Impact of vein of Marshall ethanol infusion on achieving floor line block: Is it possible to create a floor line with vein of Marshall ethanol infusion?

Figures

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  Figure 1. The voltage map (posterior-anterior view) prior to the ablation during the third procedure and the ablation points. As a result of the previous ablation, the treatment effect was observed as the expansion of low voltage areas owing to pulmonary vein isolation and ablation performed below the left inferior pulmonary vein (LIPV). However, no low-voltage areas were observed in other regions. In this procedure, only ablation targeting the vicinity of both superior pulmonary veins was performed. The number of points obtained during mapping was 1348 points. The left atrium volume was 110 mL, and the distance between the low-voltage area of the LIPV posterior and the right inferior pulmonary vein (RIPV) posterior was 40mm. LAA = left atrial appendage; LSPV = left superior pulmonary vein; RSPV = right superior pulmonary vein.

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  Figure 2. Fluoroscopic images during ethanol infusion into the vein of Marshall (Et-VOM) procedure (anterior-posterior view). A decapolar catheter was placed in the coronary sinus. A: Retrograde venography of the vein of Marshall (VOM) (white arrows). B: Retrograde venography from the wire lumen of a balloon inserted and inflated within the VOM (red arrow). This figure shows the pathway (white arrows) from the roof veins to the main trunk of the VOM and the presence of inferior veins (yellow arrows) as branches of the VOM and septal veins as collateral of inferior veins. C: Retrograde venography of the VOM after Et-VOM. The staining was apparently seen (white dashed circled). AP = anterior-posterior view; CSd = coronary sinus distal; CSp = coronary sinus proximal.

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  Figure 3. The activation map and the voltage map just after ethanol infusion into the vein of Marshall (Et-VOM). The map was created under coronary sinus (CS) proximal pacing. The voltage map was created with a threshold set at 0.20 mV. The number of points obtained during mapping was 17,724 points. A: The activation map (left) and the voltage map (right) (posterior-anterior view). The most delayed excitation area was observed just above the floor line created by Et-VOM. B: The activation map (left) and the voltage map (right) (lateral caudal view). In the voltage map, a wide range of low-voltage area was observed from the posterolateral mitral isthmus region to the vicinity of the ridge. However, under CS proximal pacing, it was evident that the block in this location was incomplete. LAA = left atrial appendage; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.