Vein of marshall ethanol infusion in persistent atrial fibrillation: insight from VOMALC-PeAF registry

Background Pulmonary vein isolation (PVI) ablation has limited efficacy in persistent atrial fibrillation (PeAF). Anatomical strategies combining PVI, vein of Marshall ethanol infusion (VOM-EI), and linear ablation targeting key atrial isthmuses have shown promising short-term outcomes in this setting. Objectives To compare the long-term effectiveness of a comprehensive anatomical strategy, including VOM-EI and linear lesions (VOM-EI+anatomical scheme, AS), vs PVI-only in patients undergoing first-time catheter ablation for PeAF. Methods In this retrospective multicenter observational cohort study, consecutive patients with PeAF who underwent either VOM-EI+AS or PVI-only were included. The primary endpoint was freedom from atrial arrhythmias (AAs) lasting >30 seconds off antiarrhythmic drugs (AADs). Procedural characteristics and safety outcomes were also evaluated. Results After 2:1 propensity score matching, 151 patients treated with VOM-EI+AS were compared with 75 treated with PVI-only. After a median 22-month follow-up (interquartile range (iqr): 9-35 months), 81% vs. 47% of patients remained free from AA without AADs in the VOM-EI+AS vs. PVI-only group (p<0.001). Achievement of bidirectional mitral isthmus (MI) block was the strongest independent predictor of arrhythmia-free survival (HR = 0.114; 95% CI: 0.041–0.321; p<0.001). On the contrary, long-lasting PeAF was independently associated with a higher risk of atrial arrhythmic recurrence (HR = 2.68; 95% CI: 1.240–5.812; p = 0.012). Conclusions In real-world PeAF population, a first ablation strategy incorporating VOM-EI, PVI and anatomical linear lesions was significantly more effective than PVI alone in preventing arrhythmic recurrences. Bidirectional block validation across the mitral line and AF duration are key determinants of long-term success.