PO-01-064 IMPROVED METHOD FOR VEIN OF MARSHALL ALCOHOL ABLATION: CASE SERIES

Abstract

Vein of Marshall (VoM) alcohol ablation has emerged as a successful method to reduce recurrence of atrial fibrillation (AF) and atrial tachyarrhythmias in patients with persistent AF. Cannulation of the VoM close to the coronary sinus (CS) ostium with an IMA guiding catheter through an unsupported CS access catheter can be challenging; extending procedure/fluoroscopy time, contrast use, and increase the risk of complications. To describe new tools & techniques for VoM alcohol ablation that make the procedure easier. We describe here an improved method for VoM alcohol ablation in 4 patients following AF ablation. A baseline 3D left atrium voltage map was obtained to assess pre-existing scar (local bipolar voltage of <0.1 mV). The CS was cannulated via the right femoral vein with either a 6 French (F) decapolar catheter or a hand-shaped 6F multipurpose guiding catheter telescoped inside a long curved 9F inner diameter (ID) sheath. The sheath was then advanced into the CS body. Next, a 0.035 in Amplatz wire (short taper) was introduced through the sheath into the CS using a 5F outer diameter (OD) vein selector to provide extra support and facilitate easy re-cannulation of the CS in case the outer sheath disengaged. An occlusive venogram was conducted in RAO 20 view. After the identification of the VoM, a 5F vein selector was used to engage it and a 0.014 mm floppy wire was advanced. An over-the-wire angioplasty balloon (size 1.5 to 2mm x 6mm) was advanced in the VoM and dilated to occlude the vessel. Three ml of 98% ethanol were delivered over 1 minute. This process was repeated twice. The balloon was deflated, and the apparatus was retracted into the sheath. We then proceeded with repeat 3D voltage mapping to assess the ethanol-induced scar. Application of this workflow using these tools reduced the use of contrast, fluoroscopy time, and total procedural time in this case series. What is new: 1. The ID of the CS access sheath was increased to 9F. 2. An Amplatz (short taper) stabilizing/support wire was added to the CS access sheath. 3. The shape of the catheter used to engage the VOM was changed from IMA to vertebral. Application of these tools reduced the use of contrast, fluoroscopy time, and total procedural time.