Pulsed field ablation (PFA) Marshall plan including Marshall vein ethanol infusion approach in primary intent for persistent atrial fibrillation treatment

Abstract Background Different ablation strategies and energies have been developed for persistent atrial fibrillation (PeAF) treatment, but early management is still controversial. In the clinical setting of PeAF, the safety and efficacy of early Marshall plan combined with pulsed field ablation (PFA) and vein of Marshall ethanol infusion (VOMEI) have not yet been evaluated. Objectives Our prospective cohort study sought to: (1) assess the safety and feasibility of the non-thermal Marshall plan approach combined with VOMEI (Marshall plan VOMEI) as a first-line therapy in PeAF patients; (2) evaluate its mid-term efficacy. Methods and Results Between November 2023 and February 2025, 55 PeAF patients were referred for Marshall plan VOEMI. The Marshall Plan sequences were implemented as follows: VOEMI first followed by left pulmonary vein isolation (PVI), then mitral plus roof lines, and then right PVI; lastly the roof line and the mitral line were once again checked. The Farapulse system was used for PFA ablation. Marshall vein failure occurred in 4/55 patients (7.3%). Fifty-one pts (92.7%) who underwent Marshall plan VOEMI as first-line therapy were included. Their clinical and echocardiographic characteristics were as follows: mean age of 70±7.6 years, 23.5% of women, mean CHA²DS²VA score of 2.9±1.7, mean left ventricular ejection fraction of 57±14%, and mean left atrial size of 26±4cm² and volume (52±22 ml/m²). Procedure steps duration (min) and X-ray exposure (min) were as follows: skin to skin procedure (47±12 and 14.4±4.7 min); VOMEI duration (10.4±3.7 and 3.6±2.4 min); transeptal puncture (4.9±3 and 2.5±2.1 min) and PFA (21.1±6.5 and 7.5±2 min). The total number of PFA applications was 60±7.6, 38±4 for PVI, 10±3 for roof line and 14±6 for the mitral line. The % of mitral line recurrence at the procedure end was 43% despite VOMEI. Accordingly, repeated new applications were required until the mitral line block was obtained. No complications occurred. At mid-term FU (6.5±3 months), freedom from any atrial arrhythmia was 80.4%. Recurrences were as follows: PeAFib in 4, paroxysmal AFib in 4, left atrial flutter in 1 and right atrial flutter in 1. Conclusions This real-life prospective cohort study showed that de novo PFA Marshall plan plus VOEMI in PeAF is feasible, safe, but associated with a high rate of acute mitral line block recovery (43%). Mid-term freedom from any atrial arrhythmia recurrences is close to 80%.