Vein of Marshall Collateralization during Ethanol Infusion in Atrial Fibrillation: Solution for Effective Myocardium Staining

Figures

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  Figure 1. VOM collateralization in a patient without ethanol infusion attempt. (A,C): Non-occluded venograms of VOM in the RAO and LAO projection, respectively. (E,G): Balloon occluded venograms of VOM in the RAO and LAO projection, respectively. (B,D,F,H): Highlighted VOMs of panels (A,C,E,G), respectively. The black arrow indicates the ostium of VOM. The white arrows and green lines indicate the drainage of the VOM. The tubule outlined in red indicates the angioplasty balloon. VOM, the vein of Marshall; RAO, right anterior oblique; LAO, left anterior oblique.

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  Figure 2. Successful ethanol infusion in a VOM with collateral circulation to the left atrium. (A,C): Non-occluded venograms of VOM in the RAO and LAO projection, respectively. (B,D): Highlighted VOMs of panels (A,C), respectively. (E–G): Balloon occluded venograms of VOM in the LAO projection after 2, 4, and 8 mL of ethanol infusion, respectively. (H): Balloon occluded venogram of VOM in the RAO projection after 8 mL of ethanol infusion. The black arrow indicates the ostium of VOM. The white arrows and green lines indicate the drainage of the VOM. The tubule outlined in red indicates the angioplasty balloon. The yellow circles indicate localized myocardium staining. VOM, the vein of Marshall; RAO, right anterior oblique; LAO, left anterior oblique.

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  Figure 3. Successful ethanol infusion in a VOM with collateral circulation to the right superior vena cava. (A,B): Non-occluded venograms of VOM in the RAO and LAO projection, respectively. C and E: Balloon occluded venograms of VOM in the RAO and LAO projection, respectively. (D,F): Highlighted VOM of panels (C,E). (G,H): Balloon occluded venograms of VOM in the RAO projection after 4 and 8 mL of ethanol infusion, respectively. The black arrow indicates the ostium of VOM. The white arrows and green lines indicate the drainage of the VOM. The tubule outlined in red indicates the angioplasty balloon. The yellow circles indicate localized myocardium staining. VOM, the vein of Marshall; RAO, right anterior oblique; LAO, left anterior oblique.

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  Figure 4. Successful ethanol infusion in a VOM with collateral circulation to the great cardiac vein. (A,C): Non-occluded venograms of VOM in the RAO and LAO projection, respectively. (B,D): Highlighted VOMs of panels (A,C), respectively. (E–G): Balloon occluded venograms of VOM in the RAO projection after 2, 4, and 8 mL of ethanol infusion, respectively. (H): Balloon occluded venograms of VOM in the LAO projection after 8 mL of ethanol infusion. The black arrow indicates the ostium of VOM. The white arrows and green lines indicate the drainage of the VOM. The tubule outlined in red indicates the angioplasty balloon. The yellow circles indicate localized myocardium staining. VOM, the vein of Marshall; RAO, right anterior oblique; LAO, left anterior oblique.

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  Figure 5. A step-by-step illustration of ethanol infusion in a VOM with collateral circulation. (A,B): Schematic diagram of non-occluded venograms of VOM in the RAO and LAO projection, respectively. (D,G,J): Schematic diagram of balloon occluded venograms of VOM in the RAO projection after 2, 4, and 8 mL of ethanol infusion, respectively. (E,H,K): Schematic diagram of balloon occluded venograms of VOM in the LAO projection after 2, 4, and 8 mL of ethanol infusion, respectively. (C): Non-occluded venogram of VOM in the LAO projection. (F,I,L): Balloon occluded venograms of VOM in the RAO projection after 2, 4, and 8 mL of ethanol infusion, respectively. The black arrow indicates the ostium of VOM. The white arrows indicate the drainage of the VOM. The tubule outlined in red indicates the angioplasty balloon. The gray and black shadows in Panels (D,E,G,H,J) and yellow circles in Panels (I,L) indicate localized myocardium staining. The black dots in Panels (A,B,D,E,G,H) indicate contrast leakage through the collateral circulation. VOM, the vein of Marshall; RAO, right anterior oblique; LAO, left anterior oblique.