The role of vein of marshall ethanol infusion combined with an anatomical ablation scheme at repeated procedures in patients with persistent atrial fibrillation
A Agresti, S Taddeucci, C Angheben, G Grifoni, F Ferraris, A Giomi, P Marchese, F Buoncristiani, G Mirizzi, M Nesti, L Panchetti, S Garibaldi, U Startari, M Piacenti, A RossiAbstract
Background
Recurrence of atrial arrhythmias (AAs) after ablation remains a major challenge in patients with persistent atrial fibrillation (PeAF). The optimal ablation strategy for this population—particularly in those without pulmonary vein (PV) reconnection—has not yet been established.
Purpose
To assess outcomes and predictors of AA recurrence after a standardized repeat ablation approach combining Vein of Marshall ethanol infusion (VOM-EI) with an anatomical lesion set in patients with PeAF.
Methods
This multicenter retrospective study included consecutive PeAF patients undergoing repeat ablation with VOM-EI and an anatomical lesion set (PV re-isolation if needed, lateral mitral isthmus [MI] line, dome line, and cavotricuspid isthmus line). Patients were categorized by AF duration phenotype: early PeAF (≤3 months), PeAF (3–12 months), and long-standing PeAF (>12 months). Index procedures were classified as PVI-only vs PVI+ (PVI plus additional lines and/or CFAE ablation). Recurrence-free survival was evaluated using Kaplan–Meier and Cox analyses. The primary endpoint was time to first AF/AT recurrence ≥30 s after a 90-day blanking period.
Results
A total of 111 patients were analyzed: 19 early PeAF (17.1%), 48 PeAF (43.2%), and 44 long-standing PeAF (39.6%); 60 (54.1%) had prior PVI-only and 51 (45.9%) PVI+. Mean follow-up was 19 months. Overall, 27 recurrences occurred (24.3%). MI block was achieved in 85% (94/111), and its absence was associated with higher recurrence (47.1% vs 20.2%; log-rank p = 0.035). Arrhythmia-free survival declined progressively from early to long-standing PeAF (log-rank p = 0.012). In multivariable analysis, AF duration phenotype independently predicted outcome (overall p = 0.045): long-standing vs early PeAF HR 9.69 (95% CI 1.23–76.6; p = 0.031). Female sex was also associated with recurrence (male sex HR 0.295, 95% CI 0.118–0.738; p = 0.009). PV reconnection and the index ablation strategy (PVI-only vs PVI+) were not associated with recurrence.
Conclusions
VOM-EI combined with an anatomical lesion set appears to be an effective repeat ablation strategy in PeAF. Long-standing AF phenotype and female sex are associated with higher recurrence risk, while procedural completeness (MI block) is key to durable rhythm control.