Sequential vs First-Intention Marshall-PLAN Strategy in Persistent Atrial Fibrillation Ablation: A Propensity Score Analysis.

BACKGROUND

The Marshall-PLAN ablation approach, combining pulmonary vein isolation (PVI) and ethanol infusion of the vein of Marshall (Et-VOM) with linear lesions, has been associated with improved rhythm outcomes in persistent atrial fibrillation (PsAF). The incremental benefit and optimal timing remain debated.

OBJECTIVES

This study compared the effectiveness of a Marshall-PLAN strategy performed as first intention vs redo ablation after prior PVI.

METHODS

This retrospective analysis included 237 patients treated for PsAF between September 2022 and April 2025. A total of 168 underwent a first-intention Marshall-PLAN procedure including Et-VOM and complementary linear ablation and 69 underwent a Marshall-PLAN procedure after PsAF recurrence despite previous PVI. The primary end point was arrhythmia recurrence lasting ≥30 seconds during follow-up. Analyses were weighted by using inverse probability of treatment weighting from a logistic regression-based propensity score.

RESULTS

Et-VOM was successful in 92.8% of cases. The sequential group had a longer AF history (122 months [Q1-Q3: 50-217 months] vs 30 months [Q1-Q3: 12-126 months]; P = 0.001). A complete Marshall-PLAN set was obtained in 90.4% of procedures. At 12 months, arrhythmia-free survival was 74.3% in the first-intention group and 80.7% in the sequential group (inverse probability of treatment weighting log-rank: P = 0.95). Incomplete Marshall-PLAN was independently associated with arrhythmia recurrence (HR: 5.55; 95% CI: 2.06-14.97; P = 0.001), whereas sequential strategy was not (HR: 0.52; 95% CI: 0.15-1.83; P = 0.30). Left atrial volume was a predictor of AF/atrial tachycardia recurrence (HR: 1.01 per mL; P = 0.015).

CONCLUSIONS

In PsAF, a sequential Marshall-PLAN procedure after prior PVI provides similar arrhythmia control to a first-intention Marshall-PLAN strategy. The completeness of the Marshall-PLAN, rather than its timing, seems to be a determinant of durable sinus rhythm maintenance.