Case report: Vein of Marshall–catheter ablation combined with left atrial appendage occlusion for treatment of atrial fibrillation

Abstract

The utilization of the one-stop strategy for treating atrial fibrillation (AF) has been on the rise, but the combination of vein of Marshall catheter ablation with left atrial appendage occlusion has been rarely reported. In this case, a 62-year-old man with persistent AF underwent a one-stop strategy that included ethanol infusion in the vein of Marshall, radiofrequency catheter ablation, and left atrial appendage occlusion. The procedures successfully achieved ablation in the vein of Marshall, pulmonary vein isolation, and left atrial appendage occlusion. The feasibility and safety of this comprehensive strategy were evaluated during a 12-month follow-up. The dynamic ECG indicated the presence of sinus rhythm, and a cerebral CT scan confirmed the absence of silent ischemia. This case highlights a novel approach to treating atrial fibrillation and demonstrates promising outcomes for patients undergoing this combined procedure.

1. Introduction

Radiofrequency catheter ablation (RFCA) is a well-established therapeutic option for managing atrial fibrillation (AF), particularly in cases of drug-refractory paroxysmal AF [1]. However, relying solely on RFCA may not always be sufficient for achieving optimal rhythm control in individuals with persistent AF. This is often attributed to the challenges in attaining durable pulmonary vein isolation (PVI) and uncertainties surrounding the benefits of additional linear and complex fractionated electrogram ablation [2]. A novel approach that shows promise in addressing persistent AF involves ethanol infusion in the vein of Marshall [3]. This technique offers several advantages, including the elimination of AF triggers, facilitation of PVI and bidirectional peri-mitral block, local denervation, and interruption of pathological conduction pathways [4]. Ethanol infusion in the vein of Marshall (EIVOM) as an initial step for mitral isthmus linear ablation has been shown to significantly reduce the number of applications required to achieve mitral isthmus block [5]. A randomized controlled study has demonstrated that the addition of EIVOM to catheter ablation improves the efficacy of achieving rhythm control without a significant increase in complications when compared to catheter ablation alone [6].

There is a significant association between atrial fibrillation (AF) and stroke, with approximately 15 %–20 % of all ischemic strokes attributed to AF [7]. Individuals with AF face a fivefold increase in the risk of experiencing stroke events, leading to elevated mortality, morbidity, and recurrence rates. In cases of nonvalvular AF, the main cause of cardioembolic stroke is often thrombus formation within the left atrial appendage (LAA), accounting for around 90 % of cases. Consequently, LAA occlusion is recommended for patients with AF at a heightened risk of stroke who are unable to undergo long-term anticoagulation therapy [8]. Recently, the integration of EIVOM with LAA occlusion has been demonstrated to be a safe and effective approach for individuals with AF in a single procedure. The emerging trend towards combining catheter ablation for AF with left atrial appendage occlusion (LAAO) in a single procedure has garnered increasing attention [10].

The efficacy and safety of a one-stop strategy involving vein of Marshall catheter ablation combined with left atrial appendage occlusion in persistent atrial fibrillation have not been previously reported.

2. Case presentation

A 62-year-old male with a history of hypertension and heart failure presented with persistent atrial fibrillation (AF). He was treated with amlodipine for hypertension control. His baseline ECG showed typical AF along with left bundle branch block. He experienced paroxysmal palpitations with The European Heart Rhythm Association (ESRA) class 2b and was referred for AF ablation due to the potential benefits of maintaining sinus rhythm for heart failure management. Additionally, LAAO was performed during the same procedure as his CHA2DS2-VASc score was 3 and he declined long-term anticoagulation therapy. Preoperative echocardiographic evaluation revealed a left ventricular ejection fraction of 45 % and a dilated left atrium (anteroposterior diameter: 50mm) without any valvular abnormalities. He had heart failure with a mid-range ejection fraction and was asymptomatic with New York Heart Association (NYHA) class I. A CT angiography scan indicated that no thrombus was detected in the left atrial appendage.

The procedure was carried out under local anesthesia. The patient was administered heparin to achieve an activated clotting time target of >300 s. A 7F-long sheath was placed into the right atrium, and a 6F guiding catheter was inserted into the coronary sinus (CS) to locate the ostium of the vein of Marshall and obtain a venogram. An over-the-wire balloon catheter was then advanced into the vein of Marshall for selective angiography (Fig. 1A). Following the injection of 10 mL of 95 % ethanol, venography was repeated to confirm the success of the procedure (Fig. 1B). Subsequently, the Matrix after EIVOM was assessed using a three-dimensional electroanatomic mapping system, and a Pentaray® catheter (Biosense-Webster Inc.) was utilized for mitral isthmus ablation (Fig. 2A). The Pentaray® catheter was positioned at the ostia of each pulmonary vein of each pulmonary vein to verify the absence of pulmonary vein potential and isolation (Fig. 2B). During the ablation of the left atrium roof using a 3.5-mm saline-irrigated ablation catheter (ThermoCool Smart Touch SF® catheter, Biosense-Webster Inc.), the heart rhythm shifted to atrial flutter (AFL). To map the right atrium and identify AFL originating from the tricuspid valve, a decapolar mapping catheter (Deca, Biosense-Webster Inc.) - Cs9 was utilized for drag measurement (Fig. 2C). Subsequently, ablation was carried out from the tricuspid annulus at the 6 o'clock position towards the inferior vena cava, resulting in the restoration of sinus rhythm. Pacing validation using Cs9 confirmed tricuspid isthmus block (Fig. 2D). The ablation catheter was placed at LAA for pacing, and it was noted that the proximal electrode potential of the Deca catheter preceded that of the distal electrode, indicating mitral isthmus block (Fig. 2E).

Fig. 1.

EIVOM (A) the vein of Marshall in selective angiography, (B) selective angiography after EIVOM.

Fig. 2.

(A) Matrix map after EIVOM and the mitral isthmus ablation. The red area represents the low voltage zone (<0.1mV) (B) Ablation location of PVI (C) Atrial flutter dragging map: Early onset of CS90 with a circumference of 219 ms atrial flutter. After overdriving pacing, the tachycardia rate increases to the pacing rate. When pacing stopped, the tachycardia rate returned to original rate (D) Pacing verification map: The conduction time of the ablation catheter in the tricuspid isthmus area or downstream area was recorded during CS proximal pacing. The conduction time from the proximal end of CS to the ablation catheter area was significantly prolonged at 132 ms which indicated tricuspid isthmus block. (E) Pacing verification map: the ablation catheter was used to pace in the LAA, and CS electrodes are used to record in the mitral isthmus area (without crossing the line). The potential of CS proximal end was earlier than the distal end, and the order of atrial excitation changed, suggesting mitral isthmus block.

The morphology and dimensions of the LAA were visualized using an angiogram to guide the selection of the LAAO device (Fig. 3A). The LAmbre™ device (28∗34mm, Lifetech Scientific) was advanced into the LAA through the delivery sheath, and its stability was assessed using a tug test. Successful LAAO was defined as the correct deployment and positioning of the device, with no evidence of peri-device leakage on intraprocedural angiography (Fig. 3B).

Fig. 3.

(A) angiogram to select the LAAO device, (B) angiography after LAAO.

Following a 3-day hospital stay, the patient was discharged in sinus rhythm and prescribed a 3-month regimen of oral rivaroxaban and amiodarone therapy. At the 12-month follow-up, a dynamic electrocardiogram (ECG) confirmed sinus rhythm, and a cerebral CT scan revealed no signs of silent ischemia, indicating the safety and effectiveness of AF treatment procedure.

3. Discussion

The groundbreaking "proof of concept" study on a one-stop strategy for AF treatment was initially reported in 2012 [11]. In recent years, the one-stop strategy has gained widespread attention and has been implemented using various devices. Previous studies have extensively documented the feasibility and safety of the one-stop strategy, with the RECORD real-world study demonstrating that the combined use of RFCA and LAAO did not increase the risk of serious adverse events [12]. Moreover, research findings from other studies have indicated that the combination of EIVOM with RFCA yields similar clinical outcomes in terms of adverse events compared to individual procedures [9]. Therefore, our team sought to implement a one-stop strategy that combines EIVOM, RFCA, and LAAO to assess the feasibility and safety of this approach based on short-term outcomes.

Durable PVI has been shown to significantly enhance the success of ablation procedures [13]. Several studies have demonstrated the benefits of EIVOM in achieving efficient and long-lasting PVI [14]. Furthermore, EIVOM has been suggested to enhance the likelihood of successful and durable PVI outcomes [2]. Consistent with previous research, EIVOM was utilized as the initial step in inducing mitral isthmus block in our case. During the one-stop procedure combining EIVOM, RFCA, and LAAO, a notable challenge encountered was the development of edema in the coumadin ridge area. However, it is worth noting that EIVOM did not compromise the effectiveness of achieving adequate occlusion rates when compared to LAAO alone [9]. In our case, successful LAAO was achieved without any peri-device leakage following the EIVOM step.

By the 12-month follow-up, the one-stop procedure incorporating EIVOM, RFCA, and LAAO had been completed successfully in this case. Nonetheless, further randomized controlled trials and long-term monitoring are essential to validate the safety and efficacy of this comprehensive approach. This case highlights a novel one-stop strategy for the treatment of atrial fibrillation.

4. Ethics approval and consent to participate

Ethical clearance was obtained from the ethical committee of Wenzhou People's Hospital and consent was obtained from the patient.

Consent to publication

Informed consent was obtained from the patient for the publication of this study.

Availability of data and materials

Not applicable.

Funding

Not applicable.

Authors' contributions

Ning Zhu and Cong Lin wrote the main manuscript text. Yizhou Zhang prepared Fig. 1, Fig. 2, Fig. 3. Ning Zhu and Wei Lin revised manuscript text. All authors reviewed the manuscript.

CRediT authorship contribution statement

Ning Zhu: Writing – review & editing, Writing – original draft, Validation, Supervision. Cong Lin: Methodology, Investigation, Data curation. Yizhou Zhang: Methodology, Investigation, Data curation. Wei Lin: Writing – review & editing, Writing – original draft, Validation, Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.