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Protocol modifications reduce risk of delayed pericardial effusions after vein of Marshall ethanol infusion: follow-up from the Maine experience

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Abstract

Background

While ethanol infusion into the vein of Marshall (VOM) as an adjunct to atrial fibrillation ablation has shown promise, adoption has been limited by the technical expertise required, unclear antiarrhythmic mechanism, and complication risk. Delayed pericardial effusions have been associated with ethanol infusion into the VOM in prior studies. Very little is known about how the procedural approach itself can impact the risk of delayed effusions. We sought to understand the incidence and influence of procedural technique on complications including delayed pericardial effusions from VOM ethanol infusion at a large single medical center.

Methods

A total of 275 atrial ablation cases wherein VOM ethanol infusion was attempted were identified from the time of the program’s inception in 2019 at Maine Medical Center (Portland, ME) until October of 2023. Cases were classified into phase I cases (early experience) and phase II cases (later experience) based upon temporal programmatic changes in the ethanol dose and infusion rate as well as the use of routine VOM venography. Procedural details and complications were adjudicated from the medical record.

Results

The overall VOM ethanol infusion success was 91.4%. Nine complications (3.3%) occurred in eight patients (2.9% of patients). These were more frequent in phase I (5.8%) compared to phase II (1.3%, p = 0.047). This difference was driven by a difference in delayed presentations of tamponade, which occurred in four patients in phase I (3.3%) and in no patients in phase II (0%, p = 0.037). Twelve-month estimated atrial arrhythmia freedom did not differ between groups (73.8% phase I vs 70.4% phase II, p = 0.24).

Conclusion

In our single-center experience, adjustments to the procedural approach with lower ethanol infusion rate and dosage, combined with utilizing selective VOM venography, associated with a lowering of complication rates and in particular, delayed pericardial tamponade.

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Acknowledgements

The authors would like to acknowledge our colleagues and our EP lab staff for their assistance in reviewing this manuscript.

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Authors and Affiliations

  1. Department of Cardiology, Maine Medical Center, Portland, ME, 04102, USA

    Jordan S. Leyton-Mange, Amanda D. Haskell, Kunal Tandon, Andrew C. Corsello, Eric Black-Maier, Edward Y. Sze & Henry W. Sesselberg

  2. Maine Medical Partners MaineHealth Cardiology, 96 Campus Drive, Scarborough, ME, 04074, USA

    Jordan S. Leyton-Mange, Kunal Tandon, Andrew C. Corsello, Eric Black-Maier, Edward Y. Sze & Henry W. Sesselberg

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  1. Jordan S. Leyton-Mange
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  6. Edward Y. Sze
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Contributions

All authors contributed to the study conception and design. J.L.M. and A.D.H. performed the data collection. J.L.M. performed the analysis and preparation of the first draft of the manuscript. All authors commented on subsequent versions as well as read and approved the final manuscript.

Corresponding author

Correspondence to Jordan S. Leyton-Mange.

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Ethical approval

This study was approved by the Maine Medical Center Institutional Review Board and performed in accordance with the Declaration of Helsinki.

Consent to participate

This is a retrospective study performed by chart review, and as such, informed consent was waived by the Institutional Review Board.

Conflict of interest

J.L.M. has received prior speaking fees from Sanofi Aventis and consulting Fees from Biosense Webster. The remaining authors have no relevant financial or non-financial interests to disclose.

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Leyton-Mange, J.S., Haskell, A.D., Tandon, K. et al. Protocol modifications reduce risk of delayed pericardial effusions after vein of Marshall ethanol infusion: follow-up from the Maine experience. J Interv Card Electrophysiol (2024). https://doi.org/10.1007/s10840-024-01842-7

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  • DOI: https://doi.org/10.1007/s10840-024-01842-7

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