Clinical Research
Heart Rhythm Disorders
Ethanol Infusion in the Vein of Marshall Leads to Parasympathetic Denervation of the Human Left Atrium: Implications for Atrial Fibrillation

Presented at the 32nd Annual Meeting of the Heart Rhythm Society, San Francisco, CA, 2011, and awarded the Eric N. Prystowsky Fellows Clinical Research Award. Dr. Báez-Escudero's current affiliation is Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Florida, Weston, Florida.
https://doi.org/10.1016/j.jacc.2014.01.032Get rights and content
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Objectives

This study sought to determine whether ethanol infusion in the vein of Marshall (VOM) can ablate intrinsic cardiac nerves (ICN).

Background

ICN cluster around the left atrial epicardium and are implicated in the genesis of atrial fibrillation (AF).

Methods

Patients undergoing catheter AF ablation underwent adjunctive ethanol injection in the VOM. A multipolar catheter was introduced in the VOM and used for high-frequency stimulation (HFS), either as HFS with P-wave synchronized (SynchHFS), 30 pulses, 100 Hz (n = 8) or as HFS with 3 to 10 s bursts (BurstHFS), 33 Hz (n = 72) at 25 mA for 1-ms duration. Atrioventricular (AV) nodal conduction slowing (asystole >2 s or R-R interval prolongation >50%) and AF inducibility were assessed before and after VOM ethanol infusion. Up to 4 1-ml infusions of 98% ethanol were delivered via an angioplasty balloon in the VOM.

Results

SynchHFS induced AF in 8 of 8 patients. In 4 of 8 AF initiated spontaneously without VOM capture. No parasympathetic responses were elicited by SynchHFS. BurstHFS was performed in 32 patients undergoing de novo AF ablation (Group 1) and 40 patients undergoing repeat ablation (Group 2). Parasympathetic responses were found in all 32 Group 1 patients and in 75% of Group 2 patients. After VOM ethanol infusion, parasympathetic responses were abolished in all patients (both groups). There were no acute complications related to VOM ethanol infusion.

Conclusions

The VOM contains ICN that connect with the AV node and can trigger AF. Retrograde ethanol infusion in the VOM reliably eliminates local ICN responses. The VOM is a vascular route for ICN-targeting therapies.

Key Words

atrial fibrillation
ethanol
intrinsic cardiac nerves
vein of Marshall

Abbreviations and Acronyms

AF
atrial fibrillation
AV
atrioventricular
BurstHFS
high-frequency stimulation using 3- to 10-s bursts at 33 Hz
HFS
high-frequency stimulation
ICN
intrinsic cardiac nerves
SynchHFS
high-frequency stimulation using P-wave-synchronized, 30 pulses, 100 Hz
VOM
vein of Marshall

Cited by (0)

Dr. Valderrábano is supported by National Institutes of Health/National Heart, Lung, and Blood Institute grants R21HL097305 and R01 HL115003. Dr. Báez-Escudero is a consultant and speaker for St. Jude Medical and Biosense Webster; and the Antonio Pacifico, MD, fellowship in electrophysiology (to Dr. Báez-Escudero). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.