Vein of Marshall ethanol infusion in persistent atrial fibrillation: Insight from VOMALC-PeAF registry

Pulmonary vein isolation (PVI) ablation has limited efficacy in persistent atrial fibrillation (PeAF). Anatomical strategies combining PVI, vein of Marshall ethanol infusion (VOM-EI), and an anatomical ablation strategy (AS) targeting key atrial isthmuses have shown promising short-term outcomes in this setting.

In this retrospective multicenter observational cohort study, consecutive patients with PeAF who underwent either VOM-EI + AS or PVI-only were included. The primary endpoint was freedom from atrial arrhythmias (AAs) lasting > 30 s off antiarrhythmic drugs (AADs). Procedural characteristics and safety outcomes were also evaluated.

After 2:1 propensity score matching, 151 patients treated with VOM-EI + AS were compared with 75 treated with PVI-only. After a median follow-up of 22-month (interquartile range (IQR): 9-35 months), 81% vs. 47% of patients remained free from AA without AADs in the VOM-EI + AS vs. PVI-only group (p < 0.001). Achievement of bidirectional mitral isthmus (MI) block was the strongest independent predictor of arrhythmia-free survival (HR = 0.114; 95% CI: 0.041-0.321; p < 0.001). On the contrary, long-standing PeAF was independently associated with a higher risk of atrial arrhythmic recurrence (HR = 2.68; 95% CI: 1.240-5.812; p = 0.012).

In a real-world PeAF population, a first ablation strategy incorporating VOM-EI, PVI and anatomical linear lesions was significantly more effective than PVI alone in preventing arrhythmic recurrences in a long-term follow-up. Bidirectional block validation across the mitral line and AF duration are key determinants of long-term success. In patients with persistent atrial fibrillation, a first-procedure ablation including vein of Marshall ethanol infusion and an anatomical ablation strategy combining pulmonary vein isolation and linear lesions significantly improved long-term arrhythmia-free survival compared with pulmonary vein isolation alone.