Vein of Marshall ethanol infusion performed in single day discharge. Is it safe and feasible?

Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF) [1], but for persistent AF PVI appears to be suboptimal and any kind of additional lesion has been proven to not enhance the efficacy of the ablation [2-3]. In this setting, the Vein of Marshall ethanol infusion (VOM-EI) has shown to improve the efficacy of AF ablation as compared to PVI [4]. In all previous studies VOM-EI and AF ablation were different step of the same procedure [5]. Nevertheless, performing voltage map right after the VOM-EI could lead to an overestimation of ethanol-induced scar due to the possibility of certain amount of reversible oedema. For that reason, we started performing VOM ethanol infusion in day surgery setting one month before the ablation procedure, demonstrating that VOM-EI related scar is indeed smaller as compared to conventional procedure.

To evaluate safety, efficacy and feasibility of single day discharge VOM-EI.

All patients referred for de novo ablation of persistent AF have been enrolled. In day 0 VOM-EI was performed according to previously described method (5) but by echo-guided left axillary vein access. Ethanol infusion was considered successful if repeat angiograms between the 3 injections showed: stability of the angioplasty balloon; visualization of the distal VOM arborization; absence of contrast leakage back in the coronary sinus; absence or limited dissection of the VOM; and progressive appearance of tissue contrast staining (tattoo).

Mean procedure time was 39,1±7,8 min and X-Ray time was 4,2±0,9 min. At least 30 days after ablation procedure was performed using The Bordeaux group protocol (PVI, ridge and saddle, posteriors box, mitral isthmus and cavo-tricuspid isthmus). We compared our data with previously published 700 patients cohort [5]

We enrolled 63 patients (81% male, 67±7.6 years old). Analyzing the safety, rate of failure and feasibility of the procedure we demonstrated that single day discharge is comparable to ordinary setting for VOM-EI. Failure rate was 19% (6% due to non-identification of VOM, 13% due to VOM dissection), peri-operative complication rate was 3.2%: notably there were only pericarditis without neither significant pericardial effusion nor cardiac tamponade (which was 1% in Kamakura cohort). This would probably be related to the absence of heparin treatment which is needed for the ablation procedure protocol in the conventional procedure.

These preliminary data shows that VOM-EI in day surgery is feasible and very promising in terms of safety. It would be also theoretically more effective in improving long term efficacy of AF ablation but this needs to be addressed in specific trial.

Map of the Scar