Elsevier

Heart Rhythm

Volume 18, Issue 4, April 2021, Pages 529-537
Heart Rhythm

Clinical
Atrial Fibrillation
Marshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation (Marshall-PLAN): Prospective, single-center study

https://doi.org/10.1016/j.hrthm.2020.12.023Get rights and content

Background

Beyond pulmonary vein isolation (PVI), the optimal ablation strategy for persistent atrial fibrillation (AF) remains poorly defined.

Objective

The purpose of this study was to examine a novel comprehensive ablation strategy (Marshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation [Marshall-PLAN]) strictly based on anatomical considerations.

Methods

Left atrial (LA) sites were sequentially targeted as follows: (1) coronary sinus and vein of Marshall (CS-VOM) musculature; (2) PVI; and (3) anatomical isthmuses (mitral, roof, and cavotricuspid isthmus [CTI]). The primary endpoint was 12-month freedom from AF/atrial tachycardia (AT).

Results

Seventy-five consecutive patients were included (age 61 ± 9 years; 10 women; AF duration 9 ± 11 months; mean LA volume 197 ± 43 mL). VOM ethanol infusion was completed in 69 patients (92%). The full Marshall-PLAN lesion set (VOM, PVI, mitral, roof, and CTI with block) was successfully completed in 68 patients (91%). At 12 months, 54 of 75 patients (72%) were free from AF/AT after a single procedure (no antiarrhythmic drugs) in the overall cohort. In the subset of patients with a complete Marshall-PLAN lesion set (n = 68), the single procedure success rate was 79%. After 1 or 2 procedures, 67 of 75 patients (89%) remained free from AF/AT (no antiarrhythmic drugs). After 1 or 2 procedures, VOM ethanol infusion was complete in 72 of 75 patients (96%).

Conclusion

A novel ablation strategy that systematically targets anatomical atrial structures (VOM ethanol infusion, PVI, and prespecified linear lesions) is feasible, safe, and associated with a high rate of freedom from arrhythmia recurrence at 12 months in patients with persistent AF.

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)

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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.

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