A case report of ethanol infusion in the vein of Marshall using the right jugular vein approach

Figures

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  Figure 1. (A) 12 lead electrocardiogram. Atypical atrial flutter with positive p waves at inferior and precordial leads. (B) Activation map during flutter using Carto system. Modified postero-anterior (PA) view. Incomplete conduction block through the posterior part of the mitral isthmus due to the vein of Marshall [the anterior part which close to the mitral annulus is blocked: the white line corresponds to the ‘Extended Early Meets Late’ algorithm which was set up at 75–25% of the cycle length (CL)]. (C) Initial CL was 320 ms (left), with activation time of 41 ms, and went up to 345 ms (right) after endocardial and epicardial point-by point-ablation of the mitral line, without any changes in the activation sequence and activation time.

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  Figure 2. (A) Fluoroscopic image PA view, showing the partial catheterization of the coronary sinus from the femoral approach. (B) Fluoroscopic image left anterior oblique (LAO) 30° view. Venogram of the VOM using an inflated 1.5 mm balloon placed inside the vein. The iodine contrast is trapped inside the vein of Marshall (injection shows dye ‘hang up’). Black arrows indicate extravasation of contrast. (C) Electrogram recordings obtained during the last ethanol infusion inside the vein of Marshall. Sinus rhythm was immediately restored. HB, His bundle; IVC, inferior vena cava; LA, left atrium; OCS, ostium of CS; SCd, distal coronary sinus; SC 7-8, proximal CS; VOM, vein of Marshall.

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  Figure 3. (A) Voltage map performed after endocardial and epicardial mitral line ablation and before ethanol infusion in the vein of Marshall. A non-complete low voltage area is visible along the mitral line. (B) Voltage map after ethanol infusion in the vein of Marshall. A large low voltage band can be seen along the mitral line. LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.

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  Figure 4. (A) Counter-clockwise peri-mitral block evidenced by pacing at the distal part of the coronary sinus while recording at the opposite site. (B) Clockwise peri-mitral block evidence by pacing at the left atrial appendage while recording at the distal coronary sinus.

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