Vein of Marshall Alcohol Ablation Facilitated by a 10‐French Bidirectional Catheter Supported by Glide Advantage Wire

Vein of Marshall (VOM) ethanol ablation is an effective adjunctive therapy for persistent atrial fibrillation and mitral-isthmus dependent atrial flutter; however, physicians often encounter technical challenges during VOM cannulation, including coronary sinus (CS) sheath disengagement during manipulation which may complicate the procedure and reduce efficiency. Our case series describes a simplified and stability focused technique that utilizes a 10 French bidirectional deflectable sheath (Medtronic Flexcath Contour) that is supported by a Terumo Glide Advantage wire to enhance CS stability. Our approach was used in three patients aged 62-74 years old, two of which were females and had persistent symptomatic atrial fibrillation and atrial flutter that were refractory to prior ablations and medical therapy. In these cases, anatomical challenges including prominent Eustachian ridges (inferred from initial cannulation difficulties and sheath instability during CS access) and variable VOM positions were identified via CS venography, contributing to cannulation difficulty. In all three cases, our technique allowed for stable CS access and successful VOM identification, facilitating cannulation, wire advancement, balloon placement, and ethanol infusion without any sheath disengagement. We used pre and post infusion voltage mapping which ultimately showed elimination of all potentials along the lateral mitral isthmus and ridge. There were no procedure complications, including those potentially associated with sheath advancement into the CS such as vessel trauma or perforation, and all patients were atrial arrhythmia free at 3- and 6-month follow-up. Our technique of using a larger-lumen deflectable bidirectional sheath with guidewire support provides enhanced catheter stability and may improve procedural efficiency, reduce cannulation time, contrast utilization, and fluoroscopy particularly in anatomically challenging cases.