The adjunctive effect for left pulmonary vein isolation of vein of Marshall ethanol infusion in persistent atrial fibrillation

Figure 1. Workflow of the patient enrollment and procedure. The outcome of two groups after subsequent ablation steps. EIVOM, ethanol infusion into the vein of Marshall; RFCA, radiofrequency catheter ablation; AF, atrial fibrillation; AFL, atrial flutter; PVI, pulmonary vein isolation; LA, left atrial.

Figure 2. Dynamic changes in LPV potential during EIVOM and RFCA. Step 1: LA voltage mapping and PV potential recording during AF rhythm before EIVOM. No low voltage area was found in LA. Step 2: after EIVOM, the change of the LSPV potential is not obvious, but LIPV is nearly isolated. Step 3: RFCA was implemented from the anterior wall to the posterior wall of the LSPV. The LSPV potential became slower gradually. PVI was achieved after ablation at the site showed by the catheter. Need for RF ablation was obviated in the majority parts of the LPV antrum. LPV, pulmonary vein; EIVOM, ethanol infusion into the vein of Marshall; RFCA, radiofrequency catheter ablation; LA, left atrial; AF, atrial fibrillation; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; PVI, pulmonary vein isolation.

Figure 3. Acute reconnection distribution. Location at areas of acute pulmonary vein reconnection determined by the mapping of gaps in ablation lesions set. RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein.

Figure 4. Distribution of LPVs antrum ablated by EIVOM. The lesions ablated by ethanol were not limited to the anterior LPV, but extended to posterior LPV and even the entire LPV antrum. LPV, left pulmonary vein; EIVOM, ethanol infusion into the vein of Marshall; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein.

Figure 5. Procedural characteristics and the locations of the left PV gaps received repeat ablation. *Multiple mechanisms participated in the development of AFL in these two patients. AT, atrial tachycardia; AFL, atrial flutter; PAF, paroxysmal atrial fibrillation; PeAF, persistent atrial fibrillation; SVC, superior vena cava; MI, mitral isthmus; VOM, vein of Marshall; CTI, cavotricuspid isthmus; RPV, right pulmonary vein; LPV, left pulmonary vein; BPV, bilateral pulmonary vein; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; RSPV, right superior pulmonary vein; PVR, pulmonary vein reconnection.

Figure 6. A representative procedural example of VOM-mediated PV connection ablated by ethanol infusion. (A, D) VOM venogram before and after EIVOM. VOM ostia was adjacent to CS7–8 through venography. (B, C) Pacing at the conductive gap (site of the catheter), the atrium was captured and the earliest atrial activation was recorded at the CS7–8. (E, F) After EIVOM, the low voltage area extended to the ridge and posterior wall. Pacing at this site again, the atrium was lost of capture and the atrial activation sequence was changed. CS, coronary sinus; EIVOM, ethanol infusion into the vein of Marshall; RAO, right anterior oblique view.