Figure legends
Figure 1. Flowchart of patient enrollment and disposition in
this study. AF = atrial fibrillation, AT = atrial tachycardia, EIVOM =
ethanol infusion in the vein of Marshall, MI = mitral isthmus, PSVT =
paroxysmal supraventricular tachycardia, RF = radiofrequency, VOM = vein
of Marshall
Figure 2. (A) A thermometer was in the esophagus, guiding
catheter, and balloon catheter placed in the great cardiac vein. The
cineangiography while inflating a balloon catheter revealed the
existence of the Marshall vein (black arrows). CS = coronary sinus, GCV
= great cardiac vein, RAO = right anterior oblique, VOM = vein of
Marshall (B) A guidewire is inserted into the VOM through an
over-the-wire balloon. An ablation catheter and Advisor HD
gridTM mapping catheter are in the left atrium. (C) An
over-the-wire balloon is placed in the most distal site of the VOM.
Cineangiography is performed to confirm that the over-the-wire balloon
is correctly inserted in the VOM. The balloon inflation pressure is set
at 4 atm to avoid leakage of the contrast medium. Following angiography,
anhydrous ethanol of 2 mL was infused in the VOM over 2 min. (D)
Immediately after the first infusion, the over-the-wire balloon was
pulled back to the most proximal site of the VOM, 3 mL more ethanol was
infused in the VOM over 2 min while inflating the balloon at 4 atm. (E)
RF applications (30 W, 40 s) were first delivered in the endocardium of
the MI line using a steerable introducer under LAA pacing. RF =
radiofrequency, LAA = left atrial appendage, MI = mitral isthmus (F) If
the MI line block was not fully achieved, additional RF applications (25
W, 30 s) were delivered in the CS. (G) If those extra applications
failed to make a complete MI line, we approached the CS from the jugular
vein to gain enough contact force.
Figure 3. (A) The schema shows reconnection of both endocardium
(red arrow) and epicardium (blue arrow). The electrogram reveals double
and parallel potentials, which consist of endocardium (dull) and
epicardium (spiky) potential, which were conducteda from the distal to
the proximal site of the CS under LAA pacing. (B) The schema represents
an endocardium-only reconnection. The dull potentials conducted from the
distal to the proximal site were observed. Meanwhile, the spiky
potentials were recognized in the proximal-to-distal sequence. Note that
these two potentials were not discreated enough. (C) The schema
represents an epicardium-only reconnection. The spiky potentials are
recognized as the proximal-to-distal sequence. The dull potentials were
recognized as the proximal-to-distal sequence, which are blocked at the
site of CS 3-4.
Figure 4. (A) A representative case (Patient 16 in the
Supplementary data 1) of low-voltage area caused by EIVOM. Low-voltage
and scarred area are set at <0.5 and <0.05 mV,
respectively. EIVOM = ethanol infusion in the vein of Marshall, LIPV =
left inferior pulmonary vein, LSPV = left superior pulmonary vein, MA =
mitral annulus, RIPV = right inferior pulmonary vein, RSPV = right
superior pulmonary vein (B) Point and box-whisker plots represent
individual low-voltage areas of initial, just after EIVOM, and one hour
after EIVOM in the 19 patients of the EIVOM/RF group. These were
measured by two independent observers, excluding the authors. The height
of the boxes corresponds to the interquartile range, and the horizontal
lines on boxes represent median value.
Figure 5. Cumulative AF- or AT-free survivals of the first and
re-do ablation cases are shown. Dotted line represents a three-month
blanking period after the procedure. AF = atrial fibrillation, AT =
atrial tachycardia, EIVOM = ethanol infusion in the vein of Marshall, HR
= hazard ratio, RF = radiofrequency