{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T23:30:18Z","timestamp":1789428618753,"version":"build-2803163510"},"reference-count":8,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2025,6,29]],"date-time":"2025-06-29T00:00:00Z","timestamp":1751155200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"CardioPath program at Federico II University of Naples","award":["39-411-18-DOT1518782-7193"],"award-info":[{"award-number":["39-411-18-DOT1518782-7193"]}]},{"name":"Universit\u00e0 degli Studi di Milano","award":["39-411-18-DOT1518782-7193"],"award-info":[{"award-number":["39-411-18-DOT1518782-7193"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Atypical atrial flutter (AFL) is a complex clinical challenge, particularly in patients with prior atrial fibrillation (AF) treated with pulmonary vein isolation (PVI). Arrhythmias involving the vein of Marshall (VOM) often require extensive lesion sets, including ethanol infusion, to effectively target the epicardial substrate. To minimize tissue damage, an alternative strategy has been proposed, emphasizing advanced electroanatomical mapping, entrainment maneuvers, and highly targeted ablation techniques. Case Presentation: We describe a 72-year-old woman with recurrent atrial arrhythmias following pulmonary vein isolation (PVI), who presented with palpitations as her primary symptom. After ineffective pharmacological therapy, she underwent a catheter ablation procedure. Electroanatomical mapping revealed significant left atrial scarring and suggested a macroreentrant circuit involving the VOM. Entrainment maneuvers confirmed the VOM\u2019s involvement. A single targeted endocardial ablation guided by the ablation index terminated the arrhythmia within 12 s, without the need for ethanol infusion or extensive lesion sets. Discussion: This case underscores the VOM\u2019s role in sustaining atypical AFL post-PVI and highlights the effectiveness of precise electroanatomical mapping combined with targeted endocardial ablation. Unlike broader ablation or ethanol infusion strategies, a focused lesion at the critical isthmus achieved arrhythmia termination with minimal tissue damage. Conclusions: Endocardial ablation at the site of entrainment can safely and effectively treat VOM-related AFL, offering symptom relief and restoration of sinus rhythm. This approach may reduce procedural risks and expand the feasibility of VOM-related arrhythmia management in centers without access to ethanol infusion.<\/jats:p>","DOI":"10.3390\/jcm14134598","type":"journal-article","created":{"date-parts":[[2025,6,30]],"date-time":"2025-06-30T13:06:17Z","timestamp":1751288777000},"page":"4598","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Endocardial Ablation of Atrial Flutter with Involvement of the Vein of Marshall: A Case Report"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-4616-9300","authenticated-orcid":false,"given":"Lucio","family":"Addeo","sequence":"first","affiliation":[{"name":"Cardiovascular Center Aalst, Azorg Hospital, 9300 Aalst, Belgium"},{"name":"Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6117-2389","authenticated-orcid":false,"given":"Konstantinos","family":"Triantafyllou","sequence":"additional","affiliation":[{"name":"Cardiovascular Center Aalst, Azorg Hospital, 9300 Aalst, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hellen","family":"Dockx","sequence":"additional","affiliation":[{"name":"Cardiovascular Center Aalst, Azorg Hospital, 9300 Aalst, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-1655-9367","authenticated-orcid":false,"given":"Monika","family":"Shumkova","sequence":"additional","affiliation":[{"name":"Cardiovascular Center Aalst, Azorg Hospital, 9300 Aalst, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4739-7004","authenticated-orcid":false,"given":"Antonio","family":"Rapacciuolo","sequence":"additional","affiliation":[{"name":"Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6906-1766","authenticated-orcid":false,"given":"Stefano","family":"Nardi","sequence":"additional","affiliation":[{"name":"Pineta Grande Hospital, 81030 Castel Volturno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-2085-0256","authenticated-orcid":false,"given":"Vittoria","family":"Marino","sequence":"additional","affiliation":[{"name":"Pineta Grande Hospital, 81030 Castel Volturno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luigi","family":"Argenziano","sequence":"additional","affiliation":[{"name":"Pineta Grande Hospital, 81030 Castel Volturno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pasquale","family":"Guarini","sequence":"additional","affiliation":[{"name":"U.O Cardiologia, Clinica Sanatrix, Centro Studi SICOA, 80127 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6516-0959","authenticated-orcid":false,"given":"Laura Adelaide","family":"Dalla Vecchia","sequence":"additional","affiliation":[{"name":"Department of Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2839-0373","authenticated-orcid":false,"given":"Francesco","family":"Donatelli","sequence":"additional","affiliation":[{"name":"Department of Clinical and Community Sciences, University of Milan, 20122 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1424-114X","authenticated-orcid":false,"given":"Tom","family":"De Potter","sequence":"additional","affiliation":[{"name":"Cardiovascular Center Aalst, Azorg Hospital, 9300 Aalst, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1341","DOI":"10.1016\/j.hrthm.2019.05.019","article-title":"The role of Marshall bundle epicardial connection in atrial tachycardias after atrial fibrillation ablation","volume":"16","author":"Vlachos","year":"2019","journal-title":"Heart Rhythm"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1443","DOI":"10.1111\/jce.14019","article-title":"Ethanol infusion for Marshall bundle epicardial connections in Marshall bundle-related atrial tachycardias following atrial fibrillation ablation: The accessibility and success rate of ethanol infusion by using a femoral approach","volume":"30","author":"Kitamura","year":"2019","journal-title":"J. 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Assoc."},{"key":"ref_5","first-page":"566","article-title":"Left atrial roof-dependent atrial tachycardia via the Marshall bundle","volume":"7","author":"Sasaki","year":"2021","journal-title":"Heart Rhythm"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1111\/jce.13797","article-title":"MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation: MARSHALL-PLAN case series","volume":"30","author":"Pambrun","year":"2019","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Motoc, A., Luchian, M.L., Scheirlynck, E., Roosens, B., Chameleva, H., Gevers, M., Galloo, X., von Kemp, B., Ramak, R., and Sieira, J. (2021). Incremental value of left atrial strain to predict atrial fibrillation recurrence after cryoballoon ablation. 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Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4598\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:01:12Z","timestamp":1760032872000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4598"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,29]]},"references-count":8,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["jcm14134598"],"URL":"https:\/\/doi.org\/10.3390\/jcm14134598","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,29]]}}}