Identification and Endocardial Ablation of the Ligament of Marshall for Pulmonary Vein Isolation

Abstract

Objectives: The aims of this study were to establish criteria for identifying ligament of Marshall (LOM) connections that are responsible for pulmonary vein isolation (PVI) failure, assess their incidence, and determine if they can be targeted by focal endocardial ablation at the anterior carina of the left superior pulmonary vein (LSPV).

Background: Wide antral ablation of the left pulmonary veins (PVs) may not achieve PVI, sometimes requiring empirical ablation of the PV carina. The mechanism could be due to epicardial conduction along the LOM, which courses adjacent to the anterior carina.

Methods: In patients undergoing radiofrequency ablation for atrial fibrillation, if wide ablation of the left PV did not achieve isolation, bidirectional mapping was performed. A presumptive LOM connection was diagnosed if the earliest entrance was mapped to the anterior LSPV, while the earliest exit was mapped inferior to the left inferior PV. Focal ablation at the LSPV anterior carina was performed, even if not at the site of earliest entrance activation. The primary endpoint was successful PVI immediately after ablation.

Results: The study included 455 consecutive patients who underwent 570 procedures, of which 364 were first-time ablations. Presumptive LOM connections were identified in 48 procedures (8.4%) and in 41 patients (11.2%) undergoing first-time ablation and were successfully ablated at the anterior carina of the LSPV in 47 of 48 procedures (98%).

Conclusions: LOM connections may be a common cause of PVI failure and can be easily identified and reliably ablated with focal endocardial ablation at the anterior LSPV carina.

Keywords: atrial fibrillation; carina; ligament of Marshall; pulmonary vein isolation.