Acute sinus node dysfunction requiring a permanent pacemaker after ethanol ablation of the vein of Marshall

Figures

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  Figure 1. A: Nonselective venogram of the coronary sinus (CS) demonstrating the origin of the vein of Marshall (VoM). B: Balloon occlusion venogram of the VoM showing several venovenous (V-V) collaterals. Specifically, note the branch (small marks left of the multipolar catheter) ascending toward the left atrial (LA) roof, which is consistent with the course of the left anterior roof vein. LAA = left atrial appendage.

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  Figure 2. A: Sequential venograms showing continuation of the left anterior roof vein toward the left atrial roof, with multiple branches. B and C: Subsequent course toward the right atrium (RA). D: Digital subtraction image of panel C. LAA = left atrial appendage.

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  Figure 3. Twelve-lead electrocardiogram immediately before and after the development of sinus arrest (asterisk). The cycle length (800 ms) and PR interval are unchanged before sinus arrest, ruling out an autonomic mechanism. With the exception of the first junctional escape complex, there is evidence of ventriculoatrial conduction.

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  Figure 4. Three-dimensional illustration showing the venovenous communications (orange and red lines) with the vein of Marshall (VoM). It is hypothesized that a left anterior roof vein (orange) communicates with a roof vein (red) near the right superior pulmonary vein (RSPV), which then drains into the right atrium (RA) at the RA–superior vena cava (SVC) junction near the sinus node. CS = coronary sinus; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RAA = right atrial appendage.