Vein of marshall ethanol infusion at the time of repeated ablation in persistent atrial fibrillation patients (Italian VERA Study)

Background Repeated catheter ablation for persistent atrial fibrillation (PeAF) is associated with high recurrence rates, and the optimal procedural strategy remains undefined. An anatomical ablation approach incorporating vein of Marshall ethanol infusion (VOM-EI) combined with linear lesion sets has demonstrated favourable outcomes in de novo PeAF, but its role in redo procedures remains poorly investigated. Purpose To evaluate the impact of an anatomical ablation strategy combining VOM-EI with a predefined linear lesion set on atrial arrhythmia (AA) recurrence after redo catheter ablation in PeAF, compared with a cohort of patients undergoing a substrate based approach (PVI- linear lesions-, EGM- or trigger-based catheter ablation), and to assess its efficacy across procedural subgroups. Methods This multicenter, observational, retrospective study included 263 PeAF patients. Patients were treated with either an anatomical strategy incorporating VOM-EI or conventional substrate-based approaches (PVI or PVI+). Propensity score matching (1:1) was performed to balance baseline characteristics. Univariable and multivariable Cox regression models were performed to adjust for confounders. Results Among 263 patients, 121 underwent VOM-EI combined with anatomical ablation and 142 received standard strategies. After matching, 111 patients were included in each group. During follow-up, AA recurrence occurred in 42% of controls vs 20% of VOM-EI patients (p < 0.01), with early and sustained separation of survival curves. In multivariable Cox regression analysis, VOM-EI remained independently associated with a more favourable outcome compared with the PVI/PVI+ cohort, with a lower recurrence risk (HR 0.35, 95% CI 0.14–0.89; p = 0.028). The benefit was preserved in the subgroup of patients without pulmonary veins (PV) reconnection. Conclusions A standardized approach combining VOM-EI with a predefined anatomical setup significantly reduces AA recurrence compared with conventional substrate-based approaches at time of redo ablation in a PeAF population. The effect seems to be preserved in patients without PV reconnection, supporting the role of VOM-EI as a key component of redo ablation strategies for PeAF.