Marshall Vein as Arrhythmogenic Source in Patients with Atrial Fibrillation: Correlation Between its Anatomy and Electrophysiological Findings

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Abstract
Background: Atrial fibrillation (AF) may originate from catecholamine‐sensitive vein of Marshall (VOM) or its ligament in addition to pulmonary veins (PVs). The anatomy of VOM and its relation to arrhythmogenic foci in the left atrium are unknown. We studied the anatomy of VOM and its relation to foci in patients with AF. Methods: The study population consisted of 100 patients with AF (mean age, 62 years; chronic AF, n = 15). AF sources were determined at baseline and after isoproterenol administration without sedation. VOM was identified by balloon‐occluded coronary sinus (CS) angiography. We determined its anatomy in relation to left PVs. Results: VOM was visualized in 73 patients (73%). Ninety‐seven patients had 269 arrhythmogenic foci (PV, n = 77; non‐PV, n = 48). Non‐PV foci included left atrial posterior wall (24, 9%), left lateral area (12, 4.5%), roof (6, 2.2%), superior vena cava (28, 10.4%), crista terminalis (8, 3.0%), CS (10, 3.7%), and others (10, 3.7%). The incidence of PV foci in the left superior PV (LSPV) was significantly higher in patients with well‐developed VOM than in those without (66% vs 42%, P < 0.05). Twenty‐eight patients had 30 non‐PV foci around the LSPV ostium. We successfully ablated the non‐PV foci at the distal end of VOM in 11 patients. The ends of the VOM branches were good markers to search for non‐PV foci. Seven of 11 (64%) patients with successful ablation of non‐PV foci were free from arrhythmia, whereas only 6 of 17 (35%) were free from arrhythmia in those with residual non‐PV foci. Conclusions: To determine VOM anatomy is important to identify non‐PV foci around the ends of VOM.