Postablation Peri-Mitral Flutter Terminated by Vein of Marshall Ethanol Infusion and Extra Epicardial Ablation

Figures

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  Visual Summary. Clinical Timeline of Stepwise EIVOM and Epicardial Ablation for MI-Dependent Perimitral Flutter

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  Figure 1. Baseline Ablation and PMF Diagnosis (A) Three-dimensional electroanatomic map demonstrating ablation lesions using the 2C3L strategy, including pulmonary vein isolation, roof line, MI line, and cavotricuspid isthmus line. (B) Activation mapping demonstrated PMF. (C and D) Entrainment pacing at 180 ms, with TCL 200 ms, further confirmed the diagnosis of PMF. PMF = peri-mitral flutter; TCL = tachycardia cycle length; MI = mitral isthmus.

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  Figure 2. EIVOM Attempt (A) Venography demonstrating opacification of the VOM. (B) Residual VOM stump (red dots) after ethanol infusion (7.5 mL in 5 divided doses). EIVOM did not terminate the flutter, with no change in activation sequence or TCL. (C) Intracardiac electrograms before EIVOM and (D) after EIVOM. EIVOM = ethanol infusion into the vein of Marshall; VOM = vein of Marshall; TCL = tachycardia cycle length.

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  Figure 3. Extra Epicardial Touch-Up at the Proximal VOM Venography before (A) and after (B) EIVOM showing high, steep-origin VOM anatomy. (C) Targeted epicardial ablations at the proximal VOM via the CS, resulting in tachycardia termination. Entrainment pacing from endocardial (D) and within the CS (E) confirmed bidirectional conduction block across the mitral isthmus. EIVOM = ethanol infusion into the vein of Marshall; VOM = vein of Marshall; CS = coronary sinus.