Vein of Marshall Ethanol Infusion in Setting of Atrial Fibrillation Ablation

Catheter ablation especially in persistent atrial fibrillation has limited success. Strategies beyond pulmonary veins isolation failed to demonstrate improvement of long-term rhythm maintenance. The vein of Marshall (VOM) is a promising therapeutic target as it fit perfectly with “Coumel’s triangle”: triggers in form of focal activities or stable reentries priming atrial fibrillation comes typically from tissue surrounding the VOM, it colocalize with mitral line especially in the epicardial part difficult to approach by endocardial ablations, it contains autonomic parasympathetic and sympathetic innervation implicated in arrhythmogenesis. Epicardial chemical ablation by ethanol delivery directly inside the vein of Marshall represents an attractive therapeutic approach eliminating arrhythmic triggers and autonomic modulators and, as it colocalize with the trajectory of the mitral isthmus, completing the integrity of that linear lesion. Based on advantages provided from VOM alcoholization, this technique has been progressively introduced in addiction to standard ablation strategies in atrial fibrillation treatment. This chapter aims to describe the electrophysiological characteristics of vein of Marshall, the technical aspects of ethanol delivery and the evidences from the literature supporting the emerging role of VOM alcoholization in atrial fibrillation treatment.