Ethanol Infusion of Vein of Marshall for the Treatment of Persistent Atrial Fibrillation: The Basics and Clinical Practice

Figures

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  Figure 1. Gross photo (A) and histochemical staining (B–E) showing the anatomy of the ligament of Marshall. (B) The CS myocardial sleeve is shown by Masson’s trichrome staining of the CS and VOM, which ends at the valve of Vieussens (VV). No myocardial sleeve is seen in the great cardiac vein (GCV). (C) The nerve (brown staining-arrow) is shown by positive avidin-biotin-peroxidase immunohistochemical staining for tyrosine. (×120). (D) Dual-staining of the nerve bundles of the LOM for DBH (blue) and ChAT (brown) showing that cholinergic nerve fibers are predominant (×5). (E) Hematoxylin-eosin staining showing the tracts of the LOM. Three tracts (arrows) emerging from the LOM are shown by subserial sections, which eventually enter the atrial wall. The last panel shows a section from the lower end of the LOM. The tract inserts into the left atrial wall (arrow) and CS (×10). CS, coronary sinus; ChAT, choline acetyl transferase; DBH, dopamine β-hydroxylase; LAA, left atrial appendage; LAFW, left atrial free wall; LOM, ligament of Marshall; M, myocardium; F, fat; PV, pulmonary vein; VOM, vein of Marshall (reproduced and modified with permission from Kim et al. [15], Chou et al. [16], and Ulphani…

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  Figure 2. Recordings of the potentials of the ligament of Marshall (LOM) in dogs and humans. (A) The catheter position and anatomy of LOM in a dog. (B) Simultaneous recording of surface ECG lead I, II, III, aVR, aVL, aVF, HB, LAA, LSPV, LIPV, LOM1-2, LOM5-6, and LOM9-10 in a dog showing LOM potentials (arrows). (C,D) Vein of Marshall (VOM) venography and LOM potentials recorded with a small catheter (VOMc) placed in the VOM in a patient with persistent atrial fibrillation. The Lasso catheter is positioned in the LSPV. (E,F) Simultaneous recording of surface ECG lead I, II, V1, CS1-2~CS9-10, Lasso1-2~Lasso9-10, and VOM1-2~VOM5-6. During a sinus beat, the left atrium potential (LA) is fused with the LOM potential (E). A premature atrial beat separates the LA and the LOM potentials (F). HB, His bundle electrogram; LAA, left atrial appendage; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; CSc, coronary sinus catheter.

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  Figure 3. Perimitral flutter mediated by VOM epicardial connections in a persistent atrial fibrillation patient undergoing PVI and linear ablation. (A) Activation mapping of the left atrium (①) and right atrium (②), and entrainment mapping of the left atrium (③～⑥). Activation mapping of the left atrium indicated a focal activation mode, and the earliest atrial activation was located at the anterior roof. The total activation time of the left atrium was 201 ms, less than the TCL of 252 ms. Activation mapping of the right atrium showed that the right atrium was passively activated by the left atrium. Entrainment from MI (③ and ④) produced significantly prolonged PPI (PPI-TCL = 72 ms in ③; PPI-TCL = 82 ms in ④), while entrainment from the anterior roof (⑤) and posterior inferior wall near the CS (⑥) produced short PPIs (PPI-TCL = 12 ms in ⑤; PPI-TCL = 7 ms in ⑥). (B) Entrainment from CS produced short PPIs. (C) Entrainment from VOM also produced short PPIs. The activation mapping and entrainment mapping indicated that the tachycardia was MI-dependent with an epicardial connection (VOM). (D) Selective VOM venography prolonged the TCL without terminating the tachycardia (① and ②). Injection of…

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  Figure 4. Fluoroscopic images in RAO view showing the procedural steps of VOM ethanol infusion. (A) Coronary sinus venography showing the presence of VOM. (B) Selective VOM venography. (C) Guidewire advanced into the VOM. (D) Balloon advanced into the VOM and inflated. (E) Selective VOM venography via the wire port of the balloon performed to confirm complete occlusion. (F) Contrast injection into VOM showing myocardial staining with the contrast medium after ethanol infusion. (G) Voltage mapping of posterior MI, left pulmonary vein-LAA ridge region, and left pulmonary veins before VOM ethanol infusion. (H) Voltage mapping in the same region showing low-voltage regions in the anatomical distribution of the VOM after VOM ethanol infusion. LAA, left atrial appendage; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; MI, mitral isthmus; MA, mitral annulus. RAO, right anterior oblique.