Elimination of non-pulmonary vein ectopy by ethanol infusion in the vein of Marshall

Abstract

Myocardial fibers and nerves adjacent to the vein of Marshall (VOM), that is, the ligament of Marshall (LOM), have been implicated as a source of ectopic beats initiating paroxysmal atrial fibrillation (AF), 1 Lin W.S. Tai C.T. Hsieh M.H. et al. Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation. 2003; 107: 3176-3183 Crossref PubMed Scopus (584) Google Scholar as a connection pathway between the left atrium (LA) and left pulmonary veins (PVs), 2 Hwang C. Chen P.S. Ligament of Marshall: why it is important for atrial fibrillation ablation. Heart Rhythm. 2009; 6: S35-S40 Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar , 3 Dave A.S. Báez-Escudero J.L. Sasaridis C. Hong T.E. Rami T. Valderrábano M. Role of the vein of Marshall in atrial fibrillation recurrences after catheter ablation: therapeutic effect of ethanol infusion. J Cardiovasc Electrophysiol. 2012; 23: 583-591 Crossref PubMed Scopus (45) Google Scholar and as a source of arrhythmogenic autonomic innervation. 4 Kamanu S. Tan A.Y. Peter C.T. Hwang C. Chen P.S. Vein of Marshall activity during sustained atrial fibrillation. J Cardiovasc Electrophysiol. 2006; 17: 839-846 Crossref PubMed Scopus (44) Google Scholar , 5 Valderrábano M. Chen H.R. Sidhu J. Rao L. Ling Y. Khoury D.S. Retrograde ethanol infusion in the vein of Marshall: regional left atrial ablation, vagal denervation and feasibility in humans. Circ Arrhythm Electrophysiol. 2009; 2: 50-56 Crossref PubMed Scopus (76) Google Scholar This various complex nature of the LOM can constitute the genesis of AF. On the other hand, the VOM location coincides with the areas usually ablated during PV isolation. It has recently been reported that VOM ethanol infusion creates a low-voltage area in the LA adjacent to the VOM and facilitates left PV isolation for AF ablation. 6 Valderrábano M. Liu X. Sasaridis C. Sidhu J. Little S. Khoury D.S. Ethanol infusion in the vein of Marshall: adjunctive effects during ablation of atrial fibrillation. Heart Rhythm. 2009; 6: 1552-1558 Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar This advocates that VOM ethanol infusion has favorable adjunctive effects on PV isolation by radiofrequency (RF) ablation. However, considering the roles that the LOM plays in the pathogenesis of AF, VOM ethanol infusion alone may cure AF in some patients. In this report, we describe the first case that underwent VOM ethanol infusion and had non-PV ectopy initiating AF that is eliminated without RF ablation for PV isolation.