Key result
First-line VOM ethanol and linear ablation linked to ~64% lower arrhythmia recurrence versus PVI alone.
Why the study?
Pulmonary vein isolation has limited efficacy in persistent atrial fibrillation, while strategies combining PVI, vein of Marshall ethanol infusion, and anatomical isthmus ablation have shown promising short-term outcomes.
Cohort (n=226)
Yes
Multicenter cohort study demonstrates superior arrhythmia-free survival with vein of Marshall ethanol infusion in persistent atrial fibrillation, indicating clear benefits over isolation alone.
PURPOSE: Pulmonary vein isolation (PVI) ablation has limited efficacy in persistent atrial fibrillation (PeAF). Anatomical strategies combining PVI, vein of Marshall ethanol infusion (VOM-EI), and an anatomical ablation strategy (AS) targeting key atrial isthmuses have shown promising short-term outcomes in this setting. METHODS: In this retrospective multicenter observational cohort study, consecutive patients with PeAF who underwent either VOM-EI + AS or PVI-only were included. The primary endpoint was freedom from atrial arrhythmias (AAs) lasting > 30 s off antiarrhythmic drugs (AADs). Procedural characteristics and safety outcomes were also evaluated. RESULTS: After 2:1 propensity score matching, 151 patients treated with VOM-EI + AS were compared with 75 treated with PVI-only. After a median follow-up of 22-month (interquartile range (IQR): 9-35 months), 81% vs. 47% of patients remained free from AA without AADs in the VOM-EI + AS vs. PVI-only group (p < 0.001). Achievement of bidirectional mitral isthmus (MI) block was the strongest independent predictor of arrhythmia-free survival (HR = 0.114; 95% CI: 0.041-0.321; p < 0.001). On the contrary, long-standing PeAF was independently associated with a higher risk of atrial arrhythmic recurrence (HR = 2.68; 95% CI: 1.240-5.812; p = 0.012). CONCLUSIONS: In a real-world PeAF population, a first ablation strategy incorporating VOM-EI, PVI and anatomical linear lesions was significantly more effective than PVI alone in preventing arrhythmic recurrences in a long-term follow-up. Bidirectional block validation across the mitral line and AF duration are key determinants of long-term success. In patients with persistent atrial fibrillation, a first-procedure ablation including vein of Marshall ethanol infusion and an anatomical ablation strategy combining pulmonary vein isolation and linear lesions significantly improved long-term arrhythmia-free survival compared with pulmonary vein isolation alone.
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Iavarone et al. (2026) conducted a cohort in Persistent atrial fibrillation (n=226). Vein of Marshall ethanol infusion (VOM-EI) + anatomical ablation strategy (AS) vs. Pulmonary vein isolation (PVI) only was evaluated on Freedom from atrial arrhythmias lasting > 30 s off antiarrhythmic drugs (p=<0.001). A first ablation strategy incorporating vein of Marshall ethanol infusion and anatomical linear lesions resulted in 81% freedom from atrial arrhythmias compared to 47% with PVI alone (p<0.001).
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