Vein of marshall ethanol infusion plus anatomical ablation versus pulmonary vein isolation alone for first ablation of persistent atrial fibrillation: long-term outcomes from the VOMALC-PeAF registry

Background — In persistent atrial fibrillation (PeAF), pulmonary vein isolation (PVI) alone yields modest long-term efficacy. Marshall vein ethanol infusion (VOM-EI) facilitates mitral isthmus block and may improve outcomes. Objective — To compare a first-procedure anatomical strategy integrating VOM-EI, linear lesions and PVI (VOM-EI+AS) versus PVI-only in PeAF. Methods — Multicentre, retrospective registry with 2:1 propensity score matching. Patients undergoing first ablation for PeAF treated with VOM-EI+AS (n=151) were compared with PVI-only (n=75). Primary endpoint: freedom from atrial arrhythmias (AA) >30 s off antiarrhythmic drugs after a 3-month blanking. Secondary endpoints: achievement of bidirectional mitral isthmus block (MIB), redo ablation, safety, and predictors (Cox regression). Median follow-up was 22 months (IQR 9–35). Results — Freedom from AA off-AADs was higher with VOM-EI+AS versus PVI-only (82% vs 47%; p<0.0001). Achievement of bidirectional MIB independently predicted success (HR 0.114; 95% CI 0.041–0.321; p<0.001), while long-standing PeAF predicted recurrence (HR 2.685; 95% CI 1.240–5.812; p=0.012). Redo ablation occurred less frequently with VOM-EI+AS (4.8% vs 26.6%; p<0.001). Safety profiles were comparable with a low rate of major complications in both groups. Conclusion — In real-world first ablation of PeAF, an anatomical strategy integrating VOM-EI with PVI and linear lesions significantly reduces recurrences and redo procedures versus PVI-only. Verification of bidirectional mitral isthmus block and AF duration are key prognostic determinants.