 9.3] vs. 9.5[5.9, 11.6] min, P = 0.019) and radiation exposure (69.0[25.3, 160.2] vs. 122.0[62.5, 234.1] mGy, P = 0.010) were documented in the empirical group with comparable procedure time, less time (455.9 ± 192.2 vs. 366.5 ± 161.3 s, P = 0.038) was consumed to achieve bidirectional MI block during endocardial ablation in the provisional group. Incidences of procedure-related complications were similar between the two groups. During a 16.5 ± 4.4-month follow-up, the empirical group of patients showed a significantly higher rate of freedom from AT recurrence (95.8% vs. 81.6%, log-rank P = 0.003), while the rate of freedom from AF or atrial tachyarrhythmias (combining AF and AT) was similar. Both univariate (HR 0.19, 95% CI 0.05–0.64, P = 0.008) and multivariate (HR 0.25, 95% CI 0.07–0.92, P = 0.037) Cox regression analyses indicated that empirical MVEI was independently associated with lower long-term AT recurrence.ConclusionAmong patients with PeAF who underwent the index MI ablation procedure, empirical MVEI could reduce endocardial MI ablation time and provide greater long-term freedom from AT recurrence.

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“… 8–10 Several authors have reported regarding electrical conduction gap mapping. Chee et al 11 investigated bidirectional conduction gap mapping after PV ablation and identified the involvement of epicardial connections through the ligament of Marshall, while Barrio-Lopez et al 12 reported epicardial connections with a prevalence of 13.5% after a first-pass encircling of PVs. In our study, the entrances and exits of uncompleted PV ablation lesions were far from each other, with gap direction lines often diagonal to the ablation lines, thus indicating that the point of the ablation line nearest to the entrance or exit is not necessarily the actual electrical conduction gap and is not always the optimal ablation site.…”

Section: Discussionmentioning

confidence: 99%

Delineation of conduction gaps of linear lesions during atrial fibrillation ablation using ultra-high-density mapping

et al. 2023

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Aims Linear lesions are routinely created by radiofrequency catheter ablation. Unwanted electrical conduction gaps can be produced and are often difficult to ablate. This study aimed to clarify the characteristics of conduction gaps during atrial fibrillation ablation by analysing bidirectional activation maps using a high-density mapping system (RHYTHMIA). Methods This retrospective study included 31 patients who had conduction gaps along pulmonary vein (PV) isolation or box ablation lesions. Activation maps were sequentially created during pacing from the coronary sinus and PV to reveal the earliest activation site, defined by the entrance and exit. The locations, length between the entrance and exit (gap length), and direction were analysed. Results Thirty-four bidirectional activation maps were drawn: 21 were box isolation lesions (box group), and 13 were PV isolation lesions (PVI group). Among the box group, 9 conduction gaps were present in the roof region and 12 in the bottom region while 9 in right PV and 4 in left PV among the PVI group. Gap lengths in the roof region were longer than those in the bottom region (26.8 ± 11.8 vs. 14.5 ± 9.8 mm; P = 0.022), while those in right PV tended to longer than those in left PV (28.0 ± 15.3 vs. 16.8 ± 8.0 mm, P = 0.201). Conclusion The entrances and exits of electrical conduction gaps were separated, especially in the roof region, indicating that epicardial conduction might contribute to gap formation. Identifying the bidirectional conduction gap might indicate the location and direction of epicardial conduction.

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Identification and Endocardial Ablation of the Ligament of Marshall for Pulmonary Vein Isolation

Cited by 9 publications

References 14 publications

Persistent Carina Conduction after Wide Area Circumferential Ablation is Associated with Inadequate Lesion Creation During Pulmonary Vein Isolation

Persistent Carina Conduction after Wide Area Circumferential Ablation is Associated with Inadequate Lesion Creation During Pulmonary Vein Isolation

The impact of empirical Marshall vein ethanol infusion as a first-choice intraoperative strategy on the long-term outcomes in patients with persistent atrial fibrillation undergoing mitral isthmus ablation

Delineation of conduction gaps of linear lesions during atrial fibrillation ablation using ultra-high-density mapping

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