Ethanol infusion to the vein of Marshall combined with anatomical and electrophysiological substrate modification improves long-term outcomes in very long-standing atrial fibrillation
M T Takigawa, T T Tsunoda, M H Honda, R T Tateishi, M N Negishi, I K Kawamura, K G Goto, T N Nishimura, K Y Yamao, S T Tao, S M Miyazaki, T S SasanoAbstract
Backgrounds
Ablation therapy in patients with very longstanding persistent atrial fibrillation (vLSPEF) >5yrs is challenging and not always suggested for catheter ablation treatment. For these patients, we performed pulmonary vein isolation (PVI), CTI-ablation, and additional minimal substrate modifications if required between 2014 - 2019 (Strategy 1). Between 2019 -2024, we started anatomical linear lesions and electrophysiological substrate modification in addition to the ethanol infusion to the vein of Marshall (EI-VOM) (Strategy 2) (Figure).
Objective
We elucidated the long-term clinical impact of this novel ablation strategy in patients with vLSPEF lasting>5yrs.
Methods
33 vLSPEF patients received initial ablation with Strategy 1 between 2014 - 2019, and 23 with Strategy 2 between 2019 -2024. These two groups were compared.
Results
Although patients with Strategy 1 was younger with lower Chads-score and higher ejection fraction, patients treated with Strategy 2 demonstrated significantly better long-term outcome. Multivariate analysis demonstrated that Strategy 2 was the only significant predictor (HR0.08, 95%CI[0.01-0.60], P=0.01)) of sinus rhythm maintenance and avoidance of AF persistence (HR0.14, 95%CI[0.03-0.62], P=0.01).
Conclusion
Despite worse backgrounds in vLSPEF-patients, anatomical linear lesions and electrophysiological substrate eliminations in addition to EI-VOM provided remarkably better outcome and remained as a significant predictor of sinus rhythm maintenance and avoidance of AF persistence.