Vein of Marshall ethanol infusion improves ablation outcomes in patients with persistent atrial fibrillation

Figure 1. Ablation approaches for persistent atrial fibrillation. Postablation 3-dimensional electroanatomic maps displayed in the posteroanterior projections. Ablation strategies among the 3 groups including patients who underwent pulmonary vein isolation only (A), patients with pulmonary vein isolation and posterior wall isolation (B), or patients with pulmonary vein isolation, posterior wall isolation, and vein of Marshall ethanol infusion along with additional ablation to ensure mitral isthmus block.

Figure 2. Vein of Marshall ethanol infusion. Procedural steps of vein of Marshall ethanol infusion is demonstrated in a patient undergoing first-time ablation of persistent atrial fibrillation. A: Fluoroscopy in the anterior posterior projection is shown, and venography of the coronary venous system demonstrates the vein of Marshall (yellow arrow) branching posteriorly and superiorly from the coronary venous system, proximal to the valve of Vieussens (green arrow). B: The vein of Marshall is instrumented with a guiding catheter, angioplasty wire, and occlusive balloon. Selective venography shows the course of the vein of Marshall (yellow arrows), and a mapping catheter is placed in the left atrial appendage to serve as an anatomic landmark. Ethanol is slowly injected in the distal and proximal sections of the vessel. C: An electroanatomic map of the lateral mitral isthmus after ethanol ablation shown, showing a small area of preserved voltage near the mitral annulus. Endocardial ablation lesions were applied in this area (red tags). D: A coronary sinus catheter was placed proximal to the endocardial lesions and pacing was performed from the left atrial appendage during endocardial…

Figure 3. Long-term arrhythmia-free survival after a single ablation procedure among patients with nonparoxysmal atrial fibrillation (AF). AT = atrial tachycardia; PVI = pulmonary vein isolation; PWI = posterior wall isolation; VoM = vein of Marshall.