{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T15:34:13Z","timestamp":1789054453961,"version":"build-2803163510"},"reference-count":29,"publisher":"MDPI AG","issue":"21","license":[{"start":{"date-parts":[[2023,11,3]],"date-time":"2023-11-03T00:00:00Z","timestamp":1698969600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: The best ablation treatment for persistent atrial fibrillation (PeAF) patients is still debated. The vein of Marshall (VOM) seems to be a promising target for ablation and could be combined with a linear set of ablation lesions. The aim of our study is to evaluate the incidence of AF recurrences in a PeAF population treated with a comprehensive ablation approach consisting of VOM ethanol infusion (EI), pulmonary vein isolation (PVI), a left atrial (LA) roofline, a mitral line (guided by the newly formed lesion after alcohol infusion into the VOM and validated by pacing), and a cavotricuspid isthmus line. Methods: Consecutive patients undergoing the first ablation procedure of catheter ablation (CA) for PeAF were enrolled. All patients underwent VOM-EI, PVI, and ablation lines along the roof of the LA, mitral, and cavotricuspid isthmus. LA voltage mapping before and after VOM-EI was also performed. An implantable loop recorder (ILR) was implanted at the end of the ablation in each patient. Results: Thirty-one consecutive patients (66 \u00b1 8 years and 71% male) affected by PeAF were included in this study. The VOM-EI procedural phase lasted 21.4 \u00b1 10.1 min. PV isolation and lines were validated in all subjects. The ML block was achieved within 10.8 \u00b1 8.7 min. At a mean follow-up of 12 \u00b1 7 months, 27 out of 31 (87%) patients remained free from AT\/AF recurrences. Among the patients with recurrences, two (50%) had incomplete ablation lesions and three (75%) had \u201csuboptimal\u201d VOM-EI. In 23\/31 patients (74%), antiarrhythmic drugs (AADs) were discontinued after 1 month of follow-up. No significant complications were reported during the follow-up. Conclusions: this single-center experience demonstrates that VOM-EI systematically combined with an anatomical ablation set in patients with PeAF resulted in feasible, safe, and effective freedom from AF\/AT recurrences in 87% of the population after a 1-year follow-up period according to an ILR.<\/jats:p>","DOI":"10.3390\/jcm12216916","type":"journal-article","created":{"date-parts":[[2023,11,3]],"date-time":"2023-11-03T10:59:54Z","timestamp":1699009194000},"page":"6916","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Impact of Vein of Marshall Ethanol Infusion Combined with Anatomical Ablation for the Treatment of Persistent Atrial Fibrillation: A Long-Term Follow-Up Based on Implantable Loop Recorders"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8995-3884","authenticated-orcid":false,"given":"Martina","family":"Nesti","sequence":"first","affiliation":[{"name":"Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5369-5382","authenticated-orcid":false,"given":"Fabiana","family":"Luca","sequence":"additional","affiliation":[{"name":"Cardiology Department, Grande Ospedale Metropolitano, 89124 Reggio Calabria, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Panchetti","sequence":"additional","affiliation":[{"name":"Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0732-3297","authenticated-orcid":false,"given":"Silvia","family":"Garibaldi","sequence":"additional","affiliation":[{"name":"Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Umberto","family":"Startari","sequence":"additional","affiliation":[{"name":"Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gianluca","family":"Mirizzi","sequence":"additional","affiliation":[{"name":"Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2106-0884","authenticated-orcid":false,"given":"Federico","family":"Landra","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alberto","family":"Giannoni","sequence":"additional","affiliation":[{"name":"Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy"},{"name":"Health Science Interdisciplinary Center, Scuola Superiore Sant\u2019Anna, 56127 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcello","family":"Piacenti","sequence":"additional","affiliation":[{"name":"Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4430-6821","authenticated-orcid":false,"given":"Andrea","family":"Rossi","sequence":"additional","affiliation":[{"name":"Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,11,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1056\/NEJM199809033391003","article-title":"Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins","volume":"339","author":"Shah","year":"1998","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1016\/j.joa.2017.08.001","article-title":"2017 HRS\/EHRA\/ECAS\/APHRS\/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary","volume":"33","author":"Calkins","year":"2017","journal-title":"J. Arrhythmia"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1335","DOI":"10.1046\/j.1540-8167.2004.04428.x","article-title":"Pulmonary vein antrum isolation: Intracardiac echocardiography-guided technique","volume":"15","author":"Verma","year":"2004","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"3057","DOI":"10.1161\/CIRCULATIONAHA.107.690578","article-title":"Small or large isolation areas around the pulmonary veins for the treatment of atrial fibrillation? Results from a prospective randomized study","volume":"115","author":"Arentz","year":"2007","journal-title":"Circulation"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2293","DOI":"10.1016\/j.jacc.2010.03.016","article-title":"Catheter ablation of atrial fibrillation: The search for substrate-driven end points","volume":"55","author":"Katritsis","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1161\/CIRCEP.109.859116","article-title":"Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation","volume":"3","author":"Cappato","year":"2010","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1403","DOI":"10.1016\/j.hrthm.2009.06.014","article-title":"Impact of type of atrial fibrillation and repeat catheter ablation on long-term freedom from atrial fibrillation: Results from a multicenter study","volume":"6","author":"Bhargava","year":"2009","journal-title":"Heart Rhythm"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1658","DOI":"10.1016\/j.hrthm.2008.09.016","article-title":"Ablation for longstanding permanent atrial fibrillation: Results from a randomized study comparing three different strategies","volume":"5","author":"Elayi","year":"2008","journal-title":"Heart Rhythm"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1812","DOI":"10.1056\/NEJMoa1408288","article-title":"Approaches to Catheter Ablation for Persistent Atrial Fibrillation","volume":"372","author":"Verma","year":"2015","journal-title":"N. Engl. J. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1054","DOI":"10.1016\/j.jacc.2005.06.016","article-title":"Predictors of non-pulmonary vein ectopic beats initiating paroxysmal atrial fibrillation","volume":"46","author":"Lee","year":"2005","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_11","doi-asserted-by":"crossref","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 fi-brillation ablation","volume":"9","author":"Vlachos","year":"2019","journal-title":"Heart Rhythm"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1629","DOI":"10.1152\/ajpheart.00139.2007","article-title":"The ligament of Marshall as a parasympathetic conduit","volume":"293","author":"Ulphani","year":"2007","journal-title":"Am. J. Physiol. Heart Circ. Physiol."},{"key":"ref_13","doi-asserted-by":"crossref","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","volume":"63","author":"Takehiko","year":"2014","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1324","DOI":"10.1016\/S0735-1097(00)00819-6","article-title":"The ligament of Marshall: A structural analysis in human hearts with implications for atrial arrhythmias","volume":"36","author":"Kim","year":"2000","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1111\/j.1540-8167.2006.00516.x","article-title":"Vein of Marshall Activity During Sustained Atrial Fibrillation","volume":"17","author":"Kamanu","year":"2006","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e008884","DOI":"10.1161\/CIRCEP.120.008884","article-title":"Impact of vein of Marshall ethanol infusion on mitral isthmus block efficacy and durability","volume":"13","author":"Nakashima","year":"2020","journal-title":"Circ. Arrhythmia Electrophysiol."},{"key":"ref_17","doi-asserted-by":"crossref","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":"Peterson","year":"2020","journal-title":"J. Am. Med. Assoc."},{"key":"ref_18","doi-asserted-by":"crossref","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":"2020","journal-title":"Heart Rhythm"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1425","DOI":"10.1016\/j.hrthm.2016.03.005","article-title":"Performance of a 9 new atrial fibrillation detection algorithm in a miniaturized insertable cardiac monitor: Results from the 10 Reveal LINQ Usability Study","volume":"13","author":"Sanders","year":"2016","journal-title":"Heart Rhythm"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1038\/s41569-020-00451-x","article-title":"Catheter ablation for atrial fibrillation: Current indications and evolving technologies","volume":"18","author":"Parameswaran","year":"2021","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1016\/j.jacep.2019.08.021","article-title":"The Electrical Isolation of the Left Atrial Posterior Wall in Catheter Ablation of Persistent Atrial Fibrillation","volume":"5","author":"Lee","year":"2019","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e007005","DOI":"10.1161\/CIRCEP.118.007005","article-title":"Feasibility, Safety, and Efficacy of Posterior Wall Isolation During Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis","volume":"12","author":"Thiyagarajah","year":"2019","journal-title":"Circ. Arrhythmia Electrophysiol."},{"key":"ref_23","doi-asserted-by":"crossref","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":"ref_24","first-page":"20200492","article-title":"Adjunctive Vein of Marshall Ethanol Infusion During Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis","volume":"14","author":"Mhanna","year":"2021","journal-title":"J. Atr. Fibrillation"},{"key":"ref_25","doi-asserted-by":"crossref","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":"ref_26","doi-asserted-by":"crossref","first-page":"1252","DOI":"10.1093\/europace\/euaa137","article-title":"Acute and mid-term outcome of ethanol infusion of vein of Marshall for the treatment of perimitral flutter","volume":"22","author":"Takigawa","year":"2020","journal-title":"Europace"},{"key":"ref_27","unstructured":"Vilcant, V., Kousa, O., and Hai, O. (2023). Implantable Loop Recorder, StatPearls Publishing."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1779","DOI":"10.1161\/CIRCULATIONAHA.119.042622","article-title":"Cryoballoon or Radiofrequency Ablation for Atrial Fibrillation Assessed by Continuous Monitoring: A Randomized Clinical Trial","volume":"140","author":"Andrade","year":"2019","journal-title":"Circulation"},{"key":"ref_29","doi-asserted-by":"crossref","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."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/21\/6916\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T21:16:34Z","timestamp":1760130994000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/21\/6916"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,11,3]]},"references-count":29,"journal-issue":{"issue":"21","published-online":{"date-parts":[[2023,11]]}},"alternative-id":["jcm12216916"],"URL":"https:\/\/doi.org\/10.3390\/jcm12216916","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,11,3]]}}}