Revisiting First-Line VoM Ablation in PeAF: Evidence based medicine also matters.

Revisiting First-Line VoM Ablation in PeAF: Evidence based medicine also matters. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Journal of Cardiovascular Electrophysiology This is a preprint and has not been peer reviewed. Data may be preliminary. 15 April 2025 V1 Latest version Share on Revisiting First-Line VoM Ablation in PeAF: Evidence based medicine also matters. Authors : Antoine Da Costa 0000-0003-3302-9988 [email protected] , Antoine Carmaux , and Karim Benali Authors Info & Affiliations https://doi.org/10.22541/au.174475633.36971518/v1 Published Journal of Cardiovascular Electrophysiology Version of record Peer review timeline 317 views 170 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Persistent atrial fibrillation (PeAF) is associated with a highly significant increase in heart failure, thromboembolism and death and a poorer quality of life. Prognosis improvement requires the sinus rhythm restoration. The first-line Marshall Plan ablation (MPA) appears to be a safe new reproducible strategy for PeAF patients. In this field the discussion is based on the safety and efficacy of this approach. Many elements are in favour of this MPA approach mainly based on randomised recently published studies but also on prospective real life cohort studies. Based on these reports a specific discussion is elaborated on the benefit/risk balance of this strategy. The evidence-based medicine studies are in favour of this strategy and remain at the heart of the debate. Revisiting First-Line VoM Ablation in PeAF: Evidence based medicine also matters. REPLY Response to the Letter to the Editor “Revisiting First-Line VoM Ablation in PeAF: Primum Non Nocere Matters “ by Cem Çöteli. Antoine Da Costa, MD, PhD, Antoine Carmaux, MD; Karim Benali, MD From the Division of Cardiology, Jean Monnet University (ADC), Saint-Etienne, France. Address for Correspondence: Professor Antoine Da Costa, Service de Cardiologie, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Etienne, F-42055 Saint-Etienne Cedex 2. Tel.: +33 (0)4 77 82 82 42; fax: +33 (0)4 77 82 81 64; email: [email protected] To Editor, We greatly appreciate the interest and the observations shown by Çöteli C. on our publication of the first-line Marshall Plan ablation (MPA) strategy in patients with persistent atrial fibrillation (PeAF) (1). Therefore, even if we agree with the formula “Primum Non Nocere Matters”, several elements may justify a more aggressive approach compared to circumferential pulmonary vein ablation (CPVA) alone in PeFA. Indeed, PeAF represents a marker of more severe atrial electrical and anatomical remodeling that means more atrial fibrosis, atrial dilatation and abundant non pulmonary vein triggers compared to paroxysmal AF (2). These findings correlate with a PeAF poorer prognosis as demonstrated in several studies including few meta-analysis (2). PeAF is associated with a highly significant increase in heart failure, thromboembolism and death and a poorer quality of life (2). Moreover, long time ago, the AFFIRM study demonstrated that the presence of sinus rhythm (SR) was associated with a lower long-term risk of death and antiarrhythmic drugs (AADs)were associated with increased mortality after adjustment for the presence of SR (3). More recently, one RCT in PeAF patients showed higher freedom from AF with catheter ablation (CA) compared with AAD (4). Accordingly, many invasive strategies have been tested for ablation delivered beyond CPVA in PeAF. As we know, evidence-based medicine matters and represents the referential (5-7). Several randomized studies argued in favor of more than CPVA alone and preferentially for MPA approach (5-7). These findings were first supported by the VENUS trial, suggesting that better long‐term outcomes are achievable in high‐volume centers, reflecting the learning curve associated with the Marshall vein ethanol infusion technique (VoMEI) (5). More recently a randomized study confirmed that among patients with PeAF, linear ablation combined with VoMEI in addition to PVI significantly improved freedom from atrial arrhythmias within 12 months compared with PVI alone (6). The PROMPT‐AF trial found more pronounced results after 12 months, 174 of 246 patients (70.7%) assigned to undergo PVI plus EIVOM and linear ablation and 153 of 249 patients (61.5%) assigned to undergo PVI alone remained free from atrial arrhythmias without taking antiarrhythmic drugs (hazard ratio, 0.73; 95% CI, 0.54–0.99, p = 0.045) (6). The intervention effect was consistent across all prespecified subgroups (6). Other randomized studies argued in favor of more than CPVA alone for PeAF approach throwing the STAR-F-2 concept away (8-11). Unfortunately, in this field the posterior wall approach isolation failed to demonstrate a superiority over standard PVI in the long-term randomized CAPLA study at a median follow-up of 3.6 years (11) emphasizing the importance of MPA strategy (11). We agree with Çöteli C that a comprehensive ablation may be justified in selected patients with advanced substrate pathology, and as related in our paper (Table 1) our selected PeAF population had an advanced atrial disease as evidenced by the left atrial size (27 ± 7 cm2 and 50 ± 20 mL/m2) (1). We recognize that as any interventional procedure the safety profile must mastered and as any interventional left atrial ablation procedure the tamponade risk exists. A recent meta-analysis provides additional arguments on the MPA safety compared with CPVA alone, demonstrating that there was no significant difference in pericardial effusion, stroke/transient ischemic attack (TIA), and all-cause death (7). Concerning the author statement that ethanol diffusion results in irreversible necrosis across an unpredictable volume of tissue, the Bordeaux group showed that the VoMEI was highly feasible with a low rate of serious complications in experienced centers (12). Moreover, the mean area of VOM-related endocardial scarring was predictable and estimated to 10.2±5.3 cm2 (12). The VoM must be considered as a source of AF triggers, and a tract for parasympathetic and sympathetic innervations that modulate electrophysiological properties of atrial tissue and contribute to AF maintenance (5). Lastly, the concept of left atrial contractile function alteration should be counterbalanced by Aranyó J et al. study demonstrating that despite the LA MPA scarring, the left atrial contractile function was not altered over the time (13). Accordingly, we agree with Çöteli C. that MPA represents an innovative and potentially powerful tool in the management of PeAF. Nowadays, at least two randomized studies and many real-life prospective cohorts as ours argue in favor of MPA feasibility, safety and efficacy in PeAF (1, 5-7, 12, 13). In the future, PeAF MPA may be considered as a first line strategy in light of scientific evidence in experienced centers. 1. Carmaux A, Yvorel C, Benali K, et al. First-Line Marshall Plan Approach in Persistent Atrial Fibrillation: A Prospective Single-Center Cohort Study. J Cardiovasc Electrophysiol. Mar 24 2025; doi:10.1111/jce.16650. 2. Ganesan AN, Chew DP, Hartshorne T, Selvanayagam JB, Aylward PE, Sanders P, et al. The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. Eur Heart J 2016; 37:1591–602. 3. Corley SD, Epstein AE, DiMarco JP, et al. Relationships Between Sinus Rhythm, Treatment, and Survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management AFFIRM) Study. Circulation 2004 Mar 30;109(12):1509-13. 4. L. Di Biase, P. Mohanty, S. Mohanty, et al., “Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial,” Circulation 133 (2016): 1637–1644. 5. M. Valderrábano, L. E. Peterson, V. Swarup, et al., “Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs. Catheter Ablation Alone on Persistent Atrial Fibrillation: The VENUS Randomized Clinical Trial,” JAMA: The Journal of the American Medical Association 324 (2020): 1620–1628. 6. C. Sang, Q. Liu, Y. Lai, et al., “Pulmonary Vein Isolation With Optimized Linear Ablation vs Pulmonary Vein Isolation Alone for Persistent AF: The PROMPT‐AF Randomized Clinical Trial,” Journal of the American Medical Association 333 (2025): 381–389. 7. Li F, Sun JY, Wu LD et al. The Long-Term Outcomes of Ablation With Vein of Marshall Ethanol Infusion vs. Ablation Alone in Patients With Atrial Fibrillation: A Meta-Analysis. Front Cardiovasc Med 2022 Apr 29;9:871654. 8. A. Verma, C. Jiang, T. R. Betts, et al., STAR AF II Investigators, “Approaches to Catheter Ablation for Persistent Atrial Fibrillation,” New England Journal of Medicine 372, no. 19 (2015): 1812–1822. 9. Deisenhofer I, Albenque JP, Busch S, and TAILORED-AF Investigators. Artificial intelligence for individualized treatment of persistent atrial fibrillation: a randomized controlled trial. Nat Med. 2025 Feb 14. doi: 10.1038/s41591-025-03517-w. 10. Huo Y, Gaspar T, Schönbauer R, Wojcik M, Fiedler L, Roithinger FX, et al. Low-voltage myocardium-guided ablation trial of persistent atrial fibrillation. NEJM Evid 2022;1: EVIDoa2200141. https://doi.org/10.1056/EVIDoa2200141. 11. William J, Chieng D, Curtin AG, Sugumar H, Ling LH, Segan L, et al. Radiofrequency catheter ablation of persistent atrial fibrillation by pulmonary vein isolation with or without left atrial posterior wall isolation: long-term outcomes of the CAPLA trial. Eur Heart J 2025; 46:132–43. 12. Kamakura T, Derval N, Duchateau J, et al. Vein of Marshall Ethanol Infusion: Feasibility, Pitfalls, and Complications in Over 700 Patients. Circ Arrhythm Electrophysiol. Aug 2021;14(8):e010001. 13. Aranyó J, Juncà G, Sarrias A, et al. Left Atrial Structure and Function Following Ethanol Infusion into Vein of Marshall (MR-SHALL Study). J Cardiovasc Electrophysiol. Jan 2025; 36(1):157-167. doi:10.1111/jce.16491 Information & Authors Information Version history V1 Version 1 15 April 2025 Peer review timeline Published Journal of Cardiovascular Electrophysiology Version of Record 24 Apr 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Journal of Cardiovascular Electrophysiology Authors Affiliations Antoine Da Costa 0000-0003-3302-9988 [email protected] UNIVERSITY OF SAINT ETIENNE View all articles by this author Antoine Carmaux Jean Monnet University View all articles by this author Karim Benali Jean Monnet University Saint-Etienne University Institute of Technology View all articles by this author Metrics & Citations Metrics Article Usage 317 views 170 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Antoine Da Costa, Antoine Carmaux, Karim Benali. Revisiting First-Line VoM Ablation in PeAF: Evidence based medicine also matters.. Authorea . 15 April 2025. DOI: https://doi.org/10.22541/au.174475633.36971518/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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