Marshall Vein as a Tract Connecting Both Sides of Mitral Isthmus Line in a Patient Post Radiofrequency Catheter Ablation of Atrial Fibrillation

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A 69-year-old man underwent the second radiofrequency (RF) ablation for the recurrence of persistent atrial fibrillation (AF). After re-isolation of the PV and making linear lesions to LA roof, bottom, and mitral annulus, AT with the cycle length of 370 msec was induced by programmed stimulation. Left atrial activation map exhibited counter-clockwise activation along the mitral annulus, with the total activation time for 290 msec and missing period for 80 msec at the mitral isthmus line. The post-pacing interval (PPI) at the mitral annulus anterior and inferior to the mitral isthmus line exceeded the tachycardia cycle length (TCL) by 30 ms. Extensive RF applications to the mitral isthmus and to the CS failed to terminate the AT. Then, a sharp small potential was recorded when the tip of ablation catheter was wedged in the proximal Marshall vein, which was confirmed by injection of contrast media from the irrigation catheter. The PPI was identical to the TCL. RF application using irrigation catheter successfully terminated the AT. Marshall vein may work as a bridge connecting both sides of mitral isthmus line. This is the first report of the perimitral AT that was successfully eliminated by the RF application in the Marshall vein.