Takigawa Masateru, Martin Claire, Jaïs Pierre
Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), 33000 Bordeaux, France.
IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, 33000 Bordeaux, France.
Rev Cardiovasc Med. 2024 Mar 25;25(4):112. doi: 10.31083/j.rcm2504112. eCollection 2024 Apr.
The Ligament of Marshall (LOM) is a remnant of the embryonic sinus venosus and the left cardinal vein, containing a combination of fat, fibrous tissue, blood vessels, muscle bundles, nerve fibers, and ganglia. Various muscular connections exist between the LOM and the left atrium (LA) and the coronary sinus (CS). The LOM is richly innervated by autonomic nerves, with ganglion cells distributed around it. The unique characteristics of the LOM are responsible for generating focal electrical activities and enable it to serve as a substrate for micro- and macro-reentrant circuits. This, in turn, leads to the initiation and perpetuation of atrial fibrillation (AF) and atrial tachycardia (AT). Endocardial ablation in this region does not consistently succeed due to anatomical constraints within the left lateral LA, including the presence of a thicker and longer mitral isthmus (MI), anatomical variations between the MI and epicardial structures such as the CS and vein of Marshall (VOM) and circumflex artery, and the presence of fibrofatty tissue insulating the LOM. Furthermore, epicardial ablation is challenging for inexperienced institutions because of its invasive nature. Ethanol infusion into the VOM (EI-VOM) represents an effective and safe approach that can be employed in conjunction with radiofrequency ablation to eliminate this arrhythmogenic structure.
马歇尔韧带（LOM）是胚胎静脉窦和左主静脉的残余物，包含脂肪、纤维组织、血管、肌束、神经纤维和神经节的组合。LOM与左心房（LA）和冠状窦（CS）之间存在各种肌肉连接。LOM由自主神经丰富地支配，其周围分布着神经节细胞。LOM的独特特征导致产生局灶性电活动，并使其能够作为微折返和大折返电路的基质。这进而导致心房颤动（AF）和房性心动过速（AT）的起始和持续。由于左外侧LA内的解剖学限制，包括存在更厚更长的二尖瓣峡部（MI）、MI与心外膜结构（如CS和马歇尔静脉（VOM））以及回旋动脉之间的解剖学变异，以及存在使LOM绝缘的纤维脂肪组织，该区域的心内膜消融并不总是成功。此外，由于其侵入性，心外膜消融对于经验不足的机构来说具有挑战性。向VOM内注入乙醇（EI-VOM）是一种有效且安全的方法，可与射频消融联合使用以消除这种致心律失常结构。
