Addeo Lucio, Triantafyllou Konstantinos, Dockx Hellen, Shumkova Monika, Rapacciuolo Antonio, Nardi Stefano, Marino Vittoria, Argenziano Luigi, Guarini Pasquale, Dalla Vecchia Laura Adelaide, Donatelli Francesco, De Potter Tom
Cardiovascular Center Aalst, Azorg Hospital, 9300 Aalst, Belgium.
Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy.
J Clin Med. 2025 Jun 29;14(13):4598. doi: 10.3390/jcm14134598.
Atypical atrial flutter (AFL) is a complex clinical challenge, particularly in patients with prior atrial fibrillation (AF) treated with pulmonary vein isolation (PVI). Arrhythmias involving the vein of Marshall (VOM) often require extensive lesion sets, including ethanol infusion, to effectively target the epicardial substrate. To minimize tissue damage, an alternative strategy has been proposed, emphasizing advanced electroanatomical mapping, entrainment maneuvers, and highly targeted ablation techniques. We describe a 72-year-old woman with recurrent atrial arrhythmias following pulmonary vein isolation (PVI), who presented with palpitations as her primary symptom. After ineffective pharmacological therapy, she underwent a catheter ablation procedure. Electroanatomical mapping revealed significant left atrial scarring and suggested a macroreentrant circuit involving the VOM. Entrainment maneuvers confirmed the VOM's involvement. A single targeted endocardial ablation guided by the ablation index terminated the arrhythmia within 12 s, without the need for ethanol infusion or extensive lesion sets. This case underscores the VOM's role in sustaining atypical AFL post-PVI and highlights the effectiveness of precise electroanatomical mapping combined with targeted endocardial ablation. Unlike broader ablation or ethanol infusion strategies, a focused lesion at the critical isthmus achieved arrhythmia termination with minimal tissue damage. Endocardial ablation at the site of entrainment can safely and effectively treat VOM-related AFL, offering symptom relief and restoration of sinus rhythm. This approach may reduce procedural risks and expand the feasibility of VOM-related arrhythmia management in centers without access to ethanol infusion.
非典型心房扑动（AFL）是一项复杂的临床挑战，对于接受过肺静脉隔离（PVI）治疗的既往有房颤（AF）的患者而言尤其如此。涉及Marshall静脉（VOM）的心律失常通常需要广泛的消融范围，包括乙醇注入，以有效靶向心外膜基质。为了将组织损伤降至最低，已提出一种替代策略，强调先进的电解剖标测、拖带操作和高度靶向的消融技术。我们描述了一名72岁女性，在肺静脉隔离（PVI）后出现复发性房性心律失常，以心悸为主要症状。药物治疗无效后，她接受了导管消融手术。电解剖标测显示左心房有明显瘢痕形成，并提示存在一个涉及VOM的大折返环路。拖带操作证实VOM参与其中。在消融指数引导下进行的单次靶向心内膜消融在12秒内终止了心律失常，无需乙醇注入或广泛的消融范围。该病例强调了VOM在PVI后维持非典型AFL中的作用，并突出了精确电解剖标测与靶向心内膜消融相结合的有效性。与更广泛的消融或乙醇注入策略不同，在关键峡部进行聚焦消融以最小的组织损伤实现了心律失常的终止。在心内膜拖带部位进行消融可以安全有效地治疗与VOM相关的AFL，缓解症状并恢复窦性心律。这种方法可能会降低手术风险，并扩大在无法进行乙醇注入的中心管理与VOM相关心律失常的可行性。
