First-Line Marshall Plan Approach in Persistent Atrial Fibrillation: A Prospective Single-Center Cohort Study

Different ablation strategies have been developed for persistent atrial fibrillation (PeAF), but early management is still controversial. In the clinical setting of PeAF, the safety and efficacy of early Marshall plan have not yet been fully studied.

Our prospective cohort study sought to: (1) assess the safety and feasibility of the thermal Marshall plan (MPA) approach as a first-line therapy in PeAF patients; (2) evaluate its long-term sinus rhythm maintenance efficacy; (3) identify the long-term predictive factors of AF recurrence in PeAF patients after MPA approach.

Between January 2020 and December 2023, 118 PeAF patients were selected for first intent Marshall plan ablation (MPA). Marshall vein failure occurred in 9/118 patients (7.6%). Accordingly, 109 patients who underwent MPA as first-line therapy were included. After the blanking period of 3 months, 62/109 patients were in sinus rhythm (SR) (57%), 33/109 were in AF (30.2%), 8/109 were in left atrial flutter (AFL) (7.3%), and six were in right AFL (5.5%). Re-ablation was performed in 4/33 patients (12.1%) and cardioversion in 29/33 (87.9%) for patients in AF at 3 months after healing. All patients in AFL at 3 months were re-ablated and all recovered SR. At 12 months postablation, two patients were lost to follow-up (1.8%), 94/107 (87.8%) were in SR and 13/107 had AF recurrence (12.2%). At 21 ± 11 months postablation, 81/107 (75.7%) were in SR at the last control, and 26/107 (24.3%) had AF recurrence. The ablation procedure ratio was 1.17 (109 primo ablation, 18 re-ablation). The only predictive factors of late AF recurrence after first-line PeAF MPA were both left atrial dilatation and low left ventricular ejection fraction (LVEF).

This real-life prospective cohort study showed that de novo MPA in PeAF is feasible, relatively safe, and associated with a high rate of freedom from arrhythmia recurrence during long-term follow-up. The percentage of patients remaining in SR during long-term follow-up was close to 76%. The only predictive MPA failure factors were both left atrial dilatation and low LVEF.