Abstract 19336: Vein of Marshall Triggers and Pulmonary Vein Reconnection in Recurrent Atrial Fibrillation After Catheter Ablation: Therapeutic Role of Ethanol Infusion
Background: Atrial fibrillation (AF) recurrences occur after pulmonary vein (PV) antral isolation (PVAI). We have shown safety and feasibility of ethanol infusion in the vein of Marshall (VOM) as an ablation strategy, and hypothesized that VOM plays a role providing AF triggers and mediating left PV reconnection in recurrent AF.
Methods and Results: 10 (5 paroxysmal, 5 persistent) patients with recurrent AF after PVAI were studied. VOM electrograms were recorded in 8 using a 1.7F multipolar catheter. PV electrograms were recorded with a circular multipolar catheter, and showed left PV reconnection in 7 patients (inferior PV in 7, superior in 6). VOM high-frequency stimulation (HFS, 20–100Hz) stimulated AF or flutter in 5/6 patients. Left inferior PV ectopy showed conduction via VOM in two patients. The VOM was cannulated with an angioplasty wire, over which a balloon (8x2mm) was advanced as distally as possible. Up to four 1cc infusions of 100% ethanol were delivered at different levels (distal to proximal) of the VOM. Ethanol infusion successfully eliminated left inferior PV reconnection in all patients without requiring radiofrequency ablation. There were no acute procedural complications. A large area of scar was created in the postero-lateral left atrium. VOM ethanol infusion abolished arrhythmia induction by VOM HFS in all patients. Perimitral flutter was induced in 3 patients that required ablation at a single site in the most anterior mitral isthmus to achieve termination. Post procedure delayed-enhanced MRI at 3 months showed scar in the lateral ridge corresponding to VOM location.
Conclusions: Epicardial connections and triggers (unmasked by HFS) via the VOM may play a role in AF recurrences after ablation. Ethanol infusion in the VOM successfully eliminates PV reconnection and triggers, and may help achieve mitral isthmus block.
- © 2010 by American Heart Association, Inc.