ClinicalAtrial FibrillationMarshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation (Marshall-PLAN): Prospective, single-center study
Introduction
Catheter ablation is an established treatment strategy for patients with drug-refractory atrial fibrillation (AF). However, the success rates in patients with persistent AF remain modest.1 Current ablation strategies for treatment of persistent AF can be broadly categorized into tailored approaches, aimed at eliminating sources of AF maintenance, and anatomical approaches in which the left atrium (LA) is electrically partitioned by predefined linear lesion sets. Although effective at terminating AF in the acute setting, tailored approaches have been associated with a high risk of subsequent organized atrial tachycardias (ATs) and impairment of atrial function.2 Anatomical approaches have shown promise, but creating durable linear lesions remains challenging. To date, both approaches have failed to demonstrate superiority to pulmonary vein isolation (PVI) in prospective randomized trials.3
Here we report the results of a novel comprehensive ablation strategy for persistent AF that focuses on anatomical targets that have individually been recognized as important for AF initiation or maintenance but thus far have not been collectively targeted in a systematic manner. We hypothesized that our ablation strategy consisting of (1) PVI; (2) targeting of the vein of Marshall (VOM) and adjacent muscular tissue; and (3) a linear ablation set to block the 3 main anatomical isthmuses enhances arrhythmia-free survival.
Section snippets
Study population
All patients referred for de novo ablation of persistent AF were enrolled. Persistent AF was defined as continuous AF for 7 days to 12 months and longstanding persistent AF as continuous AF for >12 months. Patients with a history of hypertrophic cardiomyopathy were excluded. All patients provided written consent to participate in the study. The study was approved by Institutional Review Board at CHU Bordeaux.
General principles
In the subset of patients with persistent AF in whom sinus rhythm was restored before
Patient characteristics
Seventy-five consecutive patients were included in the study. Baseline characteristics are summarized in Table 1. Mean age was 61 ± 9 years, and 10 patients (13%) were female. Forty-five patients (60%) were in AF at the outset of the procedure, with a mean longest AF episode of 9 ± 11 months. Eighteen patients had longstanding persistent AF (maximum duration 60 months).
Step 1: Elimination of CS-VOM bundles
VOM ethanol infusion was completed in 69 patients (92%). A representative procedural example is shown in Figure 1. In the
Discussion
In this prospective, consecutive series of persistent AF patients treated with the Marshall-PLAN ablation strategy, our findings are as follows. ( 1) VOM ethanol ablation was successful in a high proportion of patients (92% single procedure, 96% after 1 or 2 procedure). (2) A full Marshall-PLAN lesion set with proven block (PVI, VOM ethanol infusion, roof, mitral, and CTI line) was feasible in >90% of patients. (3) The rates of major procedure-related complications are comparable to those of
Conclusion
The Marshall-PLAN ablation strategy for persistent AF is feasible, safe, and associated with sinus rhythm maintenance in >70% at 12 months after a single ablation procedure and without antiarrhythmic drugs. These results support the need for a larger, randomized trial to confirm the value of this anatomical approach.
References (19)
- et al.
Characterization of complex atrial tachycardia in patients with previous atrial interventions using high-resolution mapping
JACC Clin Electrophysiol
(2020) - et al.
Ethanol infusion in the vein of Marshall facilitates mitral isthmus ablation
Heart Rhythm
(2012) - et al.
Durability of posterior wall isolation after catheter ablation among patients with recurrent atrial fibrillation
Heart Rhythm
(2020) Percutaneous epicardial ablation of atrial fibrillation
Card Electrophysiol Clin
(2020)- et al.
Epicardial-endocardial breakthrough during stable atrial macroreentry: evidence from ultra–high-resolution 3-dimensional mapping
Heart Rhythm
(2017) - et al.
Ligament and vein of Marshall: a therapeutic opportunity in atrial fibrillation
Heart Rhythm
(2016) - et al.
Outcomes of persistent and long-standing persistent atrial fibrillation ablation: a systematic review and meta-analysis
Europace
(2018) - et al.
Approaches to catheter ablation for persistent atrial fibrillation
N Engl J Med
(2015) - et al.
MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation: MARSHALL-PLAN case series
J Cardiovasc Electrophysiol
(2019)
Cited by (61)
Repeat catheter ablation for atrial fibrillation
2024, Heart RhythmAcute mitral isthmus block during catheter ablation with vein of Marshall ethanol infusion: Angiographic considerations
2024, Archives of Cardiovascular DiseasesSelecting Persistent Atrial Fibrillation Patients for Adjunctive Right Atrial Ablation: When You're Right, You're Right
2024, Canadian Journal of Cardiology
Funding sources/Disclosures: This study received financial support from the French Government as part of the “Investments for the Future” program managed by the National Research Agency (ANR), Grant Reference ANR-10-IAHU-04. Dr Ramirez is supported by a Canadian Institutes of Health Research Banting Postdoctoral Fellowship. Dr Krisai is supported by the University of Basel, the Mach-Gaensslen Foundation, and the Bangerter-Rhyner Foundation. Drs Derval, Duchateau, Sacher, Mahida, and Pambrun received modest consulting fees and speaking honoraria from Biosense Webster. Drs Derval, Sacher, and Jaïs received modest speaking honoraria from Boston Scientific. All other authors have reported that they have no relationship relevant to the contents of this paper to disclose.