Volkov Dmytro, Karpenko Yurii, Sidhu Alamjeet Kaur, Skoryi Dmytro, Batsak Bogdan, Akobirov Yevhen Sadatshovych, Shustytsky Roman Volodymyrovych, Kravchenko Tetiana
Zaycev V.T. Institute of General and Urgent Surgery of NAMS of Ukraine.
Neuron Medical, Brno, Czech Republic.
Ann Med Surg (Lond). 2024 Aug 14;86(9):5648-5653. doi: 10.1097/MS9.0000000000002461. eCollection 2024 Sep.
Atrial tachycardias (AT) originating from the Marshall bundle (MB) are rare and present significant challenges in diagnosis and management. The authors present the case of a 29-year-old male with recurrent AT successfully treated with a combined ethanol and radiofrequency ablation approach. This case highlights the effectiveness of this dual ablation strategy in resolving AT originating from the MB, contributing valuable insights into managing complex AT cases.
A 29-year-old male with recurrent, symptomatic palpitations was initially suspected of orthodromic atrioventricular reentrant tachycardia, but an initial electrophysiological study (EPS) failed to induce arrhythmia. Subsequent spontaneous episodes led to a detailed EPS, revealing automatic AT originating presumably from an epicardial focus on the posterior wall of the left atrium (LA). Detailed mapping identified the earliest activation at the vein of Marshall (VoM) ostium within the coronary sinus (CS). Suspecting the involvement of MB structures, VoM ethanol ablation was performed. Complete arrhythmia elimination was achieved with radiofrequency ablation (RFA) at the VoM ostium within the CS, with no recurrence.
Most cases in the literature are associated with atrial fibrillation (AF) or AT within AF, typically involving re-entry mechanisms. The given case is unique as it presents a highly probable VoM origin of automatic AT with no concomitant AF. The VoM's anatomical and electrophysiological properties make it a potential source of refractory AT. In this case, ethanol ablation supplemented by targeted, limited RFA emerged as an effective strategy, highlighting the importance of comprehensive mapping and tailored ablation approaches in managing complex atrial arrhythmias.
The potential implications for clinical practice include recognizing the VoM as a critical target in refractory AT cases and adopting a combined ablation strategy to improve patient outcomes in similarly challenging scenarios.
起源于马歇尔束（MB）的房性心动过速（AT）较为罕见，在诊断和治疗方面存在重大挑战。作者报告了一例29岁男性复发性AT患者，采用乙醇和射频消融联合方法成功治疗。该病例突出了这种双重消融策略在解决起源于MB的AT方面的有效性，为处理复杂AT病例提供了宝贵见解。
一名29岁有复发性症状性心悸的男性最初被怀疑为房室折返性心动过速，但初始电生理检查（EPS）未能诱发心律失常。随后的自发发作促使进行了详细的EPS检查，结果显示为自动性AT，推测起源于左心房（LA）后壁的心外膜病灶。详细标测确定最早激动位于冠状窦（CS）内的马歇尔静脉（VoM）开口处。怀疑MB结构受累，遂进行了VoM乙醇消融。通过在CS内的VoM开口处进行射频消融（RFA）实现了心律失常的完全消除，且无复发。
文献中的大多数病例与心房颤动（AF）或AF内的AT相关，通常涉及折返机制。该病例独特之处在于其呈现出高度可能起源于VoM的自动性AT且无合并AF。VoM的解剖和电生理特性使其成为难治性AT的潜在来源。在本病例中，乙醇消融辅以靶向性、局限性RFA成为一种有效策略，突出了在处理复杂房性心律失常时全面标测和个体化消融方法的重要性。
对临床实践的潜在影响包括将VoM识别为难治性AT病例的关键靶点，并采用联合消融策略以改善类似挑战性情况下的患者预后。
