Marshall-plan ablation strategy for recurrent persistent atrial fibrillation in patients with durably isolated pulmonary veins

Background There is evidence that vein of Marshall (VoM) ethanol infusion, as part of a standardized lesion set (Marshall-plan) in persistent atrial fibrillation (AF), reduces atrial arrhythmia recurrence when compared to pulmonary vein isolation (PVI) alone. However, data on the effectiveness of the Marshall-plan in repeat procedures with durable PVI is scarce. Purpose In a single-center prospective cohort setting with historical controls, we evaluated the effectiveness of the Marshall-plan as an ablation strategy in patients with recurrent AF who present with durable PVI at the repeat procedure. Methods Consecutive patients with recurrent persistent AF with durable PVI who received a full Marshall-plan lesion set (posterior mitral line with ethanol infusion of VoM, dome line and cavotricuspid isthmus line) at the repeat procedure were prospectively included. As historical controls, patients with a comparable profile who had undergone repeat ablation at our center prior to the introduction of the Marshall-plan were included. Primary outcome was freedom from AF or atrial tachycardia (AT) at 12 months. Results A total of 38 patients were included in each treatment group. Baseline characteristics were similar across treatment groups (mean age 66.8±9.0 years; 32.9% female; and CHA2DS2-VA of 2 (IQR: 1-3]) except from more prior AF ablations (2 [IQR: 2-3] vs 1 [IQR: 1-2], P<0.001) and longer AF history (12 [IQR: 8-18] vs 8 [IQR: 4-10], years, P=0.002) in the Marshall-plan group. All patients in the Marshall-plan group underwent a complete lesion set with block across all anatomical lines. The most common ablation strategy in the control group was posterior wall isolation (PWI; 44.7%) and anterior mitral line (36.8%). Freedom from AF or AT at 12 months was achieved in 26 (68.4%) patients in the Marshall-plan group vs. 17 (44.7%) in the control group (HR 0.45, 95% CI 0.22-0.93, P=0.030). Conclusion The Marshall-plan lesion set, including ethanol VoM infusion, improved freedom from AF or AT at 12 months in patients with recurrent persistent AF and durable PVI at repeat ablation.