What question did this study set out to answer?

This research aims to evaluate the safety and effectiveness of Vein of Marshall alcohol ablation compared to radiofrequency ablation for persistent atrial fibrillation.

March 10, 2026Open Access

The Impact of Vein of Marshall Alcohol or Radiofrequency Ablation in Patients with Persistent Atrial Fibrillation Undergoing Catheter Ablation in the REAL-AF Registry

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Adults with persistent atrial fibrillation (duration ≥7 days and <12 months) undergoing de novo radiofrequency catheter ablation (n=746). Intervention: Pulmonary vein isolation plus substrate modification plus Vein of Marshall ethanol (VoM EtOH) ablation vs. Pulmonary vein isolation only or pulmonary vein isolation plus substrate modification plus Vein of Marshall radiofrequency ablation. Primary outcome: Freedom from atrial fibrillation recurrence at 12 months post-ablation after 90-day blanking period (HR 0.46 for VoM EtOH vs PVI only unadjusted, 95% CI 0.22-0.94, p=0.033; HR 0.46 clustered by physician, 95% CI 0.27-0.77, p=0.003; HR 0.30 adjusted and clustered, 95% CI 0.09-0.95, p=0.088, 95% CI 0.09-0.95, p=0.033 unadjusted; 0.003 clustered; 0.088 adjusted).

NPNicholas O. PalmeriCapital Cardiology Associates SNSarah Neilsen JLJordan Leyton-MangeMaineHealth

Key Result

Pulmonary vein isolation plus substrate modification plus Vein of Marshall ethanol ablation reduced atrial fibrillation recurrence at 12 months to 15.3% compared to 24.4% with PVI alone (HR 0.46, 95% CI 0.22-0.94, p=0.033).

Key Points

This research aims to evaluate the safety and effectiveness of Vein of Marshall alcohol ablation compared to radiofrequency ablation for persistent atrial fibrillation.
Analysis of data from the REAL-AF Registry
Comparison of outcomes from alcohol and radiofrequency ablation techniques
Assessment of efficacy and safety in real-world clinical practice
VoM EtOH ablation shows promising safety and efficacy results
Findings support its application as an adjunctive treatment strategy in persistent atrial fibrillation
No significant cohort size constraints were indicated

Study Design

Type

Observational (n=746)

Multicenter

Yes

Structured PICO

Does Vein of Marshall alcohol or radiofrequency ablation improve outcomes in patients with persistent atrial fibrillation undergoing catheter ablation?

Population

Patients with persistent atrial fibrillation (PsAF) undergoing catheter ablation in the REAL-AF Registry

Intervention

Vein of Marshall alcohol (VoM EtOH) or radiofrequency ablation as an adjunctive strategy

Comparator

Distinct ablation strategies

Vein of Marshall alcohol ablation appears to be a safe and efficacious adjunctive strategy for treating persistent atrial fibrillation in real-world practice.

Main Result

Effect estimate: HR 0.46 for VoM EtOH vs PVI only unadjusted, 95% CI 0.22-0.94, p=0.033; HR 0.46 clustered by physician, 95% CI 0.27-0.77, p=0.003; HR 0.30 adjusted and clustered, 95% CI 0.09-0.95, p=0.088 (95% CI 0.09-0.95)

Absolute Event Rate: 15.3% vs 24.4%

p-value: p=0.033 unadjusted; 0.003 clustered; 0.088 adjusted

Limitations

Observational registry design without randomization limits causality conclusions.
Smaller sample sizes in intervention groups limit power for detecting rare safety events.
Lack of detailed procedural data on Vein of Marshall radiofrequency techniques and ethanol usage.
No independent adjudication or clinical events committee.
Variability in operator experience and procedural approaches.
The analysis is exploratory and not powered for definitive hypothesis testing.

Abstract

VoM EtOH ablation for PsAF appears safe and efficacious as an adjunctive strategy for the treatment of PsAF. Findings are not based on cohort size, but on comparative effectiveness and safety across distinct ablation strategies in real-world practice.

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Cite This Study

Palmeri et al. (Sun,) conducted a observational in Adults with persistent atrial fibrillation (duration ≥7 days and <12 months) undergoing de novo radiofrequency catheter ablation (n=746). Pulmonary vein isolation plus substrate modification plus Vein of Marshall ethanol (VoM EtOH) ablation vs. Pulmonary vein isolation only or pulmonary vein isolation plus substrate modification plus Vein of Marshall radiofrequency ablation was evaluated on Freedom from atrial fibrillation recurrence at 12 months post-ablation after 90-day blanking period (HR 0.46 for VoM EtOH vs PVI only unadjusted, 95% CI 0.22-0.94, p=0.033; HR 0.46 clustered by physician, 95% CI 0.27-0.77, p=0.003; HR 0.30 adjusted and clustered, 95% CI 0.09-0.95, p=0.088, 95% CI 0.09-0.95, p=0.033 unadjusted; 0.003 clustered; 0.088 adjusted). Pulmonary vein isolation plus substrate modification plus Vein of Marshall ethanol ablation reduced atrial fibrillation recurrence at 12 months to 15.3% compared to 24.4% with PVI alone (HR 0.46, 95% CI 0.22-0.94, p=0.033).

synapsesocial.com/papers/69af94c970916d39fea4bb0d https://doi.org/https://doi.org/10.1016/j.hrthm.2026.02.049

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