Korean Circ J.  2015 Sep;45(5):424-427. 10.4070/kcj.2015.45.5.424.

Ethanol Infusion in the Vein of Marshall in a Patient with Persistent Atrial Fibrillation

• Choi JY
• Park EJ
• Kim HD
• Park SH
• Song JY
• Lee DI
• Shim J
• Kim YH

• KMID: 2223807
• DOI: http://doi.org/10.4070/kcj.2015.45.5.424

Abstract

We report the case of a 64-year-old male with persistent atrial fibrillation (AF) terminated by ethanol infusion into vein of Marshall as add-on therapy. Three-dimensional automated complex fractionated atrial electrogram (CFAE) during AF revealed clustering of CFAE at perimitral isthmus (PMI) and its unipolar mapping showed rotor-like activation, which was suggested to be critical in the perpetuation of AF. AF was organized to atrial tachycardia (AT) by 100% ethanol infusion in the vein of Marshall. Adjunctive radiofrequency ablation at PMI successfully terminated AT and led to bidirectional block of PMI.

Keyword

Atrial fibrillation; Catheter ablation

MeSH Terms

Atrial Fibrillation*
Catheter Ablation
Electrophysiologic Techniques, Cardiac
Ethanol*
Humans
Male
Middle Aged
Tachycardia
Veins*
Ethanol

Figure

• 

  Fig. 1 CFAE mapping and unipolar mapping in LA after PVI. CFAE mapping (A and B) shows multiple CFAE areas which were located at LA septum, LAA base, PMI and posterior-inferior area. Unipolar mapping revealed reentrant atrial electrical activity at perimitral area (C). CFAE: complex fractionated atrial electrogram, LA: left atrium/left atrial, LAA: left atrial appendage, PVI: pulmonary vein isolation, PMI: perimitral isthmus.

• 

  Fig. 2 Procedure of ethanol infusion into VOM. CS was cannulated by SL1 sheath and CS venogram using balloon catheter revealed VOM (A). Angioplastic wire (Hi-Torque Floppy II guidewire 0.014, Abbott) over guiding catheter (Multipurpose A-1 guiding catheter 7 Fr, Cordis) passed through VOM (B). After ethanol infusion, angiographic contrast was stained at the tissue around VOM (C). VOM: vein of Marshall, CS: coronary sinus.

• 

  Fig. 3 Electrogram changes during the procedure. Electrograms during ethanol infusion into VOM shows that AF was organized to AT within 30 seconds after first ethanol infusion (A). Activation mapping demonstrates the perimitral flutter (B and C). AT was terminated by endocardial ablation at perimitral isthmus (D). VOM: vein of Marshall, AF: atrial fibrillation, AT: atrial tachycardia.

• 

  Fig. 4 Conduction block achievement of PMI. During atrial premature complexes from LAA, CS electrogram shows distal to proximal activation (A). After ethanol injection into VOM with additional ablation at PMI, LAA pacing shows proximal to distal activation which means conduction block of PMI (B). The fluoroscopic image, left anterior oblique, showing position of ablation catheter and coronary catheter (C). PMI: perimitral isthmus, LAA: leftatrium appendage, CS: coronary sinus, VOM: vein of Marshall, CSpx: proximal part of coronary sinuscatheter, CSds: distal part of coronary sinus catheter, ABLd: distal part of ablation catheter.

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