Adi Lador1, Leif E Peterson1, Vijay Swarup2, Paul A Schurmann3, Akash Makkar2, Rahul N Doshi4, David DeLurgio5, Charles A Athill6, Kenneth A Ellenbogen7, Andrea Natale8, Jayanthi Koneru7, Amish S Dave1, Irakli Giorgberidze9, Hamid Afshar9, Michelle L Guthrie1, Raquel Bunge1, Carlos A Morillo10, Neal S Kleiman1, Miguel Valderrábano11. 1. Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas. 2. Arizona Heart Rhythm Center, Phoenix, Arizona. 3. Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. 4. Division of Cardiology, Keck-USC University Hospital, University of Southern California, Los Angeles, California. 5. Division of Cardiology, Emory St. Joseph's Hospital, Emory University, Atlanta, Georgia. 6. San Diego Cardiac Center, Sharp Memorial Hospital, San Diego, California. 7. Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia. 8. Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas. 9. Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. 10. Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada. 11. Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas. Electronic address: MValderrabano@houstonmethodist.org.
Abstract
BACKGROUND: The Vein of Marshall Ethanol for Untreated Persistent AF (VENUS) trial demonstrated that adding vein of Marshall (VOM) ethanol infusion to catheter ablation (CA) improves ablation outcomes in persistent atrial fibrillation (AF). There was significant heterogeneity in the impact of VOM ethanol infusion on rhythm control. OBJECTIVE: The purpose of this study was to assess the association between outcomes and (1) achievement of bidirectional perimitral conduction block and (2) procedural volume. METHODS: The VENUS trial randomized patients with persistent AF (N = 343) to CA combined with VOM ethanol or CA alone. The primary outcome (freedom from AF or atrial tachycardia [AT] lasting longer than 30 seconds after a single procedure) was analyzed by 2 categories: (1) successful vs no perimitral block and (2) high- (>20 patients enrolled) vs low-volume centers. RESULTS: In patients with perimitral block, the primary outcome was reached 54.3% after VOM-CA and 37% after CA alone (P = .01). Among patients without perimitral block, freedom from AF/AT was 34.0% after VOM-CA and 37.0% after CA (P = .583). In high-volume centers, the primary outcome was reached in 56.4% after VOM-CA and 40.2% after CA (P = .01). In low-volume centers, freedom from AF/AT was 30.77% after VOM-CA and 32.61% after CA (P = .84). In patients with successful perimitral block from high-volume centers, the primary outcome was reached in 59% after VOM-CA and 39.1% after CA (P = .01). Tests for interaction were significant (P = .002 for perimitral block and P = .04 for center volume). CONCLUSION: Adding VOM ethanol infusion to CA has a greater impact on outcomes when associated with perimitral block and performed in high-volume centers. Perimitral block should be part of the VOM procedure.
BACKGROUND: The Vein of Marshall Ethanol for Untreated Persistent AF (VENUS) trial demonstrated that adding vein of Marshall (VOM) ethanol infusion to catheter ablation (CA) improves ablation outcomes in persistent atrial fibrillation (AF). There was significant heterogeneity in the impact of VOM ethanol infusion on rhythm control. OBJECTIVE: The purpose of this study was to assess the association between outcomes and (1) achievement of bidirectional perimitral conduction block and (2) procedural volume. METHODS: The VENUS trial randomized patients with persistent AF (N = 343) to CA combined with VOM ethanol or CA alone. The primary outcome (freedom from AF or atrial tachycardia [AT] lasting longer than 30 seconds after a single procedure) was analyzed by 2 categories: (1) successful vs no perimitral block and (2) high- (>20 patients enrolled) vs low-volume centers. RESULTS: In patients with perimitral block, the primary outcome was reached 54.3% after VOM-CA and 37% after CA alone (P = .01). Among patients without perimitral block, freedom from AF/AT was 34.0% after VOM-CA and 37.0% after CA (P = .583). In high-volume centers, the primary outcome was reached in 56.4% after VOM-CA and 40.2% after CA (P = .01). In low-volume centers, freedom from AF/AT was 30.77% after VOM-CA and 32.61% after CA (P = .84). In patients with successful perimitral block from high-volume centers, the primary outcome was reached in 59% after VOM-CA and 39.1% after CA (P = .01). Tests for interaction were significant (P = .002 for perimitral block and P = .04 for center volume). CONCLUSION: Adding VOM ethanol infusion to CA has a greater impact on outcomes when associated with perimitral block and performed in high-volume centers. Perimitral block should be part of the VOM procedure.
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