Successful Ethanol Infusion of Vein of Marshall With Bridge Collateral Using the Double‐Balloon Technique Incorporating a Wedged Berman Catheter

Abstract

We describe a novel double‐balloon technique incorporating a wedged Berman catheter to manage distal collateral drainage from the vein of Marshall (VOM) via a bridge collateral to the great cardiac vein, thereby enabling effective ethanol infusion. This technique may represent a viable alternative for anatomically challenging VOM ethanol infusion cases.

Vein of Marshall (VOM) ethanol infusion has become an effective adjunctive therapy for atrial fibrillation (AF) ablation, facilitating the elimination of AF triggers and the creation of conduction block along the mitral isthmus [1]. However, anatomical variations such as collateral drainage from the VOM to adjacent structures, including the great cardiac vein (GCV), can complicate the procedure and reduce ethanol delivery efficacy. To address this, modified techniques such as double‐balloon approaches have been developed to achieve full vascular occlusion and targeted infusion [2, 3]. Here, we report a novel double‐balloon technique using a wedged Berman catheter positioned in the GCV to successfully occlude collateral outflow and enable effective ethanol delivery into the VOM. To the best of our knowledge, this is the first report to describe the use of a wedged Berman catheter in the GCV as part of a double‐balloon strategy for VOM ethanol infusion.

A 59‐year‐old man with ischemic cardiomyopathy and a cardiac resynchronization therapy defibrillator (CRT‐D) (MOMENTUM, Boston Scientific, Marlborough, MA, USA) implanted 12 years earlier was referred for catheter ablation because of inappropriate shocks caused by atrial tachyarrhythmia.

Following pulmonary vein isolation and left atrial posterior wall isolation, atrial tachycardia (AT) was spontaneously induced during the procedure. Based on the activation map acquired using the Octaray catheter (Biosense Webster, Diamond Bar, CA, USA) and entrainment pacing findings from the mitral isthmus, a diagnosis of perimitral AT was established (Figure S1). Despite extensive endocardial ablation and additional ablation within the coronary sinus (CS), the perimitral AT persisted without prolongation of the cycle length from 190 ms, suggesting that complete conduction block across the mitral isthmus could not be achieved. Given the incomplete block, we proceeded with ethanol infusion into the VOM. A 6 Fr wedged Berman catheter (Teleflex Inc., Wayne, PA, USA), advanced into the GCV via a steerable Vizigo sheath (Biosense Webster) was used for initial angiography, confirming the presence of the VOM (Figure 1A). A 0.014‐in. guidewire (Cruise; Asahi Intecc, Aichi, Japan) was advanced through an over‐the‐wire 1.5 × 8 mm balloon (Emerge; Boston Scientific) into the VOM via a 5 Fr Judkins Right catheter (Terumo, Tokyo, Japan) inserted through the Vizigo sheath (Figure 1B). Selective VOM angiography revealed distal collateral draining into the GCV (Figure 1C). To prevent ethanol leakage into the GCV, a Swartz sheath (Abbott, Chicago, IL, USA) was positioned in the CS, and the Berman catheter was inflated at the convergence site of the collateral to achieve complete flow occlusion (Figure 1D,E). After confirming effective occlusion, 8 mL of ethanol was slowly infused, resulting in characteristic myocardial staining (Figure 1F) and the eventual achievement of bidirectional conduction block across the mitral isthmus. However, a transition from AT to AF occurred during the ethanol infusion, preventing the accurate assessment of the precise timing of block formation. Subsequent differential pacing following restoration of the sinus rhythm after cardioversion confirmed the presence of bidirectional block (Figure 2A–C). Note that it would be ideal to have voltage maps and compare pre‐ and post‐ablation, but they were not obtained due to the procedural sequence, where RF ablation was performed before VOM ethanol infusion (since this was the patient's first catheter session, VOM ethanol infusion was not planned in the beginning). The procedure was completed without complications. At the 12‐month follow‐up, the patient remained free of AF and AT recurrence.

FIGURE 1.

Double‐balloon technique with a wedged Berman catheter. (A) Coronary sinus (CS) angiography was performed using a 6 Fr wedged Berman catheter advanced through a steerable sheath, revealing the VOM. An Octaray catheter was positioned in the left atrial appendage to serve as an anatomical landmark. (B) A 0.014‐in. guidewire was successfully advanced into the VOM via a 5 Fr JR catheter through the Vizigo sheath. (C) The right panel shows a magnified view of the blue‐circled area in the left panel. An over‐the‐wire 1.5 × 8 mm balloon (green rectangle) was advanced into the VOM, and after removal of the guidewire, the balloon was inflated to 4 atm. Selective VOM angiography revealed distal collateral draining into the GCV, known as “bridge collateral”. (D) The right panel shows a magnified view of the blue‐circled area in the left panel. A Swartz sheath was advanced into the CS, and a 6 Fr Berman catheter, positioned within the sheath, was inflated at the site of collateral convergence to occlude collateral blood flow (red circle). After confirming complete occlusion, ethanol infusion (total volume of 8 mL) was performed. (E) Schematic illustration of the double‐balloon technique using the wedged Berman catheter. Blocking the collateral flow to the GCV may allow for the creation of a more effective VOM ethanol‐induced lesion. (F) Tissue staining (white circle) was observed during selective VOM angiography following the infusion of 8 mL of ethanol. CS, coronary sinus; GCV, great cardiac vein; JR, Judkins Right; LV, left ventricle; RAO, right anterior oblique; RV, right ventricle; VOM, vein of Marshall.

FIGURE 2.

Intracardiac echocardiograms and fluoroscopic images of the procedure. (A) During the left atrial appendage (LAA) pacing using the Octaray catheter, a proximal‐to‐distal activation sequence was observed in the CS catheter. (B) Pacing was performed at both the CS ostium (left panel) and slightly proximal to the mitral isthmus block line, closer to the ostium (right panel). The conduction time from each pacing site to the LAA was evaluated, demonstrating a shorter conduction time when pacing from the CS ostium compared to the site proximal to the mitral isthmus block line (74 ms vs. 102 ms). (C) Fluoroscopic image obtained at the time of confirming bidirectional mitral isthmus conduction block. AF, atrial fibrillation; AT, atrial tachycardia; CS, coronary sinus; LAA, left atrial appendage; LAO, left anterior oblique.

Ethanol infusion into the VOM has become an established adjunct to achieve mitral isthmus block during ablation procedures for AF and perimitral AT. However, anatomical variations, including collateral drainage from the VOM to structures such as the left atrium, superior vena cava, or GCV, can hinder effective ethanol delivery.

Distal collateral drainage from the VOM has been reported in approximately 4.3% of cases [4]. In our patient, collateral flow was noted from the proximal VOM to the GCV, complicating the procedure. To ensure effective ethanol infusion, we employed a modified double‐balloon technique, wherein a Berman catheter—originally designed for venography—was used to occlude the outflow site of the collateral within the GCV.

Although double‐balloon strategies for VOM ethanol infusion have been described previously [2, 3], to the best of our knowledge, this is the first report to utilize a Berman catheter positioned within the GCV as part of a double‐balloon approach. Compared to these previously reported double‐balloon techniques, this method is more cost‐effective since only one over‐the‐wire balloon is used. Our method is particularly useful when the collateral outflow point—commonly referred to as a “bridge collateral”—is located in the proximal GCV. On the other hand, if the diameter of the GCV at the convergence site is too large to be occluded by the Berman catheter, our approach is infeasible. Our case highlights the importance of adapting infusion techniques based on anatomical variations to achieve successful and safe VOM ethanol delivery.

Ethics Statement

This research was conducted according to the principles of the Declaration of Helsinki.

Consent

The patient provided written informed consent to publication of the details of her case.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

FIGURE S1. Left: The activation map of the left atrium, displayed in a left lateral view, demonstrates a clockwise perimitral atrial tachycardia with a cycle length of 190 ms.

Kasai Y., Kitai T., Morita J., Murakami K., and Fujita T., “Successful Ethanol Infusion of Vein of Marshall With Bridge Collateral Using the Double‐Balloon Technique Incorporating a Wedged Berman Catheter,” Journal of Arrhythmia 41, no. 4 (2025): e70152, 10.1002/joa3.70152.

Data Availability Statement

The authors confirm that all the data supporting the findings of this research are available within the article.