First-line Marshall plan approach in persistent atrial fibrillation: a prospective single-center cohort study

Abstract Background Different ablation strategies have been developed for persistent atrial fibrillation (PeAF), but early management is still controversial. In the clinical setting of PeAF, the safety and efficacy of early Marshall plan have not yet been fully studied. Objectives Our prospective cohort study sought to: (1) assess the safety and feasibility of the thermal Marshall plan approach as a first-line therapy in PeAF patients; (2) evaluate its long-term efficacy; (3) identify the long-term predictive factors of MPA failure in PeAF patients. Methods and Results Between January 2020 and December 2023, 341 PeAF patients were referred for ablation and selected for Marshall plan ablation (MPA). Marshall vein failure occurred in 23/341 patients (6.75%), inability to find the vein of Marshall in 15/23 patients, and inability to catheterize in 8/23 patients. In 209/341 patients (61.25%), the PeAF MPA was performed as second-line ablation therapy (after at least one attempted ablation procedure). One hundred and nine patients (32%) who underwent MPA as first-line therapy were included. Their clinical and echocardiographic characteristics were as follows: mean age of 66±8.5 years, 16% of women, mean CHA²DS²VASc score of 2.3±1.34, mean left ventricular ejection fraction of 55±12%, and mean left atrial size of 27±7cm². After the blanking period of 3 months, 62/109 patients were in sinus rhythm (SR) (57%), 33/109 were in AF (30.2%), 8/109 were in left atrial flutter (AFL) (7.3%), and six were in right AFL (5.5%). Re-ablation was performed in 4/33 patients (12.1%) and cardioversion in 29/33 (87.9%) for patients in AF at 3 months after healing. All patients in AFL at 3 months were re-ablated and all recovered SR. At 21±11 months post-ablation, two patients were lost to follow-up (1.8%), 81/107 (75.7%) were in SR at the last control, and 26/107 (24.3%) had AF recurrence. The only predictive factors of late AF recurrence after first-line PeAF MPA were both left atrial dilatation and low left ventricular ejection fraction (LVEF). Conclusions This real-life prospective cohort study showed that de novo MPA in PeAF is feasible, relatively safe, and associated with a high rate of freedom from arrhythmia recurrence during long-term follow-up. The percentage of patients remaining in SR during long-term follow-up was close to 76%. The only predictive MPA failure factors were both left atrial dilatation and low LVEF.