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Review
. 2024 Apr 22;13(8):2438.
doi: 10.3390/jcm13082438.

Vein of Marshall Ethanol Infusion for AF Ablation; A Review

Louisa O'Neill  1   2   3 , Benjamin De Becker  1 , Maarten De Smet  1 , Clara Francois  1 , Rene Tavernier  1 , Mattias Duytschaever  1 , Jean-Benoit Le Polain De Waroux  1 , Sebastien Knecht  1
Affiliations
Review

Vein of Marshall Ethanol Infusion for AF Ablation; A Review

Louisa O'Neill et al. J Clin Med. .

Abstract

The outcomes of persistent atrial fibrillation (AF) ablation are modest with various adjunctive strategies beyond pulmonary vein isolation (PVI) yielding largely disappointing results in randomised controlled trials. Linear ablation is a commonly employed adjunct strategy but is limited by difficulty in achieving durable bidirectional block, particularly at the mitral isthmus. Epicardial connections play a role in AF initiation and perpetuation. The ligament of Marshall has been implicated as a source of AF triggers and is known to harbour sympathetic and parasympathetic nerve fibres that contribute to AF perpetuation. Ethanol infusion into the Vein of Marshall, a remnant of the superior vena cava and key component of the ligament of Marshall, may eliminate these AF triggers and can facilitate the ease of obtaining durable mitral isthmus block. While early trials have demonstrated the potential of Vein of Marshall 'ethanolisation' to reduce arrhythmia recurrence after persistent AF ablation, further randomised trials are needed to fully determine the potential long-term outcome benefits afforded by this technique.

Keywords: Vein of Marshall; atrial fibrillation; ethanol infusion; mitral isthmus ablation.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Contrast injection of Vein of Marshall (VoM) (red arrow) through the internal mammary artery (IMA) catheter in the right anterior oblique (RAO) view. Pentaray catheter is visualised in left atrium. Decapolar catheter in coronary sinus. IMA = internal mammary artery, RAO = right anterior oblique.
Figure 2
Figure 2
(Top panel): voltage map before VoM ethanolisation. (Bottom panel): voltage map demonstrating VoM ‘effect’ with new area of confluent scar inferior and anterior to left pulmonary veins. Ablation tags at mitral isthmus indicate the site of endocardial ablation performed to achieve mitral isthmus block post VoM ethanolisation.
Figure 3
Figure 3
Effects of VoM ethanol infusion on posterior wall, with extensive low voltage seen both panels (right sided veins already isolated in right panel).
See this image and copyright information in PMC

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