The role of Marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation

Heart Rhythm. 2019 Sep;16(9):1341-1347. doi: 10.1016/j.hrthm.2019.05.019. Epub 2019 May 22.

Abstract

Background: Atrial tachycardias (ATs) are often seen in the context of atrial fibrillation (AF) ablation.

Objectives: To evaluate the role of the Marshall bundle (MB) network in left atrial (LA) ATs using high-density 3-dimensional mapping.

Methods: A total of 199 ATs were mapped in 140 patients (112 male, mean age: 61.8 years); 133 (66.8%) were macroreentrant and 66 (33.2%) were scar-related reentry circuits. MB-dependent ATs were suggested by activation mapping analysis and confirmed with entrainment along the circuit.

Results: The MB network participated in 60 (30.2%) reentrant ATs: 31 perimitral ATs (PMATs) and 29 localized reentry circuits. Of 60 MB-related ATs, 49 (81.6%) terminated with radiofrequency (RF) ablation: 44 (73.3%) at the MB-LA junction and 5 (8.3%) at the MB-coronary sinus (CS) junction, while 9 (15%) terminated after 2.5-5 cc of ethanol infusion inside the vein of Marshall (VOM). Of the 31 PMATs, 17 (54.8%) terminated at the MB-LA junction, 5 (16.1%) at the MB-CS junction, and 7 (22.6%) with ethanol infusion. Of the 29 localized reentry circuits using the MB, 27 (93.1%) terminated at the MB-LA junction, none at the MB-CS junction, and 2 (6.9%) after ethanol infusion. Recurrences were mostly observed after RF ablation (18 of 37 patients, 49%) compared to ethanol infusion (1 of 9 patients, 11%) (P = .06).

Conclusions: MB reentrant ATs accounted for up to 30.2% of the left ATs after AF ablation. Ablation of the MB-LA or CS-MB connections or ethanol infusion inside the VOM is required to treat these arrhythmias.

Keywords: Atrial fibrillation; Atrial tachycardia; Catheter ablation; Epicardial connections; Marshall bundle.

MeSH terms

  • Atrial Fibrillation / complications
  • Atrial Fibrillation / physiopathology
  • Atrial Fibrillation / surgery*
  • Body Surface Potential Mapping / methods*
  • Cardiac Electrophysiology / methods
  • Catheter Ablation* / adverse effects
  • Catheter Ablation* / methods
  • Cicatrix / diagnosis
  • Cicatrix / etiology
  • Cicatrix / physiopathology
  • Female
  • Heart Atria / physiopathology
  • Heart Conduction System* / pathology
  • Heart Conduction System* / physiopathology
  • Humans
  • Male
  • Middle Aged
  • Postoperative Complications* / physiopathology
  • Pulmonary Veins / drug effects
  • Pulmonary Veins / surgery
  • Stroke / etiology
  • Stroke / prevention & control
  • Tachycardia, Supraventricular* / diagnosis
  • Tachycardia, Supraventricular* / etiology
  • Tachycardia, Supraventricular* / physiopathology
  • Treatment Outcome