Enhancing Persistent Atrial Fibrillation Ablation: The Added Value of Vein of Marshall Ethanol Infusion in a Tailored Strategy

BACKGROUND: Outcomes following catheter ablation for persistent atrial fibrillation (AF) remain suboptimal. Low-voltage areas (LVA), as a surrogate for atrial fibrosis, have been targeted due to their association with arrhythmia recurrence. Ethanol infusion in the vein of Marshall (VoM) has emerged as an adjunctive strategy that may enhance ablation efficacy. We evaluated the effectiveness of a tailored ablation strategy guided by the presence of LVA and incorporating VoM ethanol infusion in patients with persistent AF. METHODS: This prospective, single-center study included patients referred for catheter ablation for persistent AF ablation between August 2022 and August 2024. Patients underwent a tailored ablation strategy guided by the presence of LVA. Procedural endpoints and 1-year outcomes were assessed and compared with those of a propensity score-matched cohort undergoing pulmonary vein isolation (PVI) alone. RESULTS: A total of 118 patients (71% male, mean age of 62 ± 10years) were included in our study: 59 in the tailored approach group and 59 propensity score-matched controls. In the tailored group, VoM ethanol infusion was performed in 60% of patients, while ablation beyond pulmonary veins was not performed in 14% of patients due to LVA absence. Bidirectional block was achieved in all ablation lines except in two patients. At 1-year follow-up, 22% of patients had atrial arrhythmia recurrence. The risk of recurrence was significantly lower in the tailored approach group (13.5% vs. 30.5%, p = 0.02). A tailored approach was independently associated with freedom from atrial arrhythmia recurrence (HR 0.41 [0.17-0.94], p = 0.04). No significant differences in adverse events were observed between groups. CONCLUSIONS: In patients with persistent AF, a tailored ablation guided by LVAs was associated with significantly lower arrhythmia recurrence at 1-year compared with PVI alone.