Vein of Marshall Ethanol Infusion: Feasibility, Pitfalls, and Complications in Over 700 Patients

Figures

• 

  Figure 1.. Procedural steps. Venous angiographies: Successive 8 steps of vein of Marshall (VOM) ethanol infusion. Note the progressive staining that increases with each ethanol infusion, but with a preserved arborization. Electroanatomical maps: Left atrium (LA) voltage before and after ethanol infusion. A collar-shape endocardial scarring appears in the vicinity of the left inferior pulmonary vein. Stepwise diagram: key procedural details related to each step. CS indicates coronary sinus; LIMA, an angiography catheter (5F left internal mammary artery); OH, ethanol; and OTW, over the wire.

• 

  Figure 2.. Feasibility.A, Tips and tricks for vein of Marshall (VOM) localization. VOM ostium always sites slightly proximal from the valve of Vieussens (VV), which is distinguished either indirectly by iodine pooling or directly as a translucent structure. A large balloon occluding the coronary sinus (CS) was sometimes helpful to visualize the VOM. B, Different types of VOM. A representative example of multiple branches, large trunk, and no branches morphologies. C, Representative example of inadvertent left atrial appendage (LAA) vein infusion. Note that none of the 3 key criteria for VOM identification were fulfilled: the VV is visible but proximal to the targeted vein, the targeted vein points toward the catheter tip placed at the LAA apex, and the endocardial scarring impacts the lateral portion of the LAA. LIMA indicates an angiography catheter (5F left internal mammary artery).

• 

  Figure 3.. Pitfalls.A, Angiogram of a patient with vein of Marshall (VOM) dissection (blue arrows) during the first selective VOM angiogram. Note that distal VOM arborization is never visible. B, Angiogram of a patient with a large trunk morphology and a mechanical leakage (blue arrows) that is proximal from the balloon, with iodine loss into the coronary sinus (CS). C, Representative examples of the 4 types of anatomic drainage (blue arrows) via natural anastomosis between the VOM and the great cardiac vein (GCV), left atrium (LA), CS, or the superior vena cava (SVC).

• 

  Figure 4.. Learning curve. Evolution of key procedural events over the years: successful vein of Marshall (VOM) ethanol infusion (black line), VOM dissection (pale blue), wrong vein ethanol infusion (dark blue), VOM perforation (yellow), and serious complications (orange). Statistical comparison with a P value is shown between each year (black-framed rectangle) and for each item (following identical color code). LAA indicates left atrial appendage.

• 

  Figure 5.. Complications. Column 1: type and number of minor (no frame) and serious (black framed) events. Column 2: event rate. Column 3: event timing, considered acute if it occurs during the procedure, or delayed if it occurs after the procedure. Column 4: comment related to vein of Marshall (VOM) ethanol infusion. Column 5: specific management related to VOM ethanol infusion. LAA indicates left atrial appendage.