Volume 15, Issue 1, Pages (January 2018)

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Volume 15, Issue 1, Pages 17-24 (January 2018) Spectrum of atrial arrhythmias using the ligament of Marshall in patients with atrial fibrillation Aman Chugh, MD, FHRS, Hitinder S. Gurm, MD, Kavita Krishnasamy, MD, Mohammed Saeed, MD, Watchara Lohawijarn, MD, Kyle Hornsby, MD, Ryan Cunnane, MD, Hamid Ghanbari, MD, Rakesh Latchamsetty, MD, FHRS, Thomas Crawford, MD, FHRS, Krit Jongnarangsin, MD, Frank Bogun, MD, Hakan Oral, MD, FHRS, Fred Morady, MD Heart Rhythm Volume 15, Issue 1, Pages 17-24 (January 2018) DOI: 10.1016/j.hrthm.2017.07.033 Copyright © 2017 Terms and Conditions

Figure 1 An example of a ligament of Marshall (LOM)–pulmonary vein (PV) connection. During sinus rhythm, the ring catheter placed in the left superior PV (LSPV) records 2 potentials, a far-field left atrial (LA) potential followed by the LOM. Pacing from the distal coronary sinus (CS) advances the second potential and results in reversal of activation, confirming the presence of a LOM-PV connection. The LOM is activated immediately after CS activation. Pacing from the LA appendage (LAA) further accentuates the delay between the LA and the LOM. After elimination of the LOM connection with radiofrequency ablation, delay is longer (130–160 ms), confirming the presence of a LOM connection. (Mitral isthmus block could not be achieved in this patient owing to the presence of a large pouch at the lateral isthmus.) Heart Rhythm 2018 15, 17-24DOI: (10.1016/j.hrthm.2017.07.033) Copyright © 2017 Terms and Conditions

Figure 2 A: An example of a ligament of Marshall (LOM)–pulmonary vein connection that was eliminated during radiofrequency ablation at the lateral mitral annulus (MA). B: Fluoroscopic image showing the position of the ablation catheter and the ring catheter in the left superior pulmonary vein (LSPV). CS = coronary sinus; LA = left atrium. Heart Rhythm 2018 15, 17-24DOI: (10.1016/j.hrthm.2017.07.033) Copyright © 2017 Terms and Conditions

Figure 3 A: Termination of a reentrant atrial tachycardia involving the ligament of Marshall (LOM) during radiofrequency (RF) ablation at the lateral mitral annulus in a patient who had previously undergone excision of the left atrial (LA) appendage as part of a surgical maze procedure. B: Further mapping actually revealed that tachycardia persisted at the anterior mitral annulus during sinus rhythm, suggesting that the LOM and the subjacent atrial myocardium responsible for maintaining the tachycardia were insulated from the endocardium, which was activated by the sinus rhythm wavefront. C: Schema showing the likely mechanism of the tachycardia (red arrows) and proposed route of activation of the atrial mass. Conduction block across the Bachmann bundle (BB) was caused by RF ablation of another tachycardia that was ablated at the anterior LA (not shown). D: Schema showing ongoing tachycardia with conduction block to the coronary sinus (CS) and the atria during sinus rhythm. GCV = great cardiac vein; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RA = right atrium; SA = sinoatrial node; VOM = vein of Marshall. Heart Rhythm 2018 15, 17-24DOI: (10.1016/j.hrthm.2017.07.033) Copyright © 2017 Terms and Conditions

Figure 4 A: Balloon occlusion venogram of the coronary sinus (CS) showing the vein of Marshall (VOM). B: After inflation of a 1.5-mm balloon in the VOM, contrast injection shows dye “hang up.” C: Another selective venogram of the VOM shows extensive venous-venous communication over the left atrium. Alcohol instillation into the VOM in such a case would affect not only the lateral left atrial myocardium but also numerous other areas drained by the various intercommunicating veins. GCV = great cardiac vein; LIPV = left inferior pulmonary vein. Heart Rhythm 2018 15, 17-24DOI: (10.1016/j.hrthm.2017.07.033) Copyright © 2017 Terms and Conditions

Figure 5 A: Unipolar electrograms recorded by a catheter inserted into the vein of Marshall (VOM). B: Instillation of 1 cm3 of ethanol (EtOH) into the VOM led to complete abolition of the atrial electrograms. (EtOH ablation of the VOM had no effect on atrial fibrillation; EtOH infusion in this case was performed for mitral isthmus conduction.) RAA = right atrial appendage. Heart Rhythm 2018 15, 17-24DOI: (10.1016/j.hrthm.2017.07.033) Copyright © 2017 Terms and Conditions

Figure 6 Pleiotropic effects of ethanol (EtOH) ablation of the vein of Marshall (VOM). A: Without any radiofrequency (RF) energy delivery, infusion of 1 cm3 of EtOH yielded complete bidirectional block across the mitral isthmus in this patient with prior left atrial appendage (LAA) isolation. B: Complete isolation of the left inferior pulmonary vein (LIPV). C: Complete isolation of the LAA. A bipolar voltage map after EtOH infusion of the VOM showing absence of electrical conduction into the LAA. CS = coronary sinus; LLR = left lateral ridge; LSPV = left superior pulmonary vein; PV = pulmonary vein. Heart Rhythm 2018 15, 17-24DOI: (10.1016/j.hrthm.2017.07.033) Copyright © 2017 Terms and Conditions

Figure 7 A: An example of dual-loop macroreentrant tachycardia using the ligament of Marshall (LOM). The dashed arrows over the lateral mitral isthmus denote epicardial conduction overlying the area of endocardial scar. Radiofrequency energy (delivered at sites denoted by white tags between the left superior pulmonary vein [LSPV] and the left atrial appendage [LAA]) slowed the tachycardia (not shown). Gold tags indicate sites where the postpacing interval approximated the tachycardia cycle length. B: However, tachycardia termination required ethanol (EtOH) infusion into the vein of Marshall. CS = coronary sinus; LA = left atrium; LIPV = left inferior pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein. Heart Rhythm 2018 15, 17-24DOI: (10.1016/j.hrthm.2017.07.033) Copyright © 2017 Terms and Conditions