{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T01:15:58Z","timestamp":1782782158708,"version":"3.54.5"},"reference-count":28,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,8,15]],"date-time":"2023-08-15T00:00:00Z","timestamp":1692057600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Marshall vein ethanol infusion (MVEI) as an additional therapy to conventional catheter ablation (CA) has been proved to be efficacious in patients with persistent atrial fibrillation (PeAF). However, whether empirical MVEI could be the first-line strategy in mitral isthmus (MI) ablation has seldom been investigated. Here, we aim to compare the efficacy, safety, and long-term outcomes between provisional and empirical MVEI in PeAF patients undergoing the index MI ablation procedure.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We enrolled 133 patients with PeAF either in the provisional group (<jats:italic>n<\/jats:italic>\u2009=\u200938, MVEI was performed when conventional endocardial and\/or epicardial ablation procedures were inadequate to achieve bidirectional MI block) or in the empirical group (<jats:italic>n<\/jats:italic>\u2009=\u200995, MVEI was performed empirically before MI CA).<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>All of the baseline characteristics were comparable. Less spontaneous or inducible atrial tachycardias (ATs) were encountered in the empirical group of patients (<jats:italic>P\u2009<\/jats:italic>&amp;lt;\u20090.001). More epicardial ablations were applied (26.3% vs. 9.5%, <jats:italic>P\u2009<\/jats:italic>=\u20090.016) and a higher incidence of CA-facilitated restoration of sinus rhythm was recorded (86.8% vs. 11.7%, <jats:italic>P\u2009<\/jats:italic>&amp;lt;\u20090.001) in the provisional group of patients. Although more fluoroscopy time (6.4[4.2, 9.3] vs. 9.5[5.9, 11.6] min, <jats:italic>P\u2009<\/jats:italic>=\u20090.019) and radiation exposure (69.0[25.3, 160.2] vs. 122.0[62.5, 234.1] mGy, <jats:italic>P\u2009<\/jats:italic>=\u20090.010) were documented in the empirical group with comparable procedure time, less time (455.9\u2009\u00b1\u2009192.2 vs. 366.5\u2009\u00b1\u2009161.3\u2005s, <jats:italic>P\u2009<\/jats:italic>=\u20090.038) was consumed to achieve bidirectional MI block during endocardial ablation in the provisional group. Incidences of procedure-related complications were similar between the two groups. During a 16.5\u2009\u00b1\u20094.4-month follow-up, the empirical group of patients showed a significantly higher rate of freedom from AT recurrence (95.8% vs. 81.6%, log-rank <jats:italic>P\u2009<\/jats:italic>=\u20090.003), while the rate of freedom from AF or atrial tachyarrhythmias (combining AF and AT) was similar. Both univariate (HR 0.19, 95% CI 0.05\u20130.64, <jats:italic>P\u2009<\/jats:italic>=\u20090.008) and multivariate (HR 0.25, 95% CI 0.07\u20130.92, <jats:italic>P\u2009<\/jats:italic>=\u20090.037) Cox regression analyses indicated that empirical MVEI was independently associated with lower long-term AT recurrence.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Among patients with PeAF who underwent the index MI ablation procedure, empirical MVEI could reduce endocardial MI ablation time and provide greater long-term freedom from AT recurrence.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fcvm.2023.1223064","type":"journal-article","created":{"date-parts":[[2023,8,16]],"date-time":"2023-08-16T12:08:25Z","timestamp":1692187705000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":4,"title":["The impact of empirical Marshall vein ethanol infusion as a first-choice intraoperative strategy on the long-term outcomes in patients with persistent atrial fibrillation undergoing mitral isthmus ablation"],"prefix":"10.3389","volume":"10","author":[{"given":"Xianfeng","family":"Du","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chenxu","family":"Luo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caijie","family":"Shen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yao","family":"Xu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mingjun","family":"Feng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"He","family":"Jin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guohua","family":"Fu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Binhao","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jin","family":"Liu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fang","family":"Gao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huimin","family":"Chu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2023,8,15]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"782","DOI":"10.1111\/pace.14208","article-title":"Ligament of Marshall ablation for persistent atrial fibrillation","volume":"44","author":"Vlachos","year":"2021","journal-title":"Pacing Clin Electrophysiol"},{"key":"B2","doi-asserted-by":"publisher","first-page":"786","DOI":"10.1016\/j.hrthm.2010.02.028","article-title":"Electrophysiological characteristics of the Marshall bundle in humans","volume":"7","author":"Han","year":"2010","journal-title":"Heart Rhythm"},{"key":"B3","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1016\/j.hrthm.2017.07.033","article-title":"Spectrum of atrial arrhythmias using the ligament of Marshall in patients with atrial fibrillation","volume":"15","author":"Chugh","year":"2018","journal-title":"Heart Rhythm"},{"key":"B4","doi-asserted-by":"publisher","first-page":"1207","DOI":"10.1016\/j.hrthm.2012.03.008","article-title":"Ethanol infusion in the vein of Marshall facilitates mitral isthmus ablation","volume":"9","author":"B\u00e1ez-Escudero","year":"2012","journal-title":"Heart Rhythm"},{"key":"B5","doi-asserted-by":"publisher","first-page":"617","DOI":"10.1111\/pace.13640","article-title":"Importance of the vein of Marshall involvement in mitral isthmus ablation","volume":"42","author":"Fujisawa","year":"2019","journal-title":"Pacing Clin Electrophysiol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1620","DOI":"10.1001\/jama.2020.16195","article-title":"Effect of catheter ablation with vein of Marshall ethanol infusion vs. catheter ablation alone on persistent atrial fibrillation: the VENUS randomized clinical trial","volume":"324","author":"Valderr\u00e1bano","year":"2020","journal-title":"JAMA"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1849","DOI":"10.1111\/jce.15108","article-title":"Effectiveness of ethanol infusion into the vein of Marshall combined with a fixed anatomical ablation strategy (the \u201cupgraded 2C3l\u201d approach) for catheter ablation of persistent atrial fibrillation","volume":"32","author":"Lai","year":"2021","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B8","doi-asserted-by":"publisher","first-page":"529","DOI":"10.1016\/j.hrthm.2020.12.023","article-title":"Marshall bundle elimination, pulmonary vein isolation, and line completion for anatomical ablation of persistent atrial fibrillation (Marshall-PLAN): prospective, single-center study","volume":"18","author":"Derval","year":"2021","journal-title":"Heart Rhythm"},{"key":"B9","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1016\/j.ahj.2023.01.019","article-title":"Prospective randomized comparison between upgraded \u20182C3L\u2019 vs. PVI approach for catheter ablation of persistent atrial fibrillation: PROMPT-AF trial design","volume":"260","author":"Liu","year":"2023","journal-title":"Am Heart J"},{"key":"B10","doi-asserted-by":"publisher","first-page":"e125","DOI":"10.1161\/CIR.0000000000000665","article-title":"2019 AHA\/ACC\/HRS focused update of the 2014 AHA\/ACC\/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration with the Society of Thoracic Surgeons","volume":"140","author":"January","year":"2019","journal-title":"Circulation"},{"key":"B11","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1093\/eurheartj\/ehaa612","article-title":"2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)","volume":"42","author":"Hindricks","year":"2021","journal-title":"Eur Heart J"},{"key":"B12","doi-asserted-by":"publisher","first-page":"f419","DOI":"10.1093\/europace\/eux376","article-title":"Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the \u2018CLOSE\u2019-protocol","volume":"20","author":"Phlips","year":"2018","journal-title":"Europace"},{"key":"B13","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1161\/CIRCEP.108.818427","article-title":"Retrograde ethanol infusion in the vein of Marshall: regional left atrial ablation, vagal denervation and feasibility in humans","volume":"2","author":"Valderr\u00e1bano","year":"2009","journal-title":"Circ Arrhythm Electrophysiol"},{"key":"B14","doi-asserted-by":"publisher","first-page":"1552","DOI":"10.1016\/j.hrthm.2009.07.036","article-title":"Ethanol infusion in the vein of Marshall: adjunctive effects during ablation of atrial fibrillation","volume":"6","author":"Valderr\u00e1bano","year":"2009","journal-title":"Heart Rhythm"},{"key":"B15","doi-asserted-by":"publisher","first-page":"583","DOI":"10.1111\/j.1540-8167.2011.02268.x","article-title":"Role of the vein of Marshall in atrial fibrillation recurrences after catheter ablation: therapeutic effect of ethanol infusion","volume":"23","author":"Dave","year":"2012","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B16","doi-asserted-by":"publisher","first-page":"e66","DOI":"10.1016\/j.hrthm.2019.01.02","article-title":"2019 AHA\/ACC\/HRS focused update of the 2014 AHA\/ACC\/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society","volume":"16","author":"January","year":"2019","journal-title":"Heart Rhythm"},{"key":"B17","doi-asserted-by":"publisher","first-page":"1951","DOI":"10.1016\/j.hrthm.2021.06.1202","article-title":"Epicardial course of the musculature related to the great cardiac vein: anatomical considerations and clinical implications for mitral isthmus block after vein of Marshall ethanol infusion","volume":"18","author":"Pambrun","year":"2021","journal-title":"Heart Rhythm"},{"key":"B18","doi-asserted-by":"publisher","first-page":"594","DOI":"10.1111\/j.1540-8167.2006.00375.x","article-title":"Diverse myocardial extension and autonomic innervation on ligament of Marshall in humans","volume":"17","author":"Makino","year":"2006","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B19","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1016\/j.hrcr.2016.08.008","article-title":"Vein of Marshall partially isolated with radiofrequency ablation from the endocardium","volume":"3","author":"Kashimura","year":"2017","journal-title":"HeartRhythm Case Rep"},{"key":"B20","doi-asserted-by":"publisher","first-page":"1255","DOI":"10.1016\/j.hrthm.2022.03.1228","article-title":"Effect of radiofrequency and ethanol ablation on epicardial conduction through the vein of Marshall: how to detect and manage epicardial connection across the mitral isthmus","volume":"19","author":"Kawaguchi","year":"2022","journal-title":"Heart Rhythm"},{"key":"B21","doi-asserted-by":"publisher","first-page":"1341","DOI":"10.1016\/j.hrthm.2019.05.019","article-title":"The role of Marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation","volume":"16","author":"Vlachos","year":"2019","journal-title":"Heart Rhythm"},{"key":"B22","doi-asserted-by":"publisher","first-page":"1892","DOI":"10.1016\/j.jacc.2014.01.032","article-title":"Ethanol infusion in the vein of Marshall leads to parasympathetic denervation of the human left atrium: implications for atrial fibrillation","volume":"63","author":"B\u00e1ez-Escudero","year":"2014","journal-title":"J Am Coll Cardiol"},{"key":"B23","doi-asserted-by":"publisher","first-page":"283","DOI":"10.1016\/j.jacep.2020.08.027","article-title":"Identification and endocardial ablation of the ligament of Marshall for pulmonary vein isolation","volume":"7","author":"Chee","year":"2021","journal-title":"JACC Clin Electrophysiol"},{"key":"B24","doi-asserted-by":"publisher","first-page":"1215","DOI":"10.1111\/jce.13969","article-title":"Long-term efficacy and safety of adjunctive ethanol infusion into the vein of Marshall during catheter ablation for nonparoxysmal atrial fibrillation","volume":"30","author":"Liu","year":"2019","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B25","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1016\/j.jacep.2021.06.019","article-title":"Durability of left atrial lesions after ethanol infusion in the vein of Marshall","volume":"8","author":"Laredo","year":"2022","journal-title":"JACC Clin Electrophysiol"},{"key":"B26","doi-asserted-by":"publisher","first-page":"1045","DOI":"10.1016\/j.hrthm.2021.01.005","article-title":"Determinants of outcome impact of vein of Marshall ethanol infusion when added to catheter ablation of persistent atrial fibrillation: a secondary analysis of the VENUS randomized clinical trial","volume":"18","author":"Lador","year":"2021","journal-title":"Heart Rhythm"},{"key":"B27","doi-asserted-by":"publisher","first-page":"367","DOI":"10.1016\/j.jacep.2021.11.019","article-title":"Vein of Marshall ethanol infusion as first step for mitral isthmus linear ablation","volume":"8","author":"Gillis","year":"2022","journal-title":"JACC Clin Electrophysiol"},{"key":"B28","doi-asserted-by":"publisher","first-page":"3146","DOI":"10.1111\/jce.15268","article-title":"Perimitral atrial tachycardias dependent on residual nonligament of Marshall conduction","volume":"32","author":"Sato","year":"2021","journal-title":"J Cardiovasc Electrophysiol"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2023.1223064\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,8,16]],"date-time":"2023-08-16T12:08:28Z","timestamp":1692187708000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2023.1223064\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,8,15]]},"references-count":28,"alternative-id":["10.3389\/fcvm.2023.1223064"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2023.1223064","relation":{},"ISSN":["2297-055X"],"issn-type":[{"value":"2297-055X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,8,15]]},"article-number":"1223064"}}