Selective ethanol ablation targeting the distal vein of Marshall for a peri–left atrial appendage reentrant atrial tachycardia after completing anterior mitral isthmus conduction block

Figures

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  Figure 1. A: Twelve-lead electrocardiogram during the clinical atrial tachycardia (AT) with a tachycardia cycle length (TCL) of 494 ms. B: Isochronal activation maps during the AT exhibiting endocardial activation gaps from the base of the left atrial appendage (LAA) to the top of the ridge in the superoanterior view (left panel) and along the middle portion of the ridge in the left lateral view (right panel). The local endocardial electrograms were not recorded during phase 4 in the left panel and phases 7–8 in the right panel, which appeared to indicate the activation gaps during the AT. The numbers in the local electrograms indicate the intervals from the reference electrogram recorded in the coronary sinus to the local electrogram. C–H: High-resolution activation maps exhibiting a clockwise peri-LAA reentrant AT with partial epicardial conduction along the ridge. The activation wavefront (dark red) propagated (C–D) from the top to the middle portion of the ridge and (E–F) through the lateral left atrium (LA) toward the anterolateral mitral annulus (MA), and (G–H) returned to the top of the ridge passing between the LAA and previous anterior mitral isthmus ablation line (Supplemental…

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  Figure 2. A: Fluoroscopic images showing the position of a 1.6F multielectrode catheter (EPSkinny; FMD Co, Ltd, Tokyo, Japan) placed in the vein of Marshall (VOM) (left panel), course of the VOM on retrograde VOM venography (middle panel), and position of an angioplasty balloon (Emarge; Boston Scientific, Marlborough, MA) during the VOM ethanol infusion (right panel) in the right anterior oblique 35-degree view. B: Atrial tachycardia termination 10 seconds after infusing 2.5mL of ethanol into the VOM. CS = coronary sinus; CS-EGM = coronary sinus electrogram recordings; LAA-EGM = intracardiac electrograms recorded by the circular mapping catheter in the left atrial appendage; Lateral LA-EGM = intracardiac electrograms recorded by the mini-basket catheter in the lateral left atrium. The other abbreviations are as in Figure 1.

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  Figure 3. A: Bipolar voltage maps before the vein of Marshall (VOM) ethanol infusion during the atrial tachycardia (AT) (left panel) and after the VOM ethanol infusion during left atrial appendage (LAA) pacing (right panel). The VOM ethanol infusion eliminated the electrograms along the ridge, but the electrograms from the lateral to posterolateral mitral isthmus (MI) area did not significantly change before and after the VOM ethanol infusion. The low-voltage and scar areas were defined as areas with bipolar electrogram amplitudes of <0.5 mV and <0.1 mV, respectively. B: Isochronal activation maps before the VOM ethanol infusion during the AT (left panel) and after the VOM ethanol infusion during LAA pacing (right panel). Each color between red and purple represents a 10 ms activation time. The distance between the 2 black tags in the lateral and posterolateral MI area (white dotted bidirectional arrows) is the same between the 2 isochronal maps and is 30.5 mm. The mean conduction velocity between the 2 black tags is 0.68 mm/ms before the VOM ethanol infusion and 0.64 mm/ms after, respectively. Abbreviations are as in Figure 1.