Marshall-Plan Ablation Strategy Versus Pulmonary Vein Isolation in Persistent AF

Background

Persistent atrial fibrillation (AF) is a common arrhythmia that can lead to serious cardiovascular complications. While pulmonary vein (PV) isolation is a widely accepted treatment, the optimal ablation strategy for persistent AF remains inadequately defined. This study aims to evaluate two distinct ablation strategies: one that includes comprehensive anatomical considerations and the classic PV isolation technique alone.

Methods

The Marshall-Plan trial was designed as a prospective, randomized, parallel-group, controlled clinical trial focusing on the superiority of its intervention. Conducted at Bordeaux University Hospital, it included consecutive patients diagnosed with symptomatic, documented persistent AF. Participants were randomly assigned to one of two treatment groups: the Marshall-Plan group or the PV isolation group. The Marshall-Plan intervention involved PV isolation coupled with additional ablation techniques—this included the infusion of ethanol into the vein of Marshall and the creation of conduction block lines at the mitral, dome, and cavotricuspid isthmuses. The primary outcome assessed was the freedom from any recurrence of arrhythmia (atrial fibrillation or atrial tachycardia lasting over 30 seconds) one year following a single ablation procedure, irrespective of the use of antiarrhythmic drugs.

Results

A total of 120 patients were included in the analysis, with an average age of 65 ± 8 years, of which 21 were women. Following randomization, two patients were excluded due to complications unrelated to the treatment. Both intervention groups achieved successful isolation of all pulmonary veins. In the group receiving the Marshall-Plan treatment, ethanol infusion into the vein of Marshall was successfully performed in 57 patients (97%). Conduction block was achieved across linear lesions in 93% at the mitral isthmus, 92% at the dome, and 93% at the cavotricuspid isthmus. The complete lesion set was successfully ablated in 52 patients (88%) within the Marshall-Plan group compared to 59 patients (100%) in the PV isolation group. At the 12-month follow-up, 51 out of 59 patients (86.4%) in the Marshall-Plan group remained free of recurrent atrial arrhythmia lasting over 30 seconds, compared to 39 out of 59 patients (66.1%) in the PV isolation group. The results of this comparison showed a statistically significant difference (P=0.012).

Conclusions

The Marshall-Plan ablation strategy demonstrates a significantly superior outcome over the traditional PV isolation method at the one-year mark in patients with persistent atrial fibrillation. This supports the notion that a more anatomically comprehensive approach can enhance treatment success for persistent AF.

Registration

The trial is registered at ClinicalTrials.gov with the unique identifier NCT04206982. Additional references can be found under PMID: 40392905; PMCID: PMC12094258.