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Background <p>The vein of Marshall (VoM) is a promising therapeutic target for persistent atrial fibrillation (PeAF) treatment. Ethanol infusion into the VoM (VoM-EI) has demonstrated high effectiveness in facilitating mitral isthmus (MI) block, a fundamental part of the anatomical ablation setup for the treatment of PeAF. However, reliable indexes for optimal ethanol delivery are still lacking, and the role of voltage analysis after VoM-EI in predicting MI block has been poorly explored.</p> Purpose <p>To evaluate the role of voltage analysis after VoM-EI in predicting acute bidirectional MI block and the need of coronary sinus (CS) radiofrequency (RF) applications.</p> Methods <p>Fifty-three PeAF patients who underwent catheter ablation were retrospectively enrolled. Left atrial (LA) high-density bipolar voltage mapping was performed before and after VoM-EI. Low voltage areas (LVA) were assessed for all LA maps using the area measurement tool, and the difference in area width between pre- and post-VoM-EI was defined as ∆LVA. An anatomical lesion set including VoM-EI, pulmonary vein isolation (PVI) and linear lesion for dome, lateral MI, and cavo-tricuspid isthmus (CTI) was performed. In case of residual conduction across MI, additional endocardial and/or epicardial ablations approaching the CS musculature were performed. The time required to achieve bidirectional MI block (AblTime-MI) was collected and the VoM length was measured.</p> Results <p>Forty-eight out of 53 patients enrolled (90.5%) achieved acute bidirectional MI block. After VoM-EI, mean bipolar ∆LVA was 6.6 ± 4.4 cm<sup>2</sup>, and mean AblTime-MI was 14.7 ± 10.4&#xa0;min. RF applications targeting CS musculature were required in 22/53 patients (41.5%). Linear regression showed a strong inverse correlation between ∆LVA and AblTime-MI (<i>r</i> = −0.70, <i>β</i> = −128.2; 95% CI −165.3, −91.2; <i>p</i> &lt; 0.001). Patients with higher ∆LVA were less likely to need CS applications [OR = 0.70 (95% CI 0.56–0.88); <i>p</i> = 0.002]. Patients requiring CS applications had significantly longer AblTime-MI (21.0 ± 9.0&#xa0;min vs 8.8 ± 8.2&#xa0;min; <i>p</i> &lt; 0.001), and larger left atrial volume index (LAVI) (37.0 ± 10.0&#xa0;ml/m<sup>2</sup> vs 31.8 ± 6.6&#xa0;ml/m<sup>2</sup>; <i>p</i> = 0.03). ∆LVA showed the best performance in predicting the need for CS applications (AUC 0.79) with a threshold of &lt; 5.30 cm<sup>2</sup> associated with a higher risk of requiring additional RF applications.</p> Conclusions <p>VoM-EI-induced LA lesions align with VoM trajectory and anatomy. Larger ∆LVA correlates with shorter ablation time for bidirectional MI block and predicts fewer residual epicardial MI gaps requiring RF application in CS musculature. ∆LVA represents a reliable indicator of VoM-EI effectiveness, predicting MI block failure due to epicardial gaps.</p> Graphical Abstract <p>VoM-EI is a useful technique in the treatment of PeAF, producing lesions consistent with the vein of Marshall trajectory. We identified the extent of newly formed low-voltage area (ΔLVA) as a reliable marker of ethanol delivery effectiveness, reflecting its impact on reducing ablation time required for MI block. Larger ΔLVA was associated with shorter ablation times, whereas values &lt; 5.3 cm² identified patients who required additional CS ablation.Abbreviations: PeAF, Persistent atrial fibrillation; VoM-EI, Vein of Marshall ethanol infusion; LVA, Low voltage area; LA, Left atrium; MI, Mitral isthmus; CS, Coronary sinus</p> <p></p>

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Atrial bipolar voltage analysis to assess vein of Marshall ethanol infusion acute effectiveness and its implication in predicting mitral isthmus block

  • 期刊论文

  • 发表日期：

    2025年9月27日

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  • Simone Taddeucci,
  • Silvia Garibaldi,
  • Martina Nesti,
  • Umberto Startari,
  • Luca Panchetti,
  • Gianluca Mirizzi,
  • Federico Landra,
  • Vincenzo Lionetti,
  • Marcello Piacenti,
  • Procolo Marchese,
  • Andrea Rossi

摘要

Background

The vein of Marshall (VoM) is a promising therapeutic target for persistent atrial fibrillation (PeAF) treatment. Ethanol infusion into the VoM (VoM-EI) has demonstrated high effectiveness in facilitating mitral isthmus (MI) block, a fundamental part of the anatomical ablation setup for the treatment of PeAF. However, reliable indexes for optimal ethanol delivery are still lacking, and the role of voltage analysis after VoM-EI in predicting MI block has been poorly explored.

Purpose

To evaluate the role of voltage analysis after VoM-EI in predicting acute bidirectional MI block and the need of coronary sinus (CS) radiofrequency (RF) applications.

Methods

Fifty-three PeAF patients who underwent catheter ablation were retrospectively enrolled. Left atrial (LA) high-density bipolar voltage mapping was performed before and after VoM-EI. Low voltage areas (LVA) were assessed for all LA maps using the area measurement tool, and the difference in area width between pre- and post-VoM-EI was defined as ∆LVA. An anatomical lesion set including VoM-EI, pulmonary vein isolation (PVI) and linear lesion for dome, lateral MI, and cavo-tricuspid isthmus (CTI) was performed. In case of residual conduction across MI, additional endocardial and/or epicardial ablations approaching the CS musculature were performed. The time required to achieve bidirectional MI block (AblTime-MI) was collected and the VoM length was measured.

Results

Forty-eight out of 53 patients enrolled (90.5%) achieved acute bidirectional MI block. After VoM-EI, mean bipolar ∆LVA was 6.6 ± 4.4 cm2, and mean AblTime-MI was 14.7 ± 10.4 min. RF applications targeting CS musculature were required in 22/53 patients (41.5%). Linear regression showed a strong inverse correlation between ∆LVA and AblTime-MI (r = −0.70, β = −128.2; 95% CI −165.3, −91.2; p < 0.001). Patients with higher ∆LVA were less likely to need CS applications [OR = 0.70 (95% CI 0.56–0.88); p = 0.002]. Patients requiring CS applications had significantly longer AblTime-MI (21.0 ± 9.0 min vs 8.8 ± 8.2 min; p < 0.001), and larger left atrial volume index (LAVI) (37.0 ± 10.0 ml/m2 vs 31.8 ± 6.6 ml/m2; p = 0.03). ∆LVA showed the best performance in predicting the need for CS applications (AUC 0.79) with a threshold of < 5.30 cm2 associated with a higher risk of requiring additional RF applications.

Conclusions

VoM-EI-induced LA lesions align with VoM trajectory and anatomy. Larger ∆LVA correlates with shorter ablation time for bidirectional MI block and predicts fewer residual epicardial MI gaps requiring RF application in CS musculature. ∆LVA represents a reliable indicator of VoM-EI effectiveness, predicting MI block failure due to epicardial gaps.

Graphical Abstract

VoM-EI is a useful technique in the treatment of PeAF, producing lesions consistent with the vein of Marshall trajectory. We identified the extent of newly formed low-voltage area (ΔLVA) as a reliable marker of ethanol delivery effectiveness, reflecting its impact on reducing ablation time required for MI block. Larger ΔLVA was associated with shorter ablation times, whereas values < 5.3 cm² identified patients who required additional CS ablation.Abbreviations: PeAF, Persistent atrial fibrillation; VoM-EI, Vein of Marshall ethanol infusion; LVA, Low voltage area; LA, Left atrium; MI, Mitral isthmus; CS, Coronary sinus