The impact of empirical Marshall vein ethanol infusion as a first-choice intraoperative strategy on the long-term outcomes in patients with persistent atrial fibrillation undergoing mitral isthmus ablation

Xianfeng Du; Chenxu Luo; Caijie Shen; Yao Xu; Mingjun Feng; He Jin; Guohua Fu; Binhao Wang; Jin Liu; Fang Gao; Huimin Chu

doi:10.3389/fcvm.2023.1223064

The impact of empirical Marshall vein ethanol infusion as a first-choice intraoperative strategy on the long-term outcomes in patients with persistent atrial fibrillation undergoing mitral isthmus ablation

Front Cardiovasc Med. 2023 Aug 15:10:1223064. doi: 10.3389/fcvm.2023.1223064. eCollection 2023.

Authors

Xianfeng Du^#^{1

2}, Chenxu Luo^#^{1

3}, Caijie Shen^{1

2}, Yao Xu⁴, Mingjun Feng^{1

2}, He Jin^{1

2}, Guohua Fu^{1

2}, Binhao Wang^{1

2}, Jin Liu^{1

2}, Fang Gao^{1

2}, Huimin Chu^{1

2}

Affiliations

¹ Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China.
² Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China.
³ School of Medicine, Ningbo University, Ningbo, China.
⁴ Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo City, China.

^# Contributed equally.

Abstract

Background: Marshall vein ethanol infusion (MVEI) as an additional therapy to conventional catheter ablation (CA) has been proved to be efficacious in patients with persistent atrial fibrillation (PeAF). However, whether empirical MVEI could be the first-line strategy in mitral isthmus (MI) ablation has seldom been investigated. Here, we aim to compare the efficacy, safety, and long-term outcomes between provisional and empirical MVEI in PeAF patients undergoing the index MI ablation procedure.

Methods: We enrolled 133 patients with PeAF either in the provisional group (n = 38, MVEI was performed when conventional endocardial and/or epicardial ablation procedures were inadequate to achieve bidirectional MI block) or in the empirical group (n = 95, MVEI was performed empirically before MI CA).

Results: All of the baseline characteristics were comparable. Less spontaneous or inducible atrial tachycardias (ATs) were encountered in the empirical group of patients (P < 0.001). More epicardial ablations were applied (26.3% vs. 9.5%, P = 0.016) and a higher incidence of CA-facilitated restoration of sinus rhythm was recorded (86.8% vs. 11.7%, P < 0.001) in the provisional group of patients. Although more fluoroscopy time (6.4[4.2, 9.3] vs. 9.5[5.9, 11.6] min, P = 0.019) and radiation exposure (69.0[25.3, 160.2] vs. 122.0[62.5, 234.1] mGy, P = 0.010) were documented in the empirical group with comparable procedure time, less time (455.9 ± 192.2 vs. 366.5 ± 161.3 s, P = 0.038) was consumed to achieve bidirectional MI block during endocardial ablation in the provisional group. Incidences of procedure-related complications were similar between the two groups. During a 16.5 ± 4.4-month follow-up, the empirical group of patients showed a significantly higher rate of freedom from AT recurrence (95.8% vs. 81.6%, log-rank P = 0.003), while the rate of freedom from AF or atrial tachyarrhythmias (combining AF and AT) was similar. Both univariate (HR 0.19, 95% CI 0.05-0.64, P = 0.008) and multivariate (HR 0.25, 95% CI 0.07-0.92, P = 0.037) Cox regression analyses indicated that empirical MVEI was independently associated with lower long-term AT recurrence.

Conclusion: Among patients with PeAF who underwent the index MI ablation procedure, empirical MVEI could reduce endocardial MI ablation time and provide greater long-term freedom from AT recurrence.

Keywords: Marshall vein; atrial fibrillation; catheter ablation; ethanol infusion; mitral isthmus.

Grants and funding

This work was supported by the Medical Health Science and Technology Projects of Zhejiang Province Health Commission (2022KY302, 2020KY821, and 2019KY162), the Key Technology R&D Program of Ningbo (2022Z149), and the Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province (2022E10026).