MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation: MARSHALL-PLAN case series.

INTRODUCTION: Beyond pulmonary veins (PV) isolation, the ablation strategy for persistent atrial fibrillation (AF) remains controversial. Substrate ablation may provide a high termination rate but at the cost of impaired atrial physiology and recurrent complex re-entries. To overcome these pitfalls, we investigated a new lesion set based on important anatomical considerations. METHODS AND
RESULTS: The case series included 10 consecutive patients with persistent AF. Three atrial structures were successively targeted: (1) coronary sinus and vein of Marshall (CS-VOM) musculature elimination; (2) PVs isolation; and (3) anatomical isthmuses block. The lesion set completion was the procedural endpoint. Step 1: VOM ethanol infusion was feasible in all cases (mean time of 33.4 ± 9.4 minutes), mean radiofrequency (RF) time for CS-VOM bundles was 14.4 ± 6.9 minutes. Step 2: mean RF time for PV isolation was 27.7 ± 9.3 minutes. Step 3: mean RF time for mitral, roof, and cavotricuspid lines was 5.7 ± 2.3, 8.1 ± 4.3, and 5.9 ± 1.9 minutes, respectively. The lesion set was achieved in all patients. Mean procedure time was 270 ± 29.9 minutes. AF termination and noninducibility were, respectively, obtained in 50% and 90% of the patients. After a 6-month follow-up, all patients were free from arrhythmia recurrence.
CONCLUSION: The present case series reports a new ablation strategy systematically targeting anatomical structures previously identified as possibly involved in the fibrillatory process and the recurrent tachycardias. The resulting lesion set provides good short-term outcomes. Although promising, these preliminary results need to be confirmed in the larger prospective study.