Marshall-Plan ablation strategy may help control arrhythmias in patients with persistent AF

France: In patients with persistent atrial fibrillation, an innovative three-step ablation approach, including ethanol infusion of the vein of Marshal, was shown to improve freedom from arrhythmias compared to pulmonary vein isolation (PVI) in a recent study. "Marshall-Plan strategy holds promise for patients with persistent atrial fibrillation; they need to be confirmed in a multicentre trial," the authors wrote. 

Preliminary results at ten months has been presented at EHRA 2023, a scientific congress of the European Society of Cardiology (ESC). Follow-up of the study is ongoing until 12 months. 

The cornerstone of catheter ablation of atrial fibrillation is the complete isolation of the pulmonary veins. However, only 50–60% of patients remain in sinus rhythm at two years.3 Numerous trials of different ablation strategies have failed to demonstrate superiority over PVI. 

The Marshall-Plan ablation strategy consists of 1) PVI; 2) ethanol infusion of the vein of Marshall; and 3) a linear ablation set to block the three main anatomical isthmuses to the pulmonary veins (dome, mitral and cavotricuspid isthmus lines). The technique focuses on anatomical targets that have been individually recognised as important for initiating or maintaining atrial fibrillation but have not been collectively targeted systematically. The current investigators previously reported encouraging results using this strategy in non-randomised studies.

The present study compared 12-month arrhythmia-free survival with the Marshall-Plan ablation strategy versus PVI only. This was a prospective, randomised, parallel-group trial of superiority. The trial included 120 patients with symptomatic persistent atrial fibrillation for more than one month. The average age of participants was 67 years, and 21 (18%) were women.

Participants were randomised to receive the Marshall Plan or PVI alone. Follow-up occurred at 3, 6, 9 and 12 months, during which patients underwent several tests, including an electrocardiogram (ECG), echocardiography, stress test and 24-hour Holter monitoring. Recurrence of arrhythmias was identified using ECG teletransmission, with findings sent to the hospital once a week plus any time the patient had symptoms. The primary endpoint was a recurrence of atrial fibrillation or atrial tachycardia lasting more than 30 seconds at 12 months (including a 3-month blanking period) after a single ablation procedure.

The total radiofrequency time was significantly longer in the PVI group (29 minutes) compared with the Marshall-Plan group (23 minutes; p<0.001). The full lesion set was successfully completed in 53 patients (88%) receiving the Marshall-Plan strategy and 59 (98%) receiving PVI only. In an intention-to-treat analysis, the recurrence of arrhythmias after an average follow-up of 10 months was significantly higher in the PVI group compared with the Marshall-Plan group (18 vs. 8 patients; p=0.026). Follow-up will continue until 12 months.

Principal investigator Dr. Nicolas Derval of the University Hospital of Bordeaux, France said: “After 10 months of follow up, the success rate in the Marshall-Plan group was significantly better (87%) compared to the PVI only group (70%). However, the results are still preliminary as follow up is not completed for all patients. While the findings indicate that the Marshall-Plan strategy holds promise for patients with persistent atrial fibrillation, they need to be confirmed in a multicentre trial.”

Reference:

Novel ablation strategy improves freedom from arrhythmias in atrial fibrillation patients, European Society of Cardiology, Meeting, EHRA 2023.