Outcomes and procedural characteristics of repeat ablation after vein of Marshall alcohol infusion combined with an anatomical ablation setup
F buoncristiani, P Sousa, D Minois, A Andorin, M Miled, F A Sebag, A P Wijnmaalen, S R D Piers, M Efremidis, N Pavlovic, P Marchese, G Mansi, S Taddeucci, M Nesti, A RossiAbstract
Background
A standardised ablation setup combining vein of Marshall ethanol infusion (VOMEI), pulmonary vein isolation (PVI), and anatomical isthmus ablation has demonstrated high success rates in treating persistent atrial fibrillation (AF) and atrial tachycardias (AT). However, long-term lesion durability and specific mechanisms of clinical failure require further characterisation.
Purpose
This multicentre observational study aimed to evaluate recurrence mechanisms and conduction gaps in patients undergoing repeat ablation following VOMEI setup.
Methods
We included 96 consecutive patients (mean age 66.9 ± 10.5 years; 74.0% male) who underwent repeat ablation across 7 European centres, following a successful and complete VOMEI setup during previous de novo (57, 59.4%) or repeat (39, 40.6%) ablation for AF (75, 78.1%) or stable AT (21, 21.9%). The index procedure protocol consisted of VOMEI followed by PVI and linear ablation of mitral isthmus (MI), dome, and cavotricuspid isthmus (CTI), with additional floorline ablation when deemed necessary. During re-ablation, conduction gaps were identified by high-density mapping and were correlated with the clinical arrhythmia mechanisms. All pre-existing lesion sets were consolidated. Arrhythmia-free survival post re-ablation was evaluated with Kaplan-Meier analysis.
Results
Re-ablation occurred at a mean of 14.2 ± 11.5 months post-index procedure. Presentation comprised AF in 46 patients (47.9%; 40 persistent, 6 paroxysmal) and stable AT in 50 (52.1%). Conduction breakthroughs were identified in the PVs in 43 (44.8%), MI in 48 (50.0%), dome in 40 (41.7%), and CTI in 29 (30.2%) patients. MI gaps primarily involved the coronary sinus (47.9%) and endocardial mitral annulus (41.7%). PV reconnection rates did not differ significantly between AF and AT presentations (50.0% vs 40.0%; p=0.43). Clinical macro-reentrant circuits showed high electro-anatomic concordance with anatomical breakthroughs: 92.0% (23/25) for perimitral, 90.0% (9/10) for roof-dependent, and 62.5% (5/8) for peritricuspid flutters. Targeted elimination of all gaps yielded 91.7% (88/96) arrhythmia-free survival at 17.0 ± 14.7 months follow-up.
Conclusion
In patients treated with VOMEI scheme, the mitral isthmus remains the most vulnerable site for late failure, particularly at the coronary sinus and mitral annulus. While PV reconnection is frequent, it does not predict recurrence as AF. Recurrent ATs are sustained by gaps in linear lesions with high electro-anatomic concordance. This predictable pattern of late failure facilitates the systematic diagnosis and targeted treatment of recurrences, yielding excellent long-term success.