Impact of Ethanol Infusion to the Vein of Marshall in Atrial Fibrillation and Atrial Tachycardia

Figures

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  Figure 1. Histology of ligament of Marshall. (a) Photo showing location on the posterior surface of heart. (b) Immunohistochemical staining for tyrosine hydroxylase showing positively in nerve (brown staining—arrow). M, myocardium; F, fat (avidin–biotin–peroxidase, ×120). (c–e) Subserial sections showing the LOM, isolated from the left atrial wall (in c), with 3 tracts (arrows) emerging from it (in (d)) and eventually entering the atrial wall (in (e)) (hematoxylin and eosin [H&E] stain ×10). (f) Section from the lower end of LOM showing tract entering the left atrial wall (arrow) and CS (H&E stain ×10). CS, coronary sinus; LAA, left atrial appendage; LOM, ligament of Marshall; PV, pulmonary vein; LA ENDO, left atrial endocardium. This figure is reproduced from the original manuscript [2] with permission from Elsevier.

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  Figure 2. Various connections between the LA and LOM. Locations of connections between LA and LOM is illustrated in red squares. The incidence of each connection is described in red characters. CS, coronary sinus; LA, left atrium; LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; MV, mitral valve.

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  Figure 3. Underlying mechanisms maintaining AF related to the LOM. Several mechanisms initiating or maintaining AF related to the LOM are depicted (A). When the LOM is responsible for the AF initiation or perpetuation, EI-VOM may effectively terminate AF (B,C). Red triangles in (B) show the distribution of staining after EI-VOM. (A) is modified from the original manuscript by Takigawa M et al. [36]. AF, atrial fibrillation; CS, coronary sinus; EI-VOM, ethanol infusion to the vein of Marshall; LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; MV, mitral valve; RAO, right anterior oblique; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.

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  Figure 4. Multiple complex AT circuits using the LOM displaying centrifugal activation. AT associated with the LOM should be considered whenever centrifugal activation is detected at sites along the LOM in the lateral LA. The endocardial insertion points from epicardial structures often manifest as centrifugal activation, which must be distinguished from true focal activation—an atypical occurrence in this region (endocardial lateral LA). AT, atrial tachycardia; CS, coronary sinus; LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; MV, mitral valve; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.

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  Figure 5. EI-VOM with femoral approach. Balloon occlusion of the CS ostium during venography enhances visualization of the VOM ostium (red triangles) with the Lumen BeeAT (Japan Life Line, Tokyo, Japan) inserted from the jugular vein (A). A 5 French Judkins Right (JR) catheter is wedged into the VOM ostium and slow contrast dye injection enables visualization of the distal branches (red triangles) (B). A 0.014-inch angioplasty wire is threaded through the 5Fr JR catheter, followed by an over-the-wire angioplasty balloon (6–8 mm in length, with a nominal diameter of 1.5–2.5 mm) for inflation (C). VOM distribution should be carefully assessed with different angles by VOM venography with balloon occlusion. The distribution area (red and white triangles) can be predicted and projected onto a 3D mapping system using a mapping catheter under fluoroscopy guidance. In this case, the AP view demonstrates the posterior distribution (white triangles) close to the esophagus, meaning that ablation in front of the esophagus can be avoided for left pulmonary vein isolation (D). After the confirmation of the VOM distribution with contrast, 96% ethanol (10 mL, 8.08 g, 808 mg/mL) is slowly injected at a…

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  Figure 6. Successful EI-VOM achieved by switching from a Judkins Right (JR) catheter to a multi-purpose catheter. Initially, the 2.7 French decapolar catheter (EP-star FIX AIV, Japan Life Line, Tokyo, Japan) was used to record electrograms from the VOM, with a 0.014-inch guidewire running through the JR catheter (A). However, the JR catheter had difficulty engaging with the VOM ostium due to its unsuitable tip angle. Switching to a multi-purpose catheter allowed the catheter to properly engage with the VOM ostium (B). Following this, an over-the-wire angioplasty balloon was positioned under the guidance of the 0.014-inch guidewire and then inflated at the VOM ostium (C). This setup allowed for a successful ethanol infusion into the VOM (D). Successful performance with sufficient stain is observed (red triangles) (D). AP, anteroposterior; JR, Judkins Right; LAO, left anterior oblique view; RAO, right anterior oblique view.

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  Figure 7. An example case of delayed cardiac tamponade. A 78-year-old female underwent EI-VOM (A), followed by PVI, MI line, and posterior LA isolation in the LA (B). Additionally, she underwent a CTI linear lesion and SVCI in the RA (C) to treat long-standing persistent AF. Initially, the outcomes were positive, with a significant removal of AF symptoms. During follow-up visits at 3 and 8 weeks post-procedure, the patient reported no specific symptoms, and her BNP level remained stable at <50 pg/mL. However, by the 9th week, she began experiencing shortness of breath, prompting her visit to the emergency department in the 10th week. On examination, she presented with mild hypotension (blood pressure 88/60) and sinus tachycardia (115 bpm). Her hemoglobin level remained consistent at 11 g/dL, but her BNP level had increased to 120 pg/mL. A CT scan revealed a large pericardial effusion (D). Subsequent pericardiocentesis drained 1100 mL of pale red fluid from the pericardial sac. AF, atrial fibrillation; AP, anteroposterior view; BNP, brain natriuretic peptide; CT, computed tomography; CTI, cavotricuspid isthmus; EI-VOM; ethanol infusion to the vein of Marshall; LA, left atrium; MI, mitral…