Vein of Marshall Ethanol Infusion: Feasibility, Pitfalls, and Complications in Over 700 Patients
Tsukasa Kamakura, Nicolas Derval, Josselin Duchâteau, Arnaud Denis, Takashi Nakashima, Takamitsu Takagi, F. Daniel Ramirez, Clémentine André, Philipp Krisai, Yosuke Nakatani, Romain Tixier, Rémi Chauvel, Ghassen Cheniti, Kengo Kusano, Hubert Cochet, Frédéric Sacher, Mélèze Hocini, Pierre Jaı̈s, Michel Haı̈ssaguerre, Thomas Pambrun
Abstract
Background: Vein of Marshall (VOM) ethanol infusion is a relatively new therapeutic option for atrial tachyarrhythmias. We aimed to evaluate the feasibility, pitfalls, and complications associated with this procedure in a large cohort of patients. Methods: Successful ethanol infusion, VOM-related lesion extent, and serious complications were evaluated in 713 consecutive patients treated with VOM ethanol infusion. Results: While feasible in 88.9% of cases, VOM ethanol infusion failure mainly resulted from nonidentification (6.2%), noncannulation (1.5%), or ethanol infusion in the wrong vein (1.7%). The Vieussens valve was a helpful landmark and was visible in 63.2% of cases. Multivariable analysis identified previous coronary sinus ablation as the only predictor for nonidentification. The mean area of VOM-related endocardial scarring was 10.2±5.3 cm 2 . VOM dissection (10.7%), iodine leakage (3.0%), and VOM morphology without visible branches (3.0%) were associated with smaller VOM-related scarring (5.0±3.9, 6.6±3.5, and 4.7±2.3 cm 2 , with a P <0.0001, P <0.044, and P <0.0001, respectively). Ethanol infusion in a wrong vein was associated with less mitral line block (72.7% versus 95.8%, P =0.012). A total of 14 serious complications (2.0%) occurred: 7 tamponades, of which were 6 delayed and treated with pericardiocentesis (2 of these patients had per-procedural VOM perforation), 4 strokes, 1 anaphylactic shock, 1 atrioventricular block, and 1 left appendage isolation. Only 4 of these complications occurred during the procedure. Conclusions: Although limited by previous coronary sinus ablation, VOM ethanol infusion is a highly feasible treatment for atrial tachyarrhythmia, with a low rate of serious complications.