Po-01-189 impact of coronary sinus balloon utilization on identification of the vein of marshall for adjunctive ethanol ablation for atrial fibrillation

Retrograde ethanol infusion into the vein of Marshall (EI-VOM) as an adjunct to pulmonary vein isolation (PVI) has been reported to improve success of atrial fibrillation (AF) ablation. However, identification and cannulation of the VOM remains technically challenging. It has been proposed that balloon occlusion of the coronary sinus (CS) allows for improved contrast opacification and facilitates identification of the VOM as well as differentiation of other branching veins. This study sought to assess the impact of CS balloon use on the success rate of VOM identification and time to VOM identification during adjunctive VOM ethanol ablation for AF. All patients undergoing PVI with EI-VOM at The Ohio State University Wexner Medical Center from January 2021 to November 2022 with known use or non-use of CS balloon were included. The primary endpoint was success rate of VOM identification and time to identification of VOM. The secondary endpoints were fluoroscopy time, procedure time, successful VOM cannulation, successful scar formation as defined by development of a characteristic low voltage area around the left inferior pulmonary vein on high-density electroanatomical mapping after ethanol infusion, and procedural complications. 106 patients underwent VOM ethanol ablation, 36 (34%) with and 68 (66%) without CS balloon use respectively. There was a significantly increased success rate in identification of VOM with CS balloon use (balloon 32 (89%) vs no balloon 50 (71%) patients, p=0.042). There was no significant difference in time to VOM identification. Notably, overall procedure time was significantly longer with CS balloon use (balloon 210.4 ± 51.7 vs no balloon 181.4 ± 37.1 minutes, p=0.004). There was no significant difference with balloon use in terms of fluoroscopy time, successful VOM cannulation, or successful scar formation (Table I). Notably, there were 3 (4%) cases of CS or VOM dissection in patients without balloon use as compared to 0 (0%) cases with balloon use, but this difference did not meet statistical significance. Figure 1 demonstrates the use of CS balloon during EI-VOM to facilitate identification of the VOM as well as atrial branches. CS balloon use is associated with significantly improved success in identification of the VOM during adjunctive ethanol ablation for AF. However, this is balanced by an associated increased procedure time.Tabled 1Table I: Procedural characteristicsProcedural characteristicsCoronary Sinus Balloon Used (N=36)Coronary Sinus Balloon Not Used (N=70)Total (N=106)P valueTimingTime to VOM identification, mins43.2 ± 15.546.1 ± 14.445.1 ± 14.80.419Fluoroscopy time, mins33.4 ± 10.031.4 ± 11.532.1 ± 11.00.374Procedure time, mins210.4 ± 51.7181.4 ± 37.1191.3 ± 44.60.004Key Procedural StepsCS cannulated36 (100%)68 (97%)104 (98%)0.547VOM identified32 (89%)50 (71%)82 (77%)0.042VOM cannulated29 (81%)46 (66%)75 (71%)0.112Able to advance balloon to VOM29 (81%)46 (66%)75 (71%)0.112Ethanol infused into VOM29 (81%)46 (66%)75 (71%)0.112OutcomeSuccessful formation of characteristic scar / low voltage area on high-density EAM15 (42%)35 (50%)50 (47%)0.853ComplicationsCS or VOM dissection0 (0%)3 (4%)3 (3%)0.549Values presented as mean ± 1 standard deviation for continuous variables and n (%) for categorical variables. Abbreviations: CS = coronary sinus, EAM = electroanatomical map, VOM = Vein of Marshall. Open table in a new tab