How to perform ethanol ablation of the vein of Marshall for treatment of atrial fibrillation

The arrhythmogenicity of the vein of Marshall (VoM) in atrial fibrillation (AF) has been known for more than 20 years. 1 Kim D.T. Lai A.C. Hwang C. et al. The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias. J Am Coll Cardiol. 2000; 36: 1324-1327 Crossref PubMed Scopus (165) Google Scholar A recent randomized trial showed a reduced odds ratio (0.63; 95% confidence interval 0.41–0.97; P = .04) for the primary outcome of AF or atrial tachycardia (AT) recurrence in patients with persistent AF by adding VoM ethanol infusion (VoM-Et) to the standard ablation approach. 2 Valderrábano M. Peterson L.E. Swarup V. et al. Effect of catheter ablation with vein of Marshall ethanol infusion vs catheter ablation alone on persistent atrial fibrillation: the VENUS randomized clinical trial. JAMA. 2020; 324: 1620-1628 Crossref PubMed Scopus (26) Google Scholar The VoM is involved in 30% of ATs after AF ablation, and VoM ablation significantly improves the freedom from recurrent arrhythmia. 3 Vlachos K. Denis A. Takigawa M. et al. The role of Marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation. Heart Rhythm. 2019; 16: 1341-1347 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar ,4 Takigawa M. Derval N. Martin C.A. et al. Mechanism of recurrence of atrial tachycardia: comparison between first versus redo procedures in a high-resolution mapping system. Circ Arrhythm Electrophysiol. 2020; 13e007273 Crossref PubMed Scopus (17) Google Scholar VoM-Et also improves the success rate for lateral mitral isthmus block, from 64% to nearly 100%. 5 Nakashima T. Pambrun T. Vlachos K. et al. Impact of vein of Marshall ethanol infusion on mitral isthmus block: efficacy and durability. Circ Arrhythm Electrophysiol. 2020; 13e008884 Crossref PubMed Scopus (14) Google Scholar Based on these findings, we developed the anatomy-based MARSHALL-PLAN (MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation) ablation approach for persistent AF. This protocol includes pulmonary vein (PV) isolation, a left atrial (LA) roof line, a lateral mitral isthmus line facilitated by VoM-Et, and a cavotricuspid isthmus line. 6 Pambrun T. Denis A. Duchateau J. et al. MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation: MARSHALL-PLAN case series. J Cardiovasc Electrophysiol. 2019; 30: 7-15 Crossref PubMed Scopus (33) Google Scholar First results showed promising acute and mid-term success rates, and the protocol is now being investigated in larger populations and in a randomized controlled trial (ClinicalTrials.gov Identifier: NCT04206982). To the Editor—Omissions and misconceptions on vein of Marshall ethanol infusionHeart RhythmVol. 18Issue 7PreviewThe description of the approach of Krisai et al to vein of Marshall (VOM) ethanol infusion1 contains omissions and misconceptions. Full-Text PDF