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Updated: Jun 20, 2026

Robotic Ablation of Atrial Fibrillation
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Sequential vs First-Intention Marshall-PLAN Strategy in Persistent Atrial Fibrillation Ablation: A Propensity Score

Grégoire Massoullié1, Saer Abu-Alrub1, Louise Julhes2

  • 1Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France; Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, Institut Pascal, Clermont-Ferrand, France.

JACC. Clinical Electrophysiology
|June 19, 2026
PubMed
Summary

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This summary is machine-generated.

The Marshall-PLAN ablation strategy, combining pulmonary vein isolation and ethanol infusion of the vein of Marshall, shows similar effectiveness whether performed initially or after a prior procedure. Completing the Marshall-PLAN is key for maintaining sinus rhythm in persistent atrial fibrillation.

Area of Science:

  • Electrophysiology
  • Cardiac Ablation Techniques
  • Atrial Fibrillation Management

Background:

  • The Marshall-PLAN ablation approach, integrating pulmonary vein isolation (PVI) with ethanol infusion of the vein of Marshall (Et-VOM) and linear lesions, is recognized for improving rhythm outcomes in persistent atrial fibrillation (PsAF).
  • However, the added benefits and optimal timing for implementing the Marshall-PLAN strategy remain subjects of ongoing clinical debate.

Purpose of the Study:

  • To compare the efficacy of the Marshall-PLAN ablation strategy when utilized as an initial treatment versus a secondary procedure following a prior PVI for persistent atrial fibrillation.
  • To evaluate the impact of procedural timing and completeness on long-term rhythm control in PsAF patients.

Main Methods:

  • A retrospective analysis of 237 patients with PsAF treated between September 2022 and April 2025.
Keywords:
Marshall-Plan ablationethanol infusionpersistent atrial fibrillationvein of Marshall

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  • Patients were divided into two groups: first-intention Marshall-PLAN (n=168) and sequential Marshall-PLAN after prior PVI (n=69).
  • Primary endpoint was arrhythmia recurrence (≥30 seconds), with analyses adjusted using inverse probability of treatment weighting (IPTW).

    • Main Results:

    • Ethanol infusion of the vein of Marshall (Et-VOM) achieved success in 92.8% of cases.
    • At 12 months, arrhythmia-free survival rates were comparable: 74.3% for the first-intention group and 80.7% for the sequential group (IPTW P=0.95).
    • Incomplete Marshall-PLAN was significantly associated with recurrence (HR: 5.55), while the sequential strategy was not (HR: 0.52). Increased left atrial volume predicted recurrence (HR: 1.01).

    Conclusions:

    • In patients with persistent atrial fibrillation, a sequential Marshall-PLAN procedure after prior PVI offers comparable arrhythmia control to a first-intention approach.
    • The completeness of the Marshall-PLAN procedure, rather than its timing (initial vs. sequential), is the critical factor for achieving durable sinus rhythm maintenance.