Conditions: Ventricular Tachycardia Atrial Fibrillation
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 343
Healthy volunteers: no

Brief summary:
The broad, long-term objective of this project is to evaluate the therapeutic value of vein of Marshall (VOM) ethanol infusion when added to catheter ablation of atrial fibrillation (AF). AF is the most common sustained arrhythmia in adults, and it is a leading cause of stroke, disability and increased mortality. Catheter ablation - pulmonary vein (PV) antral isolation (PVAI)- can lead to cure, but is best suited for paroxysmal AF, in which ectopic beats arising from the pulmonary veins were shown to initiate AF. PVAI success is lower in persistent AF, in which the role of the cardiac autonomic system, particularly the intrinsic cardiac ganglia, is being increasingly recognized. Expanding the ablation lesions to include greater areas the left atrial (LA) anatomy marginally improves outcomes, but also leads to increases in procedural complexity and duration, need of repeat procedures, and complications such as atrial flutters, particularly perimitral flutter (PMF). The investigators have developed a technique to perform rapid ablation of atrial tissues in AF using ethanol infusion in the vein of Marshall (VOM), and have shown: 1) Effective, rapid and safe tissue ablation of LA tissue neighboring the LA ridge and left inferior PV; 2) Regional LA vagal denervation by reaching the intrinsic cardiac ganglia; and 3) Facilitation of cure of PMF by ablating most of the mitral isthmus.

The investigators propose to evaluate outcomes differences yielded by VOM ethanol when added to conventional PVAI. The specific aims are: #1.To assesses the impact of VOM ethanol infusion in procedure success when added to de novo catheter ablation of persistent AF. The investigators will randomize patients with persistent AF undergoing a first AF ablation to standard PVAI vs. a combined VOM ethanol infusion plus PVAI (VOM-PV) #2. To assess the impact of VOM ethanol infusion added to repeat catheter ablation of recurrent AF after a failed ablation. Patients undergoing a repeat procedure for persistent AF after a failed PVAI will be randomized to either PVAI or VOM-PV as their repeat procedure. End points will include freedom from symptomatic or electrocardiographic AF after 12-15 months.

Detailed description:
Although the risk of stroke is comparable in persistent and paroxysmal AF, the prevalence of persistent AF increases dramatically with increasing age, and thus is an overall more significant cause of morbidity and mortality. In the United States, there are currently an estimated 3.0 million adults with AF, and this number is expected to double in the next 25 years. Hospitalizations with a primary diagnosis of AF are close to half a million per year, which generates a tremendous economic burden on the health care system. When compared to health care costs of non-AF control subjects, patients with AF have greater annual healthcare costs (up to $8705 total annual incremental cost). On the basis of current prevalence data, it is estimated that AF leads to a national incremental health care cost of up to $26 billion. Inadequacy of pharmacological treatment options for persistent AF Management strategies are directed at heart rate control and stroke prevention -mere palliation- or at rhythm control. It has been shown that rhythm control strategies using antiarrhythmic drugs offer no benefit in elderly patients or patients with heart failure. Most of the lack of benefit of such rhythm control strategy is thought to be due to the adverse effects and suboptimal efficacy of antiarrhythmic drugs that can potentially augment mortality. Indeed, preservation of normal sinus rhythm is associated with decreased mortality. Dronedarone, the only antiarrhythmic drug shown to improve outcomes in nonpermanent AF compared to placebo, has been shown to double mortality, stroke and hospitalization for heart failure in the PALLAS study in patients with permanent. Thus, antiarrhythmic drugs remain suboptimal at best for the treatment of AF.

Shortcomings of catheter ablation of persistent AF Weak mechanistic rationale: Isolation of the pulmonary vein (PVs2) and adjacent LA (PV antrum) is the accepted procedural endpoint, based on the mechanistic concept that atrial extrasystoles arising from the PVs initiate paroxysmal AF. Other, non-PV triggers have been demonstrated.36 The link between PV extra systoles and AF is clear in paroxysmal AF, but not in persistent AF, in which the mechanisms of AF seem to be related more to a chronic atrial substrate than to acute triggers.4 Indeed, intramural reentry in the posterior LA seems to be particularly relevant in chronic models of AF. In persistent AF, the procedure has evolved, rather simplistically, to include additional lesions -besides isolation of the PVs, variably placed in the posterior wall, LA roof, and towards the mitral annulus, the superior vena cava,44 left atrial appendage, and other areas where complex fractionated atrial electrograms (CFAE) may be mapped. This brute force approach of simply destroying more tissue has yielded additional success, but new procedural targets with solid mechanistic bases are needed.

Suboptimal success and need for repeat procedures. Despite the additional tissue destruction, ablation success in persistent AF is with much lower than in paroxysmal AF, with single procedure success reported as low as 27%, 36%, or 49%, but up to 61% or 67%, depending on study heterogeneities in: definitions of persistent AF and of recurrence of AF, the type of AF monitoring, and ablation technique and operator experience. In order to achieve overall acceptable success rates, (which can reach up to 79%-94%), there is a consistent need for repeat procedures (sometimes up to 4) and the concomitant use of antiarrhythmic drugs. The rate of repeat procedures in experienced centers can reach up to 70 to 80%.PMF after catheter ablation of persistent AF. Clinical failures of a first ablation procedure are caused, in a significant portion of patients, by atrial flutters, rather than recurrent AF, and recurrence as flutter portends a greater chance of success in a second procedure. Such atrial flutters may be caused by perimitral reentry in up to 33-60% of the patients. Catheter ablation of PMF involves the creation of a linear lesion from the mitral annulus to the left inferior PV (the so-called mitral isthmus).Achieving a complete ablation (defined by bidirectional conduction block across the ablation line) can be very difficult, with success rates reported as 32%, 64%, or 71%. It sometimes requires ablation inside the coronary sinus (CS), in close proximity to the circumflex coronary artery, which could be damaged of note, incomplete ablation of the mitral isthmus is proarrhythmogenic, increasing the risk of recurrent flutter by up to 4 times.

Arms:
arm 1: Randomized to vein of marshal ethanol infusion plus conventional pulmonary vein antral isolation (VOM-PV) to treat persistent atrial fibrillation arm 2: Conventional pulmonary vein antral isolation (PVAI) to treat persistent atrial fibrillation

Interventions: intervention 1: Ethanol intervention 2: Ablation
Intervention descriptions: intervention 1: We enter the CS with a sheath advanced from the right internal jugular vein. A sub-selector catheter with a \~90° angle at the tip (typically, a left internal mammary artery angioplasty guide catheter) is advanced through the CS sheath with its tip pointing superiorly and posteriorly. intervention 2: The doctor will perform only the standard procedure. Throughout the procedure, the researchers will document the following information for ALL patients: measurements such as whether the treatment was successful or unsuccessful, X-ray exposure time, procedure time, whether there were any complications, and other general procedural measurements.

Protocol document:
Prot_SAP_000.pdf: 
Protocol V7.2 15FEB2016 
 
 
1 
 
CLINICAL PROTOCOL 
 
VEIN OF MARSHALL ETHANOL INFUSION FOR 
PERSISTENT ATRIAL FIBRILLATION 
(IND 115,060) 
(A MULTICENTER TRIAL) 
 
Version 7.2 
February 15, 2016 
Clinical Trials.gov NCT 01898221 
NIH-NHLBI R01HL115003-02 
IND Sponsor 
Houston Methodist Research Institute (HMRI) 
6565 Fannin Street 
Houston, TX 77030 
 
Principal Investigator 
Miguel Valderrábano, MD 
Houston Methodist Hospital, Houston TX 
 
Coordinating site 
Houston Methodist Research Institute (HMRI) 
Houston TX 
 
 
 


Protocol V7.2 15FEB2016 
 
 
2 
 
 
CONTENTS 
PROTOCOL SYNOPSIS 4 
1.0 
 INTRODUCTION .................................................................................................................................................. 7 
2.0 
 SIGNIFICANCE ...................................................................................................................................................... 7 
2.1 
 AF as a clinical and health care problem ......................................................................................................................... 7 
2.2 
 Inadequacy of pharmacological treatment options for persistent AF.................................................................. 8 
2.3 
 Shortcomings of catheter ablation of persistent AF .................................................................................................... 8 
3.0 
 INNOVATION 9 
3.1 
 Targeting the intrinsic cardiac ganglia via the VOM .................................................................................................. 9 
3.2  
VOM ethanol infusion: technique........................................................................................................................................ 11 
3.3 
 Unveiling of an LA venous plexus ...................................................................................................................................... 12 
3.4 
 VOM ethanol infusion: tissue ablation and left PV disconnection ........................................................................ 12 
3.5 
 VOM ethanol infusion: a novel technique for local vagal denervation in humans......................................... 13 
3.6  
VOM ethanol infusion and perimitral flutter (PMF) ................................................................................................... 14 
3.7  
Role of VOM in failed ablations ........................................................................................................................................... 15 
4.0 
 TRIAL OVERVIEW AND PRELIMINARY DATA .......................................................................................... 16 
4.1 
 HYPOTHESIS .............................................................................................................................................................................. 16 
4.2  
Preliminary outcomes data: results of our pilot experience .................................................................................... 18 
4.3 
 Three Month Blanking Period ............................................................................................................................................ 18 
5.0 
 MATERIALS AND METHODS ......................................................................................................................... 18 
5.1 
 Specific Aims .............................................................................................................................................................................. 18 
5.2   
Study Endpoints......................................................................................................................................................................... 19 
5.3 
 Inclusion and exclusion criteria ......................................................................................................................................... 20 
5.4  
Informed Consent Process ..................................................................................................................................................... 21 
5.5 
 Study Procedures ..................................................................................................................................................................... 21 
5.6 
 Post-Procedural Data Collection: ...................................................................................................................................... 24 
5.7 
 VENUS:  Definitions of Procedural Success or Failure and Indications for Repeat Procedures ............... 25 
5.8 
 MARS:  Definitions of Procedural Success or Failure and Indications for Repeat Procedures .................. 27 
6.0 
 STATISTICAL CONSIDERATIONS ................................................................................................................. 28 


Protocol V7.2 15FEB2016 
 
 
3 
 
7.0 
 STUDY ORGANIZATION .................................................................................................................................. 44 
7.1 
 SCHEDULE OF EVENTS ......................................................................................................................................................... 44 
7.2 
Patient Recruitment, Procedures And Follow-Up ........................................................................................................ 46 
7.3  
Clinical Research Nurses/Coordinators ........................................................................................................................... 46 
7.4 
 Data Coordinating Center (DCC) ....................................................................................................................................... 46 
7.5  
Study Drug ................................................................................................................................................................................... 47 
7.6 
 Blinding ....................................................................................................................................................................................... 47 
7.7 
 Core laboratories: Echocardiography, and EKG monitoring ................................................................................. 48 
7.8 
 Safety considerations ............................................................................................................................................................. 48 
8.0 
 STUDY ADMINISTRATION & OVERSIGHT ................................................................................................. 51 
8.1  
PI Oversight ................................................................................................................................................................................. 51 
8.2  
Coordinating Center............................................................................................................................................................ 51 
8.3  
Scientific Advisory Board ....................................................................................................................................................... 51 
8.4  
DATA SAFETY MONITORING BOARD (DSMB) .............................................................................................................. 52 
9.0  
TRIAL MANAGEMENT ...................................................................................................................................... 52 
9.1 
 Statistical Management ........................................................................................................................................................ 52 
9.2 
 Data Management................................................................................................................................................................... 52 
9.3 
 STUDY MONITORING ............................................................................................................................................................. 53 
9.4 
 PROJECT MANAGEMENT ...................................................................................................................................................... 54 
10.0  
GUIDE TO ACRONYMS / DEFNITIONS ......................................................................................................... 55 
11.0 
Classes of Anti-Arrhythmic Drugs (Vaughn-Williams Classification)127 ........................................... 56 
12.0 
LITERATURE CITED ......................................................................................................................................... 57 
 
 
 


Protocol V7.2 15FEB2016 
 
 
4 
 
PROTOCOL SYNOPSIS  
Title 
Vein of Marshall Ethanol Infusion for Persistent Atrial Fibrillation  
IND Sponsor 
Houston Methodist Research Institute (HMRI) 
6565 Fannin Street  
Houston, TX 77030 
Name of Product 
Dehydrated Alcohol Injection, USP 
Clinical Phase 
III 
Patient Population 
Patients with documented, persistent atrial fibrillation (AF that persists 
beyond 7 days) that have failed to respond to at least one class of 
antiarrhythmic drugs (due to failure or intolerance), and who are 
otherwise deemed candidates for radiofrequency ablation of AF. 
Objectives 
VENUS-AF. Vein of Marshall Ethanol iNfusion in Untreated perSistent 
Atrial Fibrillation: To assess the role of VOM ethanol infusion in 
catheter ablation of persistent AF.  
MARS-AF. Vein of Marshall Alcohol in Repeat ablation of perSistent 
Atrial Fibrillation: To assess the impact of VOM ethanol infusion 
after a failed conventional ablation of persistent AF.  
Trial Design 
Subjects who meet inclusion criteria will be randomized to either a 
conventional PVAI or PVAI with VOM procedure. Subjects will return 
for follow-up evaluations at 1, 3, 6, 9, and 12 months.  One-month 
continuous cardiac event monitoring will be performed at 6 months and 
at 12 months. Studies performed at follow-up visits may include EKG, 
physical exam, QOL questionnaires, echocardiography, laboratory 
studies, anticoagulation therapy, and management of adverse events 
and AF recurrences.  Patient and co-investigator performing follow-up 
of electrocardiographic data will be blinded to the type of procedure.  
Operator is not blinded.  
Sample Size 
405 total subjects,  
VENUS: 180 (VOM-PV) + 156 (PVAI) =  336 
MARS: 37 (VOM-PV) + 32 (PVAI) = 69 
Primary Endpoints 
De Novo (VENUS-AF) 
and Previously Failed 
Ablation (MARS-AF) 
 
 
Efficacy: Freedom from symptomatic AF or atrial tachycardia (AT) 
AND reduction of AF/AT to less than 30 seconds in a continuous 
monitor at  6 and 12  months after a single procedure.  
Safety: Acute procedural complications and total mortality 


Protocol V7.2 15FEB2016 
 
 
5 
 
Secondary Endpoints 
De Novo (VENUS-AF) 
and Previously Failed 
Ablation Study 
(MARS-AF) 
1. Freedom from AF/AT after >1 procedure. 
2. Freedom from AF/AT on antiarrhythmic drugs. 
3. AF burden (% time) on continuous monitoring at 6 and 12 months.  
4. Procedural parameters: total procedure, fluoroscopy, total RF 
ablation time (first procedure), and total extent of ablated LA tissue.  
5. Clinical/partial success: less than 25% AF burden on a continuous 
event monitor at 6 and 12 months from ablation procedure. 
6. Sub-acute procedural complications (within 30 days).  
7. Recurrence as persistent or paroxysmal AF, or flutter after 1 or 2 
procedures.  
8. LA function on Doppler echocardiography (LA strain114ab) at 12 
months.  
9. Incidence and mechanisms of atrial flutters.  
10. Cardiovascular hospitalizations and  
11. QOL as determined by AFEQT questionnaire. 
Inclusion Criteria 
  
VENUS-AF 
1. Patients between the ages of 21 and 85 years undergoing their first 
ablation of AF. 
2. Diagnosed with symptomatic persistent or long-standing persistent 
AF, defined as:  
 AF not spontaneously converting to sinus rhythm, persisting for 
>7 days 
3. Resistant or intolerant to at least one class I, II, or III antiarrhythmic 
drug (AAD)  
4. Patients deemed candidates for RF ablation of AF  
5. Able and willing to comply with pre-, post-, and follow-up 
requirements. 
MARS-AF 
Inclusion criteria 
1. Patients between the ages of 21 and 85 years 
2. Prior ablation for symptomatic persistent AF: 
 Recurrence as symptomatic AF or AT at least 3 months after 
ablation 
3. Resistant or intolerant to one class I, II, or III AAD prior to index 
ablation 
4. Patients deemed candidates for RF ablation of AF  
5. Able and willing to comply with pre-, post-, and follow-up 
requirements. 
 


Protocol V7.2 15FEB2016 
 
 
6 
 
Exclusion Criteria- 
 
VENUS-AF 
MARS-AF 
 
1. Left atrial thrombus by pre-procedural imaging.  
2. LA diameter greater than 65 mm on long axis parasternal   view, or 
left atrial volume more than 200 cc. 
3. Left ventricular ejection fraction < 30%.  
4. Cardiac surgery within the previous 180 days.  
5. Expecting cardiac transplantation or other cardiac surgery within 
180 days.  
6. Coronary PTCA/stenting within the previous 90 days.  
7. Documented history of a thrombo-embolic event within the 
previous 90 days.  
8. Diagnosed atrial myxoma.  
9. Significant restrictive, constrictive, or chronic obstructive pulmonary 
disease with chronic symptoms.  
10. Significant congenital anomaly or medical problem that in the 
opinion of the investigator would preclude enrollment  
11. Women who are pregnant or who plan to become pregnant during 
the study.  
12. Acute illness or active infection at time of index procedure 
documented by pain, fever, drainage, positive culture and/or 
leukocytosis (WBC > 11.000 per mm3) for which antibiotics have 
been or will be prescribed.  
13. Creatinine > 2. 5 mg/dl (or > 221 μmol/L, except for patients in 
dialysis).  
14. Unstable angina.  
15. Myocardial infarction within the previous 60 days.  
16. History of blood clotting or bleeding abnormalities. 
17. Contraindication to anticoagulation.  
18. Life expectancy less than 1 year.  
19. Uncontrolled heart failure  
20. Presence of an intramural thrombus, tumor, or other abnormality 
that precludes catheter introduction or positioning.  
21. Presence of a condition that precludes vascular access.  
22. INR greater than 3.5 within 24 hours of procedure- for patients 
taking warfarin.  
23. Cannot be removed from antiarrhythmic drugs for reasons other 
than AF.  
24. Unwilling or unable to provide informed consent.  
 
 
 
 


Protocol V7.2 15FEB2016 
 
 
7 
 
1.0 
INTRODUCTION 
Atrial fibrillation (AF)* is the most common sustained arrhythmia in adults, and is a leading 
cause of stroke, disability and increased mortality.1 Catheter ablation has become an 
increasingly accepted form of rhythm control and –other than surgery- is the only treatment form 
that can potentially cure AF.  The ablation procedural strategy –pulmonary vein (PV) antral 
isolation (PVAI)- is best suited for paroxysmal AF,2 in which ectopic beats arising from the PVs 
were shown to initiate AF.3 However, it is unclear whether this mechanistic rationale applies to 
persistent AF,4, 5 in which the role of the cardiac autonomic system, particularly the intrinsic 
cardiac ganglia, is being increasingly recognized as a modulator of atrial physiology leading to 
AF.6, 7 The success of PVAI is significantly lower in persistent AF.8 Expanding the ablation 
lesions to include larger areas of the atrial anatomy -such as the left atrial (LA) roof, coronary 
sinus (CS), LA appendage, septum, posterior wall, superior vena cava, and others- has 
improved outcomes, but also led to increases in procedural complexity and duration, need of 
repeat procedures,9-12 and complications such as atrial flutters, particularly perimitral flutter 
(PMF).13 Little mechanistic evidence supports this approach, which does not specifically 
address the intrinsic cardiac ganglia. Given that persistent AF has far greater prevalence and is 
a greater cause of stroke, disability and mortality than paroxysmal AF,14 strategies to improve 
outcomes of catheter ablation of persistent AF are much needed.  
We have developed a technique to perform rapid ablation of targeted atrial tissues in AF using 
ethanol infusion in the vein of Marshall (VOM).15, 16 A previous R21 project has generated 
sufficient human data to support the safety –no safety issues were identified- and mechanistic 
utility of this technique by showing: 1) Effective, rapid and safe tissue ablation of LA tissue 
neighboring the LA ridge and left inferior PV; 2) Facilitation of cure of PMF by ablating most of 
the mitral isthmus; and 3) Regional LA vagal denervation.  The broad, long term objective is to 
improve the outcomes of catheter ablation of persistent AF using the VOM as a target and a 
route to deliver ablative therapies.  
2.0 
SIGNIFICANCE 
2.1  
AF AS A CLINICAL AND HEALTH CARE PROBLEM 
AF is the most common arrhythmia in the United States,1 and is associated with significant 
morbidity and mortality, including up to 5-fold increased risk of stroke,17, 18 2-fold increased risk 
of dementia,19-21 a 3-fold increased risk of heart failure18 and a 40 to 90% increased risk of 
overall mortality.22 Although the risk of stroke is comparable in persistent and paroxysmal AF,23 
the prevalence of persistent AF increases dramatically with increasing age,24, 25 and thus is an 
overall more significant cause of morbidity and mortality. In the United States, there are 
currently an estimated 3.0 million adults with AF,26 and this number is expected to double in the 
                                                          
* Abbreviations used: 3D: 3-dimensional; AF: atrial fibrillation; CFAE: complex fractionated atrial electrograms; CS: 
coronary sinus; LA: left atrium; PMF: perimitral flutter; PV: pulmonary vein; PVAI: PV antral isolation; RF: 
radiofrequency; VOM: vein of Marshall; VOM-PV: combined VOM ethanol infusion plus PVAI 


Protocol V7.2 15FEB2016 
 
 
8 
 
next 25 years.27 Hospitalizations with a primary diagnosis of AF are close to half a million per 
year,28 which generates a tremendous economic burden on the health care system. When 
compared to health care costs of non-AF control subjects, patients with AF have greater annual 
healthcare costs (up to $8,705 total annual incremental cost). On the basis of current 
prevalence data, it is estimated that AF leads to a national incremental health care cost of up to 
$26 billion.29 
2.2  
INADEQUACY OF PHARMACOLOGICAL TREATMENT OPTIONS FOR PERSISTENT AF 
Management strategies are directed at heart rate control and stroke prevention –mere palliation- 
or at rhythm control.  It has been shown that rhythm control strategies using antiarrhythmic 
drugs offer no benefit in elderly patients30 or patients with heart failure.31 Most of the lack of 
benefit of such rhythm control strategy is thought to be due to the adverse effects and 
suboptimal efficacy of antiarrhythmic drugs, that can potentially augment mortality.32 Indeed, 
preservation of normal sinus rhythm is associated with decreased mortality.32 Dronedarone, the 
only antiarrhythmic drug shown to improve outcomes in nonpermanent AF compared to 
placebo,33 has been shown to double mortality, stroke and hospitalization for heart failure in the 
PALLAS study in patients with permanent AF (prematurely terminated: www.clinicaltrials.gov 
and www.theheart.org/article/1264551.do). Thus, antiarrhythmic drugs remain suboptimal at 
best for the treatment of AF. 
2.3  
SHORTCOMINGS OF CATHETER ABLATION OF PERSISTENT AF 
Weak mechanistic rationale.  Isolation of the PVs2 and adjacent LA (PV antrum)34, 35 is the 
accepted procedural endpoint, based on the mechanistic concept that atrial extrasystoles 
arising from the PVs initiate paroxysmal AF.3 Other, non-PV triggers have been demonstrated.36 
The link between PV extrasystoles and AF is clear in paroxysmal AF, but not in persistent AF, in 
which the mechanisms of AF seem to be related more to a chronic atrial substrate than to acute 
triggers.4 Indeed, intramural reentry in the posterior LA seems to be particularly relevant in 
chronic models of AF.37 In persistent AF, the procedure has evolved, rather simplistically, to 
include additional lesions -besides isolation of the PVs,11, 38-40 variably placed in the posterior 
wall,34 LA roof,41, 42 and towards the mitral annulus,43 the superior vena cava,44 left atrial 
appendage,45, 46 and other areas where complex fractionated atrial electrograms (CFAE)  may 
be mapped.13, 47 This brute force approach of simply destroying more tissue has yielded 
additional success, but new procedural targets with solid mechanistic bases are needed. 
Suboptimal success and need for repeat procedures. Despite the additional tissue 
destruction, ablation success in persistent AF is with much lower than in paroxysmal AF,48 with 
single procedure success reported as low as 27%,40 36%,49or 49%,50 but up to 61%13 or 67%,51 
depending on study heterogeneities in: definitions of persistent AF and of recurrence of AF, the 
type of AF monitoring, and ablation technique and operator experience. In order to achieve 
overall acceptable success rates, (which can reach up to 79%-94%),13, 40, 51 there is a consistent 
need for repeat procedures (sometimes up to 4) and the concomitant use of antiarrhythmic 
drugs. The rate of repeat procedures in experienced centers can reach up to 70 to 80%.9-12 
PMF after catheter ablation of persistent AF. Clinical failures of a first ablation procedure are 


Protocol V7.2 15FEB2016 
 
 
9 
 
caused, in a significant portion of patients, by atrial flutters,52-54 rather than recurrent AF, and 
recurrence as flutter portends a greater chance of success in a second procedure.55 Such atrial 
flutters may be caused by perimitral reentry in up to 33-60% of the patients.52, 54-56 Catheter 
ablation of PMF involves the creation of a linear lesion from the mitral annulus to the left inferior 
PV (the so-called mitral isthmus).43, 57 Achieving a complete ablation (defined by bidirectional 
conduction block across the ablation line) can be very difficult,10, 43, 58 with success rates  
reported as 32%,59 64%,60 or 71%.61 It sometimes requires ablation inside the CS,54, 56 in close 
proximity to the circumflex coronary artery, which could be damaged.60 Of note, incomplete 
ablation of the mitral isthmus is proarrhythmogenic,62, 63 increasing the risk of recurrent flutter by 
up to 4 times.62 
3.0 
INNOVATION 
The basis of this application is an entirely novel technique that was developed in our laboratory 
from its original conception, to its validation in animals,15 to the demonstration of safety and 
feasibility in humans.16 Ethanol is used in hypertrophic cardiomyopathy,64 and in ventricular 
tachycardias that do not respond to conventional RF ablation.65 When delivered in the VOM, we 
have shown that ethanol can help ablate neighboring atrial tissues, all of which are routinely 
targeted during conventional ablation.15 Supported by an R21 grant that started in July 2010, 
significant human pilot data have been acquired that lend further support to the mechanistic 
rationale, safety, and potential clinical utility of this technique. 
3.1  
TARGETING THE INTRINSIC CARDIAC GANGLIA VIA THE VOM 
The role of autonomic regulation in AF is highly relevant.66 The cardiac autonomic system 
(Figure 1) can be divided into extrinsic cardiac nerves –vagus nerves and sympathetic chain-, 
and an intrinsic cardiac ganglia (a complex atrial epicardial network of ganglionated plexi with 
vagal and sympathetic nerves, including the ligament of Marshall). The intrinsic cardiac ganglia 
contain parasympathetic ganglia and its sympathetic nerves are only postganglionic.67 These 
ganglia are not simple relay stations, but process multiple inputs from vagal efferent neurons, 
extrinsic sympathetic neurons, vagal afferent neurons, and sensory neurons.67-73 Acetylcholine 
release by postganglionic neurons exerts effects on myocytes via muscarinic receptors and IKAch 
channels, which shorten the action potential, allowing myocytes to sustain rapid activation rates 
(shorten refractoriness) and favoring the formation of rotors in AF.75 Sympathetic innervation 
(norepinephrine) leads to enhanced automaticity, increased intracellular calcium and favors 
afterdepolarizations76-78 that create extrasystoles that can initiate AF,77 and destabilize rotors.75, 
79 Thus, a synergistic pro-AF effect can occur if both parasympathetic influences (shortening the 
action potential and refractoriness) and sympathetic influences (leading to extrasystoles via 
after depolarizations) activate simultaneously. Indeed, combined simultaneous sympathetic and 
parasympathetic discharges lead to AF.6 Sympathovagal (stellate ganglion and vagus nerve) 
cryoablation of the extrinsic cardiac nerves eliminates paroxysmal AF episodes in a rapid atrial 
pacing model, but does not prevent the ultimate development of persistent AF.6 The intrinsic 
cardiac autonomic system shows enhanced activity preceding AF, independent of the extrinsic 
system, that can play a role in developing persistent AF.7  
 


Protocol V7.2 15FEB2016 
 
 
10 
 
 
Figure 1. Lateral LA and VOM 
 
 
 
 
 
 
 
 
 
 
Translating this information into a modification of the ablation procedure to enhance its efficacy 
has proven difficult.  Ablation of intrinsic autonomic ganglia has been proposed,80 but the 
strategy has been RF ablation of the LA at locations where ganglia were identified as sites 
where bradycardic reflexes are triggered during high-frequency stimulation. Disappointingly, this 
approach has not been shown to add significant clinical benefit beyond PVAI.81-83 Identification 
of vagal ganglia by finding bradycardic reflexes has not been shown to be more effective than 
simply using a standardized anatomic approach,84 or to decrease AF inducibility.83 Possible 
reasons for the failure of vagal ganglia RF ablation to impact procedural outcomes include: 
inaccurate ganglia localization, inadequate elimination of vagal innervation, given their 
epicardial location, and inadequate elimination of sympathetic innervation (not localizable by 
high-frequency stimulation).  
The ligament of Marshall is the embryologic remnant of the left cardinal vein (superior vena 
cava), which, as it becomes atretic during development,85 remains open as the VOM.86 This vein 
drains in the CS and runs posteriorly and superiorly in the epicardial surface of the LA, towards 
the anterior aspect of the left-sided PVs, as part of a thick pectinate muscle that separates the 
veins from the LA appendage (left atrial ridge).87 (See Figure 2).The VOM has been robustly 
shown to contain parasympathetic88 and sympathetic89 innervation,90 and is part of the intrinsic 
cardiac ganglia.91 The ligament of Marshall has been solidly implicated in arrhythmogenesis. As 
a source of ectopic rhythms, Scherlag, et al 92 demonstrated an ectopic rhythm arising from the 
ligament area upon left cardiac sympathetic nerve stimulation. Doshi, et.al. demonstrated the 
role of the ligament of Marshall in adrenergic atrial tachycardia.93 Hwang et al demonstrated 
ectopic beats from the VOM leading to AF,86, 94 as confirmed by others.36, 95-99  
A, Cut open left atrium 
with left PVs and lateral 
ridge. Red dotted line 
indicates location of 
commonly placed ablation 
lesions. B, Microscopic 
view of the lateral ridge, 
showing the VOM 
(inset).C, Epicardial view 
of the lateral ridge, with 
VOM. Modified from ref. 87.


Protocol V7.2 15FEB2016 
 
 
11 
 
Focal ectopy arising in the VOM triggering AF has been demonstrated clinically36, 86 and in 
experimental models of persistent AF.100  
Figure 2.   Autonomic cardiac nerves 
 
 
 
 
 
 
High-frequency stimulation in the ligament of Marshall (without exciting the atrial myocardium) 
leads to induction of AF, and this induction is inhibited by both esmolol and atropine, suggesting 
autonomic mediation.101 The VOM is present and can be cannulated in ~85% of patients,94 and 
our data confirm that it is a direct vascular route to the intrinsic cardiac ganglia that could be 
therapeutically utilized. 
3.2  
VOM ETHANOL INFUSION: TECHNIQUE  
We have refined the technique over the past 3 years. We enter the CS with a sheath advanced 
from the right internal jugular vein. A sub-selector catheter with a ~90° angle at the tip (typically, 
a left internal mammary artery angioplasty guide catheter) is advanced through the CS sheath 
with its tip pointing superiorly and posteriorly. Contrast injections through the sub-selector 
catheter help identify the VOM and direct the catheter tip to the VOM ostium. Then, an 
angioplasty wire is inserted into the VOM, over which an angioplasty balloon is advanced 
distally into the VOM. Contrast injections through the angioplasty balloon help delineate the size 
and branching patterns of the VOM. Ethanol injections are then delivered (up to four injections 
of 1 cc over 2 minutes each), each at different levels of the VOM –from distal in the VOM, where 
the first injection is delivered, the balloon is retracted ~1 cm after each injection until the balloon 
reaches the VOM ostium or 4 injections are given.  Figure 3 shows an example.  
 
 
 
 
 
 
Inputs from the vagus (cholinergic nicotinic, 
Ach(N)), the sympathetic chain (using 
norepinephrine, NE) and from sensory neurons 
and interneurons (other neuromodulators, see 
text) are processed by intrinsic cardiac ganglia. 
Atrial myocytes receive output from 
postganglionic neurons via cholinergic 
muscarinic (Ach (M) receptors), and from 
sympathetic postganglionic adrenergic 
innervation. 


Protocol V7.2 15FEB2016 
 
 
12 
 
Figure 3. VOM cannulation technique and LA venous plexus.  
 
 
 
 
 
 
 
In our experience to date, we have been able to perform successful cannulation of the VOM and 
to complete the protocol of ethanol infusion in 89 of a total of 106 patients (85%).  Our success 
rates in the last half of the patients versus the first half have been higher (90% vs. 73%, 
p<0.05), suggesting that success is not only determined by anatomical factors (e.g., size and 
tortuosity of the VOM), but also by operator experience. 
3.3  
UNVEILING OF AN LA VENOUS PLEXUS 
Our initial experience has confirmed that the VOM is a true atrial vein, communicating via 
capillaries with the LA myocardium, rather than a simple residual lumen of the ligament of 
Marshall, and thus the VOM is a viable route to deliver therapeutic agents in the LA. 
Additionally, with occlusive VOM venograms, we have found a heretofore-undescribed 
epicardial atrial venous plexus filled via collaterals. 
3.4  
VOM ETHANOL INFUSION: TISSUE ABLATION AND LEFT PV DISCONNECTION  
The obvious effect of ethanol infusion is rapid ablation of atrial tissues in the vicinity of the VOM. 
Such areas are standard targets of ablation in persistent AF, and encompass the lateral ridge of 
the left atrium (which due its thickness can be difficult to ablate, see Figure 2), extending 
variably to areas around the left PVs, and towards the mitral annulus, including a large portion 
of the mitral isthmus. In our total experience of up to 89 cases, ethanol infusion can lead to 
isolation of the left inferior PV in up to 74% of the cases, and isolation of the left superior PV in 
44% and generates an area of ablated tissue of 9.7±4.8 cm2.  Figure 4 shows an example.  
A, Contrast injection in the 
CS  lumen through the sub-
selector catheter with its tip 
close to the VOM, showing 
the VOM take-off and 
branching patterns outlined 
in B. C, selective venogram 
via an angioplasty balloon in 
a VOM branch. Collaterals 
fill LA veins in the LA roof 
(outlined in D). 


Protocol V7.2 15FEB2016 
 
 
13 
 
Figure 4. Tissue ablation by VOM ethanol infusion  
.A, Contrast injection in the CS 
showing the VOM take-off. B, 
VOM cannulation with 
angioplasty balloon. Contrast is 
injected prior to ethanol. A 
circular catheter is placed in the 
left inferior PV (LIPV). C-D, 
Voltage maps (scar in red, of 7 
cm2) of the left atrium pre-and 
post-ethanol. E, Signals from 
the LIPV during ethanol 
infusion, showing elimination of 
PV potentials (LASSO). 
 
 
 
 
 
 
3.5  
VOM ETHANOL INFUSION: A NOVEL TECHNIQUE FOR LOCAL VAGAL DENERVATION IN 
HUMANS 
The location of the VOM coincides with that of the left dorsal pathway of vagal innervation to the 
intrinsic cardiac ganglia102 (Figure 5). In our recent experience we have shown that high-
frequency stimulation (30 Hz, 25 mA) in the VOM can induce vagal reflexes reaching the AV 
node (causing transient AV node conduction blockade) in 75% of patients (n=32) and inducing 
AF in 100%.  Such responses are completely abolished in all patients after VOM ethanol 
infusion (Figure 5).Of note, because AF is consistently induced during high-frequency 
stimulation –due to direct left atrial capture-, vagal responses are only assessable by the 
presence of AV nodal block. Of the vagal plexi of the atria, it is the right inferior PV plexus that 
directly connects with the AV node.103 The VOM is remote from the AV node, so inducing AV 
conduction slowing by VOM high-frequency stimulation supports VOM-to-right inferior PV 
plexus-to-AV node connection, and thus supports that the VOM is a vascular route to the 
intrinsic cardiac ganglia (see Figure 5A). Vagal responses were abolished in all patients in 
whom such responses were elicited at baseline, and AF induction by VOM high-frequency 
elimination was eliminated in all patients. Thus, VOM ethanol infusion is an effective strategy to 
achieve regional denervation of the human LA.104 


Protocol V7.2 15FEB2016 
 
 
14 
 
Figure 5. Vagal denervation by VOM ethanol infusion  
A, Vagal innervation (histochemical 
staining) of the LA. Dotted line is 
the location of the VOM, coinciding 
with the left dorsal (LD) tract of 
vagal nerves, connected with 
neural plexi (insets). From indicated 
reference. B, VOM cannulation with 
a quadripolar catheter to perform 
high-frequency stimulation, 
indicated by the blue arrow in C 
and D, Electrograms during high-
frequency stimulation in the VOM 
during on-going AF. Pre-ethanol 
infusion (C), atrioventricular block 
with asystole of 4.1 s is induced. 
Such response is abolished after 
ethanol infusion (D). 
3.6  
VOM ETHANOL INFUSION AND PERIMITRAL FLUTTER (PMF) 
Due to the frequent incidence of PMF, the difficulties in achieving perimitral bidirectional 
conduction block to treat it, and the potential risk of damaging the left circumflex coronary artery 
with RF ablation, there is a clinical need for new treatment strategies. We have evaluated the 
effect of VOM ethanol infusion on perimitral conduction in 43 patients (25 of which had PMF 
mapped prior to ethanol delivery). Although VOM ethanol infusion by itself only led to 
bidirectional perimitral block in 3 patients, this was easily achieved with minimal RF ablation in 
the most anterior aspect of the mitral isthmus (2.5±1.3 min), anterior to the scar created by 
ethanol, in 98% of patients.105 Figure 6 shows examples. Considering the low success rate 
reported by RF ablation (32%59, 64%,60 or 71%61)  –including epicardial ablation in the CS-, and 
the potential iatrogenic induction of recurrent flutters when bidirectional perimitral block is not 
achieved due to incomplete ablation, this novel technique promises to make a significant 
difference in the treatment of PMF.  


Protocol V7.2 15FEB2016 
 
 
15 
 
Figure 6.  PMF treated by VOM ethanol infusion 
A, Example of PMF 
(counterclockwise, colors represent 
time). B, Conventional ablation sites 
(blue dots) in the mitral isthmus to 
treat PMF. C-F, Examples of ethanol-
induced scar maps (voltage color 
scale) and locations of RF ablation 
lesions (arrowheads), required to 
achieve bidirectional mitral block. 
 
 
 
3.7  
ROLE OF VOM IN FAILED ABLATIONS  
We have assessed the role of VOM activity in patients presenting for a repeat ablation 
procedure after a failed PVAI, as part of our R21 project. In 58 patients with recurrent AF, the 
VOM was cannulated in 51 and VOM signals were present in all of them, indicating that a 
conventional PVAI procedure does not ablate VOM activity. This was the case even in cases in 
which extensive LA ablation had been performed in the index procedure. Figure 7 shows an 
example that illustrates that, even with extensive LA ablation (that caused most of the LA 
endocardium to be scarred –without detectable electrograms) the VOM remains electrically 
active. 
Thus, as a novel catheter ablation technique, our preliminary mechanistic data in humans 
supports that VOM ethanol infusion provides rapid tissue ablation of targeted areas, helps treat 
PMF and achieves regional LA vagal denervation. The VOM is not otherwise ablated by 
conventional PVAI. 
 
 
 
 
 
 
 
 


Protocol V7.2 15FEB2016 
 
 
16 
 
Figure 7. Lack of VOM ablation by PVAI 
 
A patient with recurrent 
AF after an extensive PVAI 
underwent VOM ethanol 
infusion. A, intracardiac 
signals from the CS, VOM 
and the endocardium 
adjacent to the VOM 
(LASSO). Pre-ethanol 
infusion, large signals are 
recorded from the VOM 
(red arrows) that are 
abolished post-ethanol (*).  
B, 3D Voltage amplitude 
map of LA endocardium, 
showing scar (red) 
specifically on the 
endocardial side of the 
VOM. C, Fluoroscopic catheter position. 
 
4.0 
TRIAL OVERVIEW AND PRELIMINARY DATA 
4.1  
HYPOTHESIS  
Our hypothesis is that a combined procedure of VOM ethanol infusion plus conventional PVAI 
(VOM-PV) is superior to PVAI alone in the catheter ablation treatment of persistent AF. We will 
compare the two treatments in a randomized fashion in 2 subsets of patients: de novo ablation, 
and repeat ablation in patients with persistent AF (Figure 8). Given the extent of tissue ablation 
required, we have chosen to use this technique in persistent AF, rather than in paroxysmal AF, 
in which less extensive tissue ablations may suffice. VOM ethanol infusion must be an add-on to 
the standard catheter ablation procedure, since it has no effect on other ablation targets such as 
the right PVs, septum, etc. Over our past experience we have established the safety of this 
procedure, uncovered novel mechanistic effects such as vagal denervation, and generated pilot 
data to support an improvement in outcomes.  
 
 


Protocol V7.2 15FEB2016 
 
 
17 
 
 
 
 
Figure 8.  Clinical Trial Design. 
Commented [DE1]: Month 9 needs a description of what will 
happen at that time point 


Protocol V7.2 15FEB2016 
 
 
18 
 
4.2  
PRELIMINARY OUTCOMES DATA: 
RESULTS OF OUR PILOT EXPERIENCE  
We have compared our ablation 
outcomes in persistent AF patients 
treated with VOM-PV with those treated 
with PVAI.  In 174 patients undergoing 
conventional PVAI, our single-
procedure success rate at one year has 
been 45% (consistent with literature 
reports of 27%,45 36%,57 or 49%58). In 
contrast, in 66 patients with persistent 
AF subjected to VOM-PV, our success 
rate has been 61%. These data will be 
used for sample size statistical 
calculations for VENUS-AF, which 
enrolls a patient population undergoing 
their first AF ablation. Additionally, 62 
patients with recurrent AF or flutter after 
a conventional ablation have 
undergone a repeat procedure 
including VOM-PV with a success rate 
of 76%. In our previous experience in 
such repeat procedures (n=169) our 
success rate was 42%, consistent with 
that of the literature. 45, 57, 58 These data 
will be used for ,MARS- AF which 
enrolls a patient population undergoing repeat ablations.  
4.3  
THREE MONTH BLANKING PERIOD 
This protocol uses a three month “blanking period” as a period of time following an atrial 
fibrillation procedure in which atrial fibrillation episodes can occur as part of the body’s healing 
response.  Any atrial fib/flutter activity during that blanking period is not counted in the study’s 
results and is not used in determining success or failure of the procedure as it is a common and 
expected outcome.   
5.0 
MATERIALS AND METHODS 
5.1 SPECIFIC AIMS 
Aim for VENUS is to assess the impact of VOM ethanol infusion in single-procedure 
success when added to de novo catheter ablation of persistent AF. 
VOM triggers and innervation may play a role in persistent AF, and are not addressed by a 
standard PVAI. Our hypothesis is that VOM ethanol infusion will do so and lead to improved 
1. 
For all patients: 
a. 
Total procedure, RF ablation, and fluoroscopy times. 
b. 
RF time and success of bidirectional block across the mitral 
isthmus line tested by differential pacing. 
c. 
Pre-ablation 3D voltage maps. 
d. 
Ablation lesion sets: 3D maps (Carto or NavX), including 
ablated scar surface area, as measured by bipolar voltage 
less than 0.1 mV. 
e. 
Any procedural complications. 
2. 
In patients randomized to VOM ethanol infusion: 
a. 
Successful vs. unsuccessful cannulation with angioplasty wire 
and balloon.  
b. 
Extent of tissue ablation achieved by ethanol infusion, defined 
as areas with local electrogram voltage <0.1 mV on 3D 
mapping. (Pre-PVAI voltage map). 
c. 
Added procedural and fluoroscopy time. 
d. 
Effect on AF: termination, conversion into flutter or no 
change. 
e. 
RF time to achieve block around the mitral annulus. 
f. 
Complications related to VOM instrumentation. 
g. 
Blood ethanol level measurement. 
h. 
LA instrumentation time. 
i. 
Ablation lesion sets: 3D maps (Carto or NavX) including total 
(RF plus ethanol) ablated scar surface area, as measured by 
bipolar voltage less than 0.1 mV 
j. 
Periprocedural data collection. 


Protocol V7.2 15FEB2016 
 
 
19 
 
outcomes. This is a prospective, multi-center, randomized study comparing a combined 
procedure including VOM ethanol infusion plus PVAI (VOM-PV) with PVAI alone in patients 
with persistent AF. The trial design incorporates a plan for possible repeat procedures if AF 
recurs after the 3-month blanking period, as this is common in clinical practice.  
The aim of MARS is to assess the impact of VOM ethanol infusion after a failed 
conventional ablation of persistent AF.  
Ablation failures requiring repeat procedures after PVAI are common, and can be due to 
recurrent AF, or new onset atrial flutters. We hypothesize that VOM ethanol infusion can be 
beneficial in these repeat procedures.  
Our reported experience shows that VOM signals are uniformly intact in patients with 
recurrent AF after failed PVAI,1 supporting the idea that VOM-dependent AF mechanisms 
are not addressed in conventional PVAI. Thus, we hypothesize that VOM ablation by 
ethanol infusion may have added value in this setting. Additionally, PVAI ablation failures 
may present as atrial flutters, including PMF and other circuits utilizing the mitral isthmus (e. 
g. reentry around the left PV antrum). We hypothesize, as supported by our recently 
reported data,3 that VOM ethanol infusion can assist achieving bidirectional mitral isthmus 
block by ablating most of the mitral isthmus and requiring minimal RF applications in the 
most anterior aspect of the isthmus (Figure 6). Patients with AF or flutter occurring beyond 3 
months after a previous standard PVAI performed outside this study will be randomized to 
either a repeat PVAI procedure alone or a VOM-PV. The goal is to assess the role of VOM 
as an added salvage procedure to a repeat ablation. Heterogeneities in the index PVAI 
procedure are likely, but will be characterized in detail in the pre-procedure scar map using 
voltage mapping. Additionally, patients with recurrences as flutter are expected to have a 
greater success, so randomization will be stratified per flutter vs. AF recurrence.  
5.2   
STUDY ENDPOINTS  
 
Primary endpoints: 
1. Primary Efficacy Endpoint  Freedom from AT/AF clinical recurrence on 
follow-up visits AND less than 30 seconds of AT/AF on a 1 month continuous 
electrocardiographic monitor at 6 and 12 months. 
2. Primary Safety Endpoint  -  Acute procedural complications and total mortality.  
 
Secondary Endpoints 
1. Freedom from AF/AT after >1 procedure. 
2. Freedom from AF/AT on antiarrhythmic drugs. 
3. AF burden (% time) on continuous monitoring at 6 and 12 months. 
4. Procedural parameters: total procedure, fluoroscopy, total RF ablation time (first 
procedure), and total extent of ablated LA tissue.  
5. Clinical/partial success: less than 25% AF burden on a continuous event monitor at 6 
and 12 months from ablation procedure. 
6. Sub-acute procedural complications (within 30 days).  
7. Recurrence as persistent or paroxysmal AF, or flutter after 1 or 2 procedures.  


Protocol V7.2 15FEB2016 
 
 
20 
 
8. LA function on Doppler echocardiography (LA strain114ab) at 12 months.  
9. Incidence and mechanisms of atrial flutters.  
10. Cardiovascular hospitalizations and  
11. QOL as determined by AFEQT questionnaire. 
 
5.3  
INCLUSION AND EXCLUSION CRITERIA 
Inclusion criteria 
1. Patients between the ages of 21 and 85 years 
2. Ablation History 
Patients for VENUS must meet the following: 
• 
Diagnosed with symptomatic not previously ablated persistent AF,  
• 
AF not spontaneously converting to sinus rhythm, persisting for ≥7 days 
Patients for MARS must meet the following 
• 
Recurrent AF or AT after a previous ablation of persistent AF at least 3 
months prior to enrollment. 
3. Resistant or intolerant to at least one class I, II, or III AAD 
4. Patients deemed candidates for RF ablation of AF  
5.   Able and willing to comply with pre-, post-, and follow-up requirements.  
 
Exclusion criteria 
1. Left atrial thrombus.  
LAA thrombus can be determined by pre-procedural imaging:  CT, TEE or MRI. 
Documentation by exception (ie. no LAA thrombus on imaging reports) is 
permitted for determination of eligibility. 
2. LA diameter greater than 65 mm on long axis parasternal view, or left atrial volume 
more than 200 cc. 
3. Left ventricular ejection fraction < 30%.  
4. Cardiac surgery within the previous 90 days.  
5. Expecting cardiac transplantation or other cardiac surgery within 180 days.  
6. Coronary PTCA/stenting within the previous 90 days.  
7. Documented history of a thrombo-embolic event within the previous 90 days.  
8. Diagnosed atrial myxoma.  
9. Significant restrictive, constrictive, or chronic obstructive pulmonary disease with 
chronic symptoms.  
10. Significant congenital anomaly or medical problem that in the opinion of the 
investigator would preclude enrollment  
11. Women who are pregnant or who plan to become pregnant during the study. 
12. Acute illness or active infection at time of index procedure documented by either 
pain, fever, drainage, positive culture and/or leukocytosis (WBC > 11k/ mm3) for 
which antibiotics have been or will be prescribed.  
13. Creatinine > 2. 5 mg/dl (or > 221 μmol/L, except for patients in dialysis).  
14. Unstable angina.  


Protocol V7.2 15FEB2016 
 
 
21 
 
15. Myocardial infarction within the previous 60 days.  
16. History of blood clotting or bleeding abnormalities.  
17. Contraindication to anticoagulation.  
18. Life expectancy less than 1 year.  
19. Uncontrolled heart failure. 
20. Presence of an intramural thrombus, tumor, or other abnormality that precludes 
catheter introduction or positioning.  
21. Presence of a condition that precludes vascular access.  
22. INR greater than 3.5 within 24 hours of procedure – for patients taking warfarin.  
23. Cannot be removed from antiarrhythmic drugs for reasons other than AF.  
24. Unwilling or unable to provide informed consent.  
5.4  
INFORMED CONSENT PROCESS 
The informed consent should be signed by the potential subject prior to any study-
specific procedures taking place.   
An appropriately trained study team member will conduct the informed consent process 
with potential subjects in the approved manner for the institution, to include (at a 
minimum) the following procedures: ensuring the use of the most currently IRB approved 
document, allowing the potential subject sufficient time to read the consent and ask 
questions of the study staff, and ensure subjects have a clear understanding of the 
voluntary nature of their consent and the expectations for their commitment.  The 
process above should be documented in the study record, apart from a copy being 
placed into the study file. 
5.5  
STUDY PROCEDURES  
SCREENING/BASELINE  
1.   Initial assessment.  
After signing informed consent, the following data will be collected; a significant 
medical history and recent targeted physical exam, electrocardiogram (EKG), 
echocardiogram within one year prior to the procedure for evaluation of cardiac 
structure, and function, and laboratory tests. In addition, a review of medications that 
patient is taking (limited to AAD and anticoagulants), and a quality of life (QOL) 
questionnaire especially developed for AF (AFEQT)113 will be filled out by patients.  
Screening assessments performed pre-consent signature that are completed under 
standard of care can be included as viable source documents for patient study 
inclusion/exclusion and may be collected to screen potential study patients. 
2. Pre-procedural imaging. 
Imaging prior to enrollment is required to rule out structural heart disease and, as 
needed, to rule out the presence of LA appendage thrombus. Ruling out LAA 
thrombus can be performed by the following: TEE, CT or MRI within 48 hours of the 


Protocol V7.2 15FEB2016 
 
 
22 
 
procedure; at least one month of oral anticoagulation prior to the procedure; or 
documented prior procedures of LAA occlusion or ligation. For ruling out structural 
heart disease, either a cardiac MRI, CT or transthoracic echocardiogram within 1 
year prior to participation in the study is sufficient. Documentation by exception (ie. 
no LAA thrombus documented on imaging report) is permitted for determination of 
eligibility. Left atrial diameter and estimated left atrial volume will be obtained from 
any of these diagnostic modalities. There is no specific requirement for a pre-ablation 
CT or MR, since anatomical details of the LA can be obtained intra-procedurally with 
current mapping systems.  
3 Randomization.  
Randomization should take place after confirmation that all inclusion/exclusion 
criteria are met and measurements of LA volume are obtained. Patients will be 
randomized in a 1.15:1 fashion (to account for an 85% technical feasibility of the 
VOM procedure) to receive either VOM-PV or the conventional PVAI. Patients will be 
blinded to the randomization outcome.  
PROCEDURE/DAY 0: 
1 PVAI procedure 
As part of a conventional catheter ablation of AF the following will be performed, all 
considered standard of care: 
a)  Electrophysiological catheters will be inserted, including a CS catheter, a 
duodecapolar circumferential catheter, and an ablation catheter.  The last two will 
be inserted in the LA via trans-septal punctures.  
b)  Prior to ablation, geometry of the LA will be obtained using a 3-dimensional (3D) 
mapping system (any of the commercially available systems).  This will generate 
a computerized geometry of the LA, including baseline voltage amplitudes in 
different regions. LA scar surface area (bipolar voltage less than 0.1 mV) will be 
collected. 
c) Lesion sets delivered by RF application will include, in a step-wise fashion, the 
following ablations, starting with PVAI and added sequentially per the operator’s 
judgment if AF persists after each step is completed: 
i) PVAI. RF should be applied 1 cm proximal to the PV ostia in a wide area 
circumferential pattern. Isolation will be verified by the absence of 
electrical activity from each PV and/or dissociated activity.  
ii) The greater PV antra, including posterior wall and roof.  
iii) Mitral isthmus: a line of RF ablation from the left inferior PV to the mitral 
annulus. Bidirectional block should be verified after completion by 
differential pacing.  


Protocol V7.2 15FEB2016 
 
 
23 
 
iv) Areas of complex, fractionated potentials. 
v)  Sustained atrial flutters will be mapped and ablated as directed by the 
map and flutter location.  
vi) Following step 4c, if AF persists after all the RF ablations, the patient will 
be cardioverted to restore sinus rhythm. Given the potential variability of 
the extent of ablations, maps of the lesion sets (see below) will be 
collected and maintained in an imaging core laboratory.  
2 VOM procedure 
In patients randomized to VOM-PV, prior to the conventional PVAI, the following 
will be performed: 
a) A 7F-9F sheath will be advanced in the CS via a right internal jugular vein 
access. Femoral vein access is also appropriate to cannulate the CS. Contrast 
injection in the CS will be performed via a sub-selector catheter (recommended 
6F left internal mammary angiographic guide catheter) to identify the VOM. We 
will obtain a CS venogram and identify the location of the VOM. Cannulation of 
the VOM will be performed using the sub-selector catheter that can be torqued 
so that its tip is engaged in the ostium of the VOM. Contrast will be injected via 
the lumen of the sub-selector catheter to verify such engagement.  
b) If large enough, the VOM will be cannulated with an angioplasty wire (0. 014”) 
that will be advanced through the sub-selector catheter and into it. If the VOM is 
too small to accommodate the wire, venodilation with 200 µgm of nitroglycerine 
through the sub-selector catheter will be administered to facilitate VOM 
cannulation.  
c) An angioplasty balloon (1.5 -2 mm diameter, 6-8 mm length) will be advanced 
over the wire and positioned in the ostium of the VOM. The balloon will be 
inflated to occlude the vein. Contrast venograms of the VOM will be recorded in 
left and right anterior oblique projections. The angioplasty balloon will be then 
advanced as distally as possible in the VOM and the first ethanol injection will be 
performed there after balloon inflation. The balloon will be then deflated and 
retracted 1-2 cm for a repeat inflation and ethanol injection. Up to four, 1 cc 
injections (depending on the VOM length) of 98% ethanol will be delivered in the 
VOM by sequentially retracting the balloon up to the VOM ostium.  
d) The procedure will then continue with standard PVAI procedure as outlined in 
section 4.  
3 Bipolar voltage amplitude maps to be performed: 
Using an electro-anatomical mapping system, the extent of the scar –measured as 
bipolar voltage <0.1 mV- will be recorded: 
a. At baseline after gaining trans-septal access to the LA in both randomization 


Protocol V7.2 15FEB2016 
 
 
24 
 
groups. 
b. After ethanol infusion, if randomized to VOM-PV. 
c. After completion of the PVAI ablation lesions, in both randomization groups. 
5.6  
POST-PROCEDURAL DATA COLLECTION:   
Patients may receive follow-up standard of care procedures (ECG, physical exam, review of 
medical history and concomitant medications) at the study site or at a provider of their choice.  If 
an investigator at a study site does not perform the visit, the study staff will have the patient sign 
a Release of Medical Information and request the applicable medical records from the patient’s 
provider. All ECG tracings must be reviewed and interpreted by a study investigator. The 
AFEQT questionnaire may be conducted by telephone call with the patient. 
1. Seven day telephone follow-up (+/- 3 days) should be conducted by study coordinator 
to assess patient for symptoms of procedure related or disease related complications.  
2.  Thirty-day (30D) follow-up (+/- 10 days). Follow up evaluation will include an EKG, 
assessment for complications including a targeted physical exam and a review of adverse 
events and concomitant medications (limited to AAD and anticoagulants) will be 
documented. Routine medications, including AAD may be continued. Symptomatic AF or 
flutter should be treated with AAD or cardioversion as needed but will not be recorded for 
endpoint assessment. 
3. Three-month (90D) follow-up (+/- 30 days). Evaluation will include an EKG, and 
assessment for complications, targeted physical exam and a review of adverse events 
and concomitant medications  (limited to AAD and anticoagulants) will be documented.   
If the patient is in AF or flutter, a cardioversion will be performed electively within 2 weeks 
so that all patients are in sinus rhythm after the 3 month blanking period. AAD therapy will 
be discontinued in all patients at this time if they are clinically stable and in sinus rhythm.  
4.  Six-month (180D) follow-up up (+/- 60 days). Follow up evaluation will include an EKG, 
and physical exam. Additionally, patients will fill out the AFEQT113 QOL questionnaire and  
will undergo a 3-4 week continuous EKG monitor (4 weeks if tolerated by patient) (see 
Core laboratories, below). Subjects who have a miniaturized, implantable rhythm 
recording device (such as Medtronic LinQ and others) or an implanted 
pacemaker/defibrillator may have the continuous rhythm data obtained from that device, 
and may forego the portable recorder.  The purpose of this EKG monitor (4 weeks if 
tolerated by patient) is to screen for recurrent AF that may prompt an early repeat 
procedure. Patients that have clinical or EKG recurrences will undergo a PVAI procedure 
(see below and Figure 8).  
5. Nine-month follow-up up (+/- 30 days). Follow up evaluation will include an EKG and 
physical exam. Patients that have clinical or EKG recurrences will undergo a repeat 
PVAI procedure. The timing of a repeat procedure will be encouraged to be within 6 
months of randomization. 
6. Twelve-month follow-up up (+/- 60 days). Follow up evaluation will include an EKG, 
and physical exam. Additionally, patients will fill out the AFEQT113 QOL questionnaire 


Protocol V7.2 15FEB2016 
 
 
25 
 
and  undergo a continuous EKG monitor (4 weeks if tolerated by patient) to determine 
the primary efficacy endpoint.  
Subjects who have a miniaturized, implantable rhythm recording device (such as 
Medtronic LinQ and others) or an implantable pacemaker/defibrillator may have the 
continuous rhythm data obtained from that device, and may forego the portable recorder.  
Patients will fill out the AFEQT113 QOL questionnaire. Additionally, echocardiographic 
assessment of LA function (LA ejection fraction, strain114ab) will be performed by a 
central reader at Houston Methodist Hospital.  
– 
5.7  
VENUS:  DEFINITIONS OF PROCEDURAL SUCCESS OR FAILURE AND INDICATIONS FOR 
REPEAT PROCEDURES 
1. Success: Freedom from AT/AF clinical recurrence on follow-up visits AND less than 30 
seconds of AT/AF on a 1 month continuous electrocardiographic monitor . 
 
 
2.  Clinical Success. Freedom from AT/AF clinical recurrence on follow-up visits but 
documented AF or flutter up to 25% of the time on a 1-month continuous 
electrocardiographic monitor. The rationale is to account for patients in whom a repeat 
procedure would not be clinically indicated, yet AF/AT would not be considered cured.  
 
3. Repeat procedures. A repeat procedure will constitute an effectiveness failure for 
the purpose of the primary efficacy endpoint. However, repeat procedures and their 
outcomes will be recorded for secondary outcome analysis. First, repeat procedures are 
a clinical reality in persistent AF, and a single-procedure success endpoint –does not 
capture it. Second, it is possible that VOM-PV on a first procedure may increase success 
of a second procedure –e. g. if the recurrences in VOM-PV group are as AT instead of 
AF. Both represent a clinical failure of the procedure, but a repeat procedure for AT is 
more likely to succeed.65 Repeat procedures will be encouraged to be timed within the 
first 6 months of the randomization procedure. Although this may seem short, it is our 
clinical experience that the bulk of AF recurrences tend to occur shortly after the 
blanking period.115 Thus, we expect a minority of patients to recur late in this window.  
  
Indications for a repeat procedure include: 
a.  Procedure failure: Symptomatic, recurrent persistent AF or flutter detected clinically 
during the scheduled follow-up visits.  
b. 
Less than partial/clinical success: AF or flutter burden on electrocardiographic 
monitoring exceeding 25% regardless of symptoms. Monitoring will be performed 
at 6 months post randomization procedure. 
c.  Symptomatic AF or flutter detected on electrocardiographic monitoring regardless 
of AF or flutter burden. Monitoring will be performed at 6 months post 
randomization procedure. 
Data to be collected during a repeat procedure will include 


Protocol V7.2 15FEB2016 
 
 
26 
 
a.  Documentation of PV isolation: number and location of reconnected PV at the 
baseline of the repeat procedure.  
b.  Perimitral conduction: presence or absence of perimitral block. 
c. 
Mechanisms of atrial flutter, if present. 
d.    Documentation of other RF ablation sites 
e.  Documentation of RF time, time to perimitral block (if not already achieved), 
fluoroscopy time, LA instrumentation time, and procedure time. 
f. 
Baseline and Final LA voltage map (using any commercially available 
electroanatomical mapping systems). Measurement of baseline and Final LA scar 
surface area. 
 
4. Effectiveness (Treatment) Failures 
Effectiveness failures towards the primary endpoint will include the following (see Figure 8): 
a. 
Clinical recurrence of AF or AT after 3-months. 
b. 
Documented AF or AT of 30 seconds or more on EKG monitor at obtained at 6 and 
12 months. 
c. 
Requirement of a repeat ablation procedure for recurrent AT-AF. 
d. 
Death. 
VENUS and MARS patients who have a recurrence after 3 months post randomization will 
have a repeat procedure (PVAI). Patients will be deemed to be effectiveness failure for the 
primary efficacy endpoint of the trial after repeat procedures. Still, subjects will: 
a. Remain in the study for the purpose of all secondary endpoints: these include 
quality of life, AF burden on event monitoring, success after multiple procedures.  
b. Undergo all clinically necessary procedures and treatments, including prescription 
of antiarrhythmic therapy and additional procedures needed to control atrial 
fibrillation or flutter.  A crossover VOM procedure will be offered to those 
randomized to PVAI after 2 in-study procedures. 
c. Data on such additional procedures or treatment will be collected in the Electronic 
Data Capture system (EDC). 
d. An additional secondary endpoint will be created: total number of procedures 
performed and requirement of antiarrhythmic drugs. 
5. 
VENUS:  Cross-over of patients initially randomized to PVAI only.  
If a VENUS patient is originally randomized to conventional PVAI and experiences a 
treatment failure after a repeat procedure he or she may undergo an additional 
conventional PVAI ablation procedure during the study. Crossover to VOM ethanol will 
only be allowed after 2 procedures are performed in the setting of study participation. 
This is allowed because certain recurrent flutters are particularly suited to respond to 
VOM ethanol. The primary and secondary endpoints will be computed following their 
original randomization group. 
 


Protocol V7.2 15FEB2016 
 
 
27 
 
5.8  
MARS:  DEFINITIONS OF PROCEDURAL SUCCESS OR FAILURE AND INDICATIONS FOR 
REPEAT PROCEDURES 
1. Success: Freedom from AT/AF clinical recurrence on follow-up visits AND less than 30 
seconds of AT/AF on a 1 month continuous electrocardiographic monitor . 
 
2.  Clinical Success. Freedom from AT/AF clinical recurrence on follow-up visits but 
documented AF or flutter up to 25% of the time on a 1-month continuous 
electrocardiographic monitor. The rationale is to account for patients in whom a repeat 
procedure would not be clinically indicated, yet AF/AT would not be considered cured.  
 
3. Repeat procedures. A repeat procedure will constitute an effectiveness failure for 
the purpose of the primary efficacy endpoint. However, repeat procedures and their 
outcomes will be recorded for secondary outcome analysis. First, repeat procedures are 
a clinical reality in persistent AF, and a single-procedure success endpoint –does not 
capture it. Second, it is possible that VOM-PV on a first procedure may increase success 
of a second procedure –e. g. if the recurrences in VOM-PV group are as AT instead of 
AF. Both represent a clinical failure of the procedure, but a repeat procedure for AT is 
more likely to succeed.65 Repeat procedures will be encouraged to be timed within the 
first 6 months of the randomization procedure. Although this may seem short, it is our 
clinical experience that the bulk of AF recurrences tend to occur shortly after the 
blanking period.115 Thus, we expect a minority of patients to recur late in this window.  
  
Indications for a repeat procedure include: 
a.  Procedure failure: Symptomatic, recurrent persistent AF or flutter detected clinically 
during the scheduled follow-up visits.  
b. 
Less than partial/clinical success: AF or flutter burden on electrocardiographic 
monitoring exceeding 25% regardless of symptoms. Monitoring will be performed 
at 6 months post randomization procedure. 
c.  Symptomatic AF or flutter detected on electrocardiographic monitoring regardless 
of AF or flutter burden. Monitoring will be performed at 6 months post 
randomization procedure. 
Data to be collected during a repeat procedure will include 
a.  Documentation of PV isolation: number and location of reconnected PV at the 
baseline of the repeat procedure.  
b.  Perimitral conduction: presence or absence of perimitral block. 
c. 
Mechanisms of atrial flutter, if present. 
d.    Documentation of other RF ablation sites 
e.  Documentation of RF time, time to perimitral block (if not already achieved), 
fluoroscopy time, LA instrumentation time, and procedure time. 
f. 
Baseline and Final LA voltage map (using any commercially available 
electroanatomical mapping systems). Measurement of baseline and Final LA scar 
surface area. 
 


Protocol V7.2 15FEB2016 
 
 
28 
 
4. Effectiveness (Treatment) Failures 
Effectiveness failures towards the primary endpoint will include the following (see Figure 8): 
e. 
Clinical recurrence of AF or AT after 3-months. 
f. 
Documented AF or AT of 30 seconds or more on EKG monitor at obtained at 6 and 
12 months. 
g. 
Requirement of a repeat ablation procedure for recurrent AT-AF. 
h. 
Death. 
Patients who have a recurrence after 3 months post randomization will have a repeat 
procedure (PVAI). Patients will be deemed to be effectiveness failure for the primary endpoint 
of the trial after repeat procedures. Still, subjects will: 
e. Remain in the study for the purpose of all secondary endpoints: these include 
quality of life, AF burden on event monitoring, success after multiple procedures.  
f. Undergo all clinically necessary procedures and treatments, including prescription 
of antiarrhythmic therapy and additional procedures needed to control atrial 
fibrillation or flutter.  A crossover VOM procedure will be offered to those 
randomized to PVAI after 2 in-study procedures. 
g. Data on such additional procedures or treatment will be collected in the Electronic 
Data Capture system (EDC). 
h. An additional secondary endpoint will be created: total number of procedures 
performed and requirement of antiarrhythmic drugs. 
5. 
Cross-over option for of patients initially randomized to PVAI only.  
If a patient is originally randomized to conventional PVAI and experiences a treatment 
failure after a repeat procedure he or she may undergo an additional conventional PVAI 
ablation procedure during the study. Crossover to VOM ethanol will only be allowed after 
2 procedures are performed in the setting of study  participation. This is allowed 
because certain recurrent flutters are particularly suited to respond to VOM ethanol. The 
primary and secondary endpoints will be computed following their original randomization 
group. 
 
6.0 
STATISTICAL CONSIDERATIONS 
A) Assumptions.  
Single-procedure versus multiple-procedure success.  Our initial preliminary data suggested 
an overall procedure success of 45% in patients undergoing PVAI and 61% for those 
undergoing VOM-PV (difference of 16%).  This included patients with repeat procedures 
performed in some, but not all of the failed procedures (45% all patients in the PVAI group 
and 30% in the VOM-PV group). The single-procedure success was 38% in patients 
undergoing PVAI and 56% in patients undergoing VOM-PV (difference of 18%). Thus, the 
endpoint of single-procedure success is likely to show greater differences amongst groups. 
Mortality. The expected mortality is low in this study as it has been in AF ablation trials. 


Protocol V7.2 15FEB2016 
 
 
29 
 
Mortality will be recorded as a safety endpoint. 
One-year follow-up time. In previous versions of the protocol, additional follow-up time (up to 
15 months) was included in the VENUS trial, in order to accommodate for appropriate follow-
up of patients undergoing repeat procedures. Therefore, a trial duration of 12 months is 
sufficient if just single-procedure success is the primary efficacy endpoint. Procedural failures 
(events counted as the primary efficacy endpoint) occur mostly during the first year. 
Additionally, 12-month follow-up is consistent with the recommendations for clinical trials in 
AF by the HRS/EHRA/ECAS Catheter and Surgical Ablation consensus document.2 
Unknown classification as success or failure.  Patients who cannot be classified as 
successes or failures on the primary efficacy endpoint will be excluded from the primary 
analysis. 
 
B) VENUS Group Sequential Clinical Trial Design 
Power and sample size determination.  Group sequential two proportions power analysis 
using simulation was performed using PASS V12 (Kaysville, UT).  The following 
assumptions were made: 
• 
Response rate in PV-VOM: p1=0.56 
• 
Response rate in PVAI: p2= 0.38 
• 
Hypotheses: H0: p1= p2; H1: p1 ≠ p2 
• 
Test Statistic: Z-Test (Unpooled) 
• 
Zero Adjustment Method: None 
• 
Alpha-Spending Function: O'Brien-Fleming Analog 
• 
Beta-Spending Function: None 
• 
Futility Boundary Type: None 
• 
Number of Looks: 3 
• 
Simulations: 100000 
 
Results.   A group sequential trial with sample sizes of N1=180 and N2=156 at the final 
look achieves 91% power to detect a difference of 0.18 between a treatment group success 
proportion of 0.56 and a control group success proportion of 0.38 at the 0.05 significance 
level (alpha) using a two-sided Z-Test (Unpooled).  The table below lists the sample sizes 
required for 91% power.   
 
Table 5. Sample size requirements for a group sequential trial based on 100,000 
iterations. 
Value 
95% LCL 
95% UCL 
Target 
Actual 
95% LCL 
95% UCL Beta 
0.909 
0.908 
0.911 
0.050 
0.049 
0.048 
0.051 0.091 
 
                           ----- Average Sample Size ---- 
                           -- Given H0 --    -- Given H1 -- 
N1 
N2 
Grp1 
Grp2 
Grp1 
Grp2 
Diff0 
Diff1 P1|H1 
P2 
180 
156 
179 
155 
144 
125 
0.00 
0.18 
0.56 
0.38 
 
Efficacy Monitoring.  We propose to monitor efficacy at two interim time points and one final 
time period (i.e., three “looks”) when primary outcome data (12 month follow-up) are available 
for 1/3, 2/3 and 3/3 of the total sample size of VENUS subjects.  For the VENUS trial, these 
values are provide in the following table in terms of information time: 


Protocol V7.2 15FEB2016 
 
 
30 
 
 
Table 6.  Efficacy monitoring schedule for VENUS with cumulative sample size, significance 
boundaries and 95%CIs, and alpha- and beta-spending.  
Accumulated primary outcomes for VENUS 
 
 
 
 
Accumulated 
 
 
 
                    Information            -------- Accumulated Sample Size -------- 
Look 
Percent 
VOM 
PVAI 
Total 
1 
33.33 
60 
52 
112 
2 
66.67 
120 
104 
224 
3 
100.00 
180 
156 
336 
Significance Boundaries with 95% Simulation Confidence Intervals 
                  --------- Z-Value Boundary ---------    --------- P-Value Boundary --------- 
Look 
Value 
95% LCL 
95% UCL 
Value 
95% LCL 
95% UCL 
1 
+/- 3.953 
3.809 
4.289 
0.000 
0.000 
0.000 
2 
+/- 2.543 
2.516 
2.578 
0.011 
0.010 
0.012 
3 
+/- 2.011 
1.994 
2.036 
0.044 
0.042 
0.046 
Alpha-Spending  
                                                         --------- Target ---------   --------- Actual ----------  Proportion          Cum. 
 
 
 
 
Cum. 
 
 
H1 Sims 
H1 Sims 
 
--- Signif. Boundary--- Spending Spending 
 
Cum. 
Outside 
Outside 
 
Z-Value 
P-Value 
Function 
Function 
Alpha 
Alpha 
Signif. 
Signif. 
Look 
Scale 
Scale 
Alpha 
Alpha 
Spent 
Spent Boundary Boundary 
1 
+/- 3.953 
0.000 
0.000 
0.000 
0.000 
0.000 
0.033 
0.033 
2 
+/- 2.543 
0.011 
0.012 
0.012 
0.011 
0.012 
0.547 
0.579 
3 
+/- 2.011 
0.044 
0.038 
0.050 
0.038 
0.049 
0.329 
0.909 
 
 
The hypothesis test applied at the kth look is a two-tailed test of equality of two independent 
proportions, functionally composed as  
𝑍𝑍𝑘𝑘=
𝑝𝑝̂1𝑘𝑘−𝑝𝑝̂2𝑘𝑘
ට
𝑝𝑝ො1𝑘𝑘(1−𝑝𝑝ො1𝑘𝑘)
𝑛𝑛1𝑘𝑘
+ 
𝑝𝑝ො2𝑘𝑘(1−𝑝𝑝ො2𝑘𝑘)
𝑛𝑛2𝑘𝑘
 
where 𝑝𝑝̂1𝑘𝑘 is the proportion of successful primary outcomes in the PVAI-VOM arm of VENUS at 
the kth look, and 𝑝𝑝̂2𝑘𝑘 is the proportion of successful primary outcomes within the PVAI arm of 
VENUS at the kth look.   𝑍𝑍𝑘𝑘 follows a standard normal distribution, N(0,1).   If during the first 
look when at least N=60 VOM and N=52 PVAI primary outcomes have been observed (N=112 
total), if 𝑍𝑍1exceeds 3.953, then the trial will be evaluated for early termination due to beneficial 
efficacy, whereas if the power is 30% or less, the trial will be evaluated for early termination for 
futility.  However, if the power of the test falls in the “promising zone” (30-70%), we will continue 
the trial.  The same rule applies for the 2nd look when at least N=120 VOM and 104 PVAI 
primary outcomes (224 total) have been observed in both arms, for which the tabled critical 
value of Z2 is ±2.543.  The overall efficacy of the trial will be determined when at least N=180 
VOM and N=156 (336 total) primary outcomes have been observed, for which the critical value 
of Z3 is ±2.011. 


Protocol V7.2 15FEB2016 
 
 
31 
 
 
Figure S1.   Efficacy boundaries at 33%, 66%, and 100% accrual of VENUS 
primary outcomes. 
VENUS Interim Analysis - Conditional Power and Futility For Various Test Results.    
During the interim analysis, estimations of conditional power and futility will be performed, to 
provide information for clinical trial continuation decisions. The sample size will not be subject to 
any changes. 
Conditional power runs were made using PASS 12 (Kaysville, UT).   During the first look at 33% 
information time, there will be 60 VOM and 52 PVAI primary outcomes available.  Using a one-
sided (α=0.025) test of two proportions, θ=p2-p1,  where p2 is the PVAI success rate and p1  is 
the VOM success rate, the expectation is that the test statistic Zk is less than zero, since Ha: 
p2<p1.   The table below list the conditional power and futility at the first look for a range of Zk 
values: 
Table 7.  VENUS Conditional power and futility at the first look (33% information, 60 VOM, 
52 PVAI) for a range of Zk values from a one-sided test of two independent proportions. 
Boundary Plot
Look
1.0
1.5
2.0
2.5
3.0
-5
-3
-1
1
3
5
Boundary Type
Upper
Lower


Protocol V7.2 15FEB2016 
 
 
32 
 
Cond. 
Power 
Pred. 
Power 
Total 
Sample 
Size 
VOM/PVAI 
Current 
Sample 
Size 
n1k|n2k 
Prop. 
Group 
1 
P1 
Prop. 
Group 
2 
P2 
Test 
Statistic 
Zk 
Alpha 
Futility 
0.99994 
1 
180|156 
60|52 
0.56 
0.38 
-5 
0.025 
0.00006 
0.99974 
0.99998 
180|156 
60|52 
0.56 
0.38 
-4.5 
0.025 
0.00026 
0.9991 
0.99978 
180|156 
60|52 
0.56 
0.38 
-4 
0.025 
0.0009 
0.99717 
0.99814 
180|156 
60|52 
0.56 
0.38 
-3.5 
0.025 
0.00283 
0.99209 
0.98894 
180|156 
60|52 
0.56 
0.38 
-3 
0.025 
0.00791 
0.98027 
0.95313 
180|156 
60|52 
0.56 
0.38 
-2.5 
0.025 
0.01973 
0.95597 
0.85624 
180|156 
60|52 
0.56 
0.38 
-2 
0.025 
0.04403 
0.91184 
0.67408 
180|156 
60|52 
0.56 
0.38 
-1.5 
0.025 
0.08816 
0.84101 
0.43598 
180|156 
60|52 
0.56 
0.38 
-1 
0.025 
0.15899 
0.74056 
0.2196 
180|156 
60|52 
0.56 
0.38 
-0.5 
0.025 
0.25944 
0.61467 
0.08289 
180|156 
60|52 
0.56 
0.38 
0 
0.025 
0.38533 
 
Table 8.  VENUS Conditional power and futility at the second look (66% information, 120 
VOM, 104 PVAI) for a range of Zk values from a one-sided test of two independent 
proportions. 
Cond. 
Power 
Pred. 
Power 
Total 
Sample 
Size 
VOM/PVAI 
Current 
Sample 
Size 
n1k|n2k 
Prop. 
Group 
1 
P1 
Prop. 
Group 
2 
P2 
Test 
Statistic 
Zk 
Alpha 
Futility 
1.00000 
1.00000 
180|156 
120|104 
0.56 
0.38 
-5.0 
0.025 
0 
1.00000 
1.00000 
180|156 
120|104 
0.56 
0.38 
-4.5 
0.025 
0 
0.99998 
0.99998 
180|156 
120|104 
0.56 
0.38 
-4.0 
0.025 
0.00002 
0.99973 
0.99950 
180|156 
120|104 
0.56 
0.38 
-3.5 
0.025 
0.00027 
0.99703 
0.99233 
180|156 
120|104 
0.56 
0.38 
-3.0 
0.025 
0.00297 
0.97954 
0.94042 
180|156 
120|104 
0.56 
0.38 
-2.5 
0.025 
0.02046 
0.90942 
0.75562 
180|156 
120|104 
0.56 
0.38 
-2.0 
0.025 
0.09058 
0.73567 
0.43104 
180|156 
120|104 
0.56 
0.38 
-1.5 
0.025 
0.26433 
0.46930 
0.14923 
180|156 
120|104 
0.56 
0.38 
-1.0 
0.025 
0.5307 
0.21648 
0.02834 
180|156 
120|104 
0.56 
0.38 
-0.5 
0.025 
0.78352 
0.06795 
0.00279 
180|156 
120|104 
0.56 
0.38 
0.0 
0.025 
0.93205 
C) MARS Group Sequential Clinical Trial Design 
MARS Preliminary Data. For patients that had a history of previous ablation (original MARS 
trial sample size calculations) the pilot data showed that among 169 patients we observed a 
response rate of p1=42% for repeat PVAI and p2=76% for 32 patients undergoing VOM-PV.  
Power and sample size determination.  Group sequential two proportions power analysis 
using simulation was performed using PASS V12 (Kaysville, UT).  The following assumptions 
were made: 
• 
Response rate in PV-VOM: p1=0.76 


Protocol V7.2 15FEB2016 
 
 
33 
 
• 
Response rate in PVAI: p2= 0.42 
• 
Hypotheses: H0: p1= p2; H1: p1 ≠ p2 
• 
Test Statistic: Z-Test (Unpooled) 
• 
Zero Adjustment Method: None 
• 
Alpha-Spending Function: O'Brien-Fleming Analog 
• 
Beta-Spending Function: None 
• 
Futility Boundary Type: None 
• 
Number of Looks: 3 
• 
Simulations: 100000 
 
Table 9. Sample size requirements for a group sequential trial based on 100,000 
iterations. 
----------------- Power -------------------      -------------------------- Alpha ---------------------------- 
Value 
95% LCL 
95% UCL 
Target 
Actual 
95% LCL 
95% UCL 
Beta 
0.810 
0.807 
0.812 
0.050 
0.049 
0.047 
0.050 
0.190 
 
                           ----- Average Sample Size ---- 
                           -- Given H0 --    -- Given H1 -- 
N1 
N2 
Grp1 
Grp2 
Grp1 
Grp2 
Diff0 
Diff1 P1|H1 
P2 
33 
33 
33 
33 
28 
28 
0.00 
0.34 
0.76 
0.42 
 
 
Results. Group sequential trials with sample sizes of 33 and 33 at the final look achieve 81% 
power to detect a difference of 0.34 between a treatment group proportion of 0.76 and a control 
group proportion of 0.42 at the 0.05 significance level (alpha) using a two-sided Z-Test 
(Unpooled). 
 
Efficacy Monitoring.  We propose to monitor efficacy at two interim time points and one final 
time period (i.e., three “looks”) when primary outcome data (12-15 month follow-up) are 
available for 1/3, 2/3 and 3/3 of the total sample size of MARS subjects.  For the MARS trial, 
these values are provide in the following table in terms of information time: 
 
Table 10.  Efficacy monitoring schedule for MARS with cumulative sample size, significance 
boundaries and 95%CIs, and alpha- and beta-spending.  
Accumulated primary outcomes for MARS 
 
Accumulated 
 
 
 
                    Information            -------- Accumulated Sample Size -------- 
Look 
Percent 
Group 1 
Group 2 
Total 
1 
33.33 
11 
11 
22 
2 
66.67 
22 
22 
44 
3 
100.00 
33 
33 
66 
 
 
Significance Boundaries with 95% Simulation Confidence Intervals for Scenario 1 
                  --------- Z-Value Boundary ---------    --------- P-Value Boundary --------- 
Look 
Value 
95% LCL 
95% UCL 
Value 
95% LCL 
95% UCL 
1 
+/- 5.014 
5.014 
6.675 
0.000 
0.000 
0.000 
2 
+/- 2.708 
2.640 
2.708 
0.007 
0.007 
0.008 
3 
+/- 2.055 
2.055 
2.080 
0.040 
0.037 
0.040 
 
Alpha-Spending 


Protocol V7.2 15FEB2016 
 
 
34 
 
 
                                                        --------- Target ---------   --------- Actual ----------  Proportion          Cum. 
 
 
 
 
Cum. 
 
 
H1 Sims 
H1 Sims 
 
--- Signif.  Boundary--- 
Spending 
Spending 
 
Cum. 
Outside 
Outside 
 
Z-Value 
P-Value 
Function 
Function 
Alpha 
Alpha 
Signif. 
Signif. 
Look 
Scale 
Scale 
Alpha 
Alpha 
Spent 
Spent 
Boundary Boundary 
1 
+/- 5.014 
0.000 
0.000 
0.000 
0.000 
0.000 
0.017 
0.017 
2 
+/- 2.708 
0.007 
0.012 
0.012 
0.010 
0.011 
0.404 
0.422 
3 
+/- 2.055 
0.040 
0.038 
0.050 
0.038 
0.049 
0.388 
0.810 
 
 
Figure S2.   Efficacy boundaries at 33%, 66%, and 100% accrual of MARS primary 
outcomes. 
During the interim analysis, estimations of conditional power and futility will be performed, to 
provide information for clinical trial continuation decisions. The sample size will not be subject to 
any changes. 
Boundary Plot
Look
1.0
1.5
2.0
2.5
3.0
-6
-4
-2
0
2
4
6
Boundary Type
Upper
Lower


Protocol V7.2 15FEB2016 
 
 
35 
 
 
 
Table 11.  MARS Conditional power and futility at the first look (33% information, 11 VOM, 
11 PVAI) for a range of Zk values from a one-sided test of two independent proportions. 
Cond. 
Power 
Pred. 
Power 
Total 
Sample 
Size 
VOM/PVAI 
Current 
Sample 
Size 
n1k|n2k 
Prop. 
Group 
1 
P1 
Prop. 
Group 
2 
P2 
Test 
Statistic 
Zk 
Alpha 
Futility 
0.9997 
1 33|33 
11|11 
0.76 
0.42 
-5 
0.025 
0.0003 
0.99894 
0.99998 33|33 
11|11 
0.76 
0.42 
-4.5 
0.025 
0.00106 
0.99674 
0.99978 33|33 
11|11 
0.76 
0.42 
-4 
0.025 
0.00326 
0.99104 
0.99814 33|33 
11|11 
0.76 
0.42 
-3.5 
0.025 
0.00896 
0.97798 
0.98894 33|33 
11|11 
0.76 
0.42 
-3 
0.025 
0.02202 
0.95155 
0.95313 33|33 
11|11 
0.76 
0.42 
-2.5 
0.025 
0.04845 
0.90431 
0.85624 33|33 
11|11 
0.76 
0.42 
-2 
0.025 
0.09569 
0.82969 
0.67408 33|33 
11|11 
0.76 
0.42 
-1.5 
0.025 
0.17031 
0.72555 
0.43598 33|33 
11|11 
0.76 
0.42 
-1 
0.025 
0.27445 
0.5971 
0.2196 33|33 
11|11 
0.76 
0.42 
-0.5 
0.025 
0.4029 
0.45712 
0.08289 33|33 
11|11 
0.76 
0.42 
0 
0.025 
0.54288 
 
 
Table 12.  MARS Conditional power and futility at the second look (66% information, 22 VOM, 22 
PVAI) for a range of Zk values from a one-sided test of two independent proportions. 
Cond. 
Power 
Pred. 
Power 
Total 
Sample 
Size 
VOM/PVAI 
Current 
Sample 
Size 
n1k|n2k 
Prop. 
Group 
1 
P1 
Prop. 
Group 
2 
P2 
Test 
Statistic 
Zk 
Alpha 
Futility 
1.00000 
1.00000 33|33 
22|22 
0.76 
0.42 
-5 
0.025 
0 
1.00000 
1.00000 33|33 
22|22 
0.76 
0.42 
-4.5 
0.025 
0 
0.99995 
0.99998 33|33 
22|22 
0.76 
0.42 
-4 
0.025 
0.00005 
0.99925 
0.9995 33|33 
22|22 
0.76 
0.42 
-3.5 
0.025 
0.00075 
0.99323 
0.99233 33|33 
22|22 
0.76 
0.42 
-3 
0.025 
0.00677 
0.96097 
0.94042 33|33 
22|22 
0.76 
0.42 
-2.5 
0.025 
0.03903 
0.85426 
0.75562 33|33 
22|22 
0.76 
0.42 
-2 
0.025 
0.14574 
0.636 
0.43104 33|33 
22|22 
0.76 
0.42 
-1.5 
0.025 
0.364 
0.35968 
0.14923 33|33 
22|22 
0.76 
0.42 
-1 
0.025 
0.64032 
0.14311 
0.02834 33|33 
22|22 
0.76 
0.42 
-0.5 
0.025 
0.85689 
0.03807 
0.00279 33|33 
22|22 
0.76 
0.42 
0 
0.025 
0.96193 
 
 
C) Statistical Analyses.   
Pre-specified subgroup analyses: The following subgroups are defined to assess potential 
impact on outcomes: 
• 
Male vs female. 


Protocol V7.2 15FEB2016 
 
 
36 
 
• 
Longstanding persistent AF (duration of more than 1 year) vs persistent AF of less than 
one year 
• 
Left atrial volume strata: defined as mild or no left atrial enlargement (LA volume - up to 
75 ml/m2), moderate enlargement (76-89 ml/m2), or severe enlargement -90+ ml/m2) 
• 
Enrollment as AF or AT –for MARS-AF trial only. 
• 
Pre-existing low voltage scar and extent of low-voltage scar after ablation procedure 
(divided in tertiles). 
 
Primary Outcome.   Hypothesis tests for the equality of two proportions (unpooled standard 
errors) will be employed for determining whether or not the VOM success rate is significantly 
greater than the success rate for PVAI.   The test statistic is a z-score which is standard normal 
distributed and the relevant lookup critical values (percentage points) are listed in the interim 
analysis section for group sequential designs.   From a post-hoc perspective, we may use the 
stratified Mantel-Haenszel odds ratio test of proportions if we learn that success rates track with 
a particular covariate, such as LA volume or AF duration, and the strata weights are not highly 
imbalanced. 
Secondary Outcomes.   The secondary outcomes are listed below along with their 
corresponding storage location (various tables or Excel .csv files on output after report 
generation).  Model building strategies (MBS) will be employed using univariate and 
multivariable regression models for post-hoc analyses of secondary outcomes.   During MBS, 
univariate predictors whose p<0.25 will be selected as multiple variable model candidates.   
MBS regression methods may include linear, logistic, Poisson, and Cox proportional hazards 
(PH) along with regression diagnostics using the relevant goodness-of-fit criteria, residuals, 
variance inflation factors (VIF), ROC-AUC, and assumption-checking techniques (e.g. normally-
distributed standardized residuals for linear regression).   Regression diagnostics for linear 
regression will include estimation and filtering of overly influential records based on residuals, 
standardized, residuals, deletion residuals, Cook’s distance, leverage, DFFITS, DFBETAS, and 
VIFs.   Regression diagnostics for logistic and Poisson regression will include filtering on 
Pearson, deviance, and leverage residuals and the Hosmer-Lemeshow test for logistic 
regression GOF.   Cox PH regression diagnostics will include Schoenfeld and Nelson-Aelen 
residuals, and possible employment of stratified models when the PH assumption fails.         
 
The table below lists the primary outcomes which are to be analyzed during each interim 
analysis, as well as the secondary outcomes which will be analyzed and reported prior to all 
DSMB review meetings.     
 
 


Protocol V7.2 15FEB2016 
 
 
37 
 
 
Primary Endpoints 
EDC Pages 
Data Fields 
1. Freedom from symptomatic AF or 
flutter AND reduction of AF/flutter to 
less than 30 seconds in a continuous 
4 week monitor at 6 and 12 months 
• 
12 month continuous ECG 
page- MARS 
• 
12 month continuous ECG 
page- Venus 
 
• 
6-12 month AF/AT Burden less 
than 30 seconds on continuous 
ECG monitoring 
 
2. Safety: Acute procedural 
complications 
• 
AE pages 
Day 7 Telephone FU 
 
• 
Acute AE’s related to Day 0 
procedure 
• 
Day 7 reported complications 
Secondary Endpoints:  
 
 
1. Single vs. 2-procedure success.  
 
• 
Status change page 
• 
Single: reached primary endpoint 
#1 after first procedure with no 
repeats 
• 
Two procedure: reached primary 
endpoint #1 after second 
procedure with no 3rd procedure 
2. AF burden (% time) on continuous 
monitoring at 12 months.  
 
• 
6-12 month continuous ECG 
page- MARS 
• 
12 month continuous ECG 
page- Venus 
• 
6- 12 month AF/AT Burden (%) on 
continuous ECG monitoring 
3. Procedural parameters: total 
procedure, fluoroscopy, total RF 
ablation time (first procedure), and 
total extent of ablated LA tissue.  
• 
PVAI Page 
• 
VOM page 
• 
Total procedure time, PVAI only 
• 
Total procedure time, VOM 
procedure 
• 
Total fluoro time 
• 
Scar measurements pre and post 
PVAI and VOM 
4. Clinical success: freedom from 
symptomatic AF/flutter but AF/flutter 
> 1 min/day < than 1% at 12 months.  
• 
12 month continuous ECG 
page- MARS 
• 
12 month continuous ECG 
page- Venus 
• 
12 month AF/AT Burden less than 
25% continuous event monitor at 6 
and 12 months from ablation 
procedure 
5 Sub-acute procedural 
complications (within 30 days).  
• 
Symptoms page 
• 
AE page 
Day 30 reported, procedure related 
complications via symptoms and/or 
AEs 
6 Recurrence as persistent or 
paroxysmal AF, or flutter after 1 or 2 
procedures.  
 
• 
12 lead Ecg page 
• 
Evaluation for repeat procedure 
page 
• 
AE page 
• 
Type of recurrence (rhythm) 
• 
Characterization of recurrence e.g. 
persistent or paroxysmal for a fib; 
typical or atypical for a flutter. 
7. LA function on Doppler 
echocardiography (LA strain114ab) 
at 12 months.  
 
Central echocardiogram page 
LA Strain 
8. Incidence and mechanisms of 
atrial flutters.  
 
• 
12 lead ECG page 
• 
AE page 
• 
Evaluation for repeat procedure 
page 
• 
Date of occurrence 
• 
Type of flutter (typical vs atypical) 
 
9. Cardiovascular hospitalizations 
and QOL.  
• 
Hospitalizations 
• 
SAEs 
• 
QOL 
• 
Total # of CV related 
hospitalizations 
• 
QOL score 
 
Use of propensity scores in multivariate models. An ideal goal for observational etiological 


Protocol V7.2 15FEB2016 
 
 
38 
 
studies is to allocate randomly subjects into different treatment groups in order to guarantee on 
average that there are no systematic differences in covariates between groups.120 After 
randomization, there is nevertheless a possibility for observing large differences in confounders 
which may lead to bias in results. The propensity score provides a scalar summary of covariate 
information and is defined as the propensity (probability) that a subject’s covariate profile 
represents subjects truly assigned to a given treatment group. Propensity scores based on 
significantly different confounder variables can be used to create a quasi-randomized 
experiment with adjustment to the treatment effect. We will assess the role of propensity scores 
in prediction models in order to reduce the effects of baseline factors that may be significantly 
different among subjects in different treatment groups. Firstly, we will identify baseline 
covariates which are significantly different across treatment groups (using t-tests with skew-zero 
transformed covariates or Mann-Whitney tests). Significant covariates will be incorporated into a 
logistic regression model (y=0 PVAI, 1-VOM-PV) to generate subject-specific logits, which are 
normally-distributed.121, 122 Treatment-subject-specific logits will then be used for matching 
subjects across the treatment groups in order to construct a sample of subjects with balanced 
covariates. We suspect that propensity matching will not be required to tackle the problem of 
extreme confounder differences, but will nevertheless evaluate the effect of propensity matching 
prior to logistic regression to determine treatment effect possibly adjusted for age. 
 
Missing data. The critical piece of data required for endpoint analysis is the 
electrocardiographic event monitor. Failure to comply with wearing the monitor will lead to 
missing data. We request patients to wear monitors for 1–month. However, only a minimum of 
1-week of monitored time is required for Endpoint assessment. Patients with less than 1 –week 
of monitoring will be considered as missing data. Patients who die before then study end will be 
considered not to have a response to treatment.   For patients with missing primary outcomes, 
we will perform multiple imputation (MI) based on Monte Carlo Markov chain (MCMC) methods 
(Refs 1-3).   MI will only be used for dealing with missing data as a secondary analysis tool of 
the primary endpoint. In Stata, MI is available for many procedures, especially the regression 
modules (linear, logistic, Poisson, Cox PH).  MI can be performed to iteratively impute central 
estimates of missing outcome measures based on subjects’ covariate patterns. The most 
straightforward example can be envisioned in this study, where logistic regression with MI is 
employed to train a model based on primary outcome (0-failure,1-success) as the dependent 
variable and age, gender, baseline AF duration, and baseline LA volume as independent 
predictors to impute P(y=1|x) for subjects with missing primary outcome.     
 
Sensitivity analysis.  Following methods introduced in Proschan et al. (Ref 4), we simulated 
success rates for patients with missing 12-month outcomes in VOM and PVAI arms for VENUS 
and MARS at 33%, 66%, and 100% information time (looks 1-3).   B=100,000 iterations were 
used with proportions of Pm=0, 0.05, 0.10, 0.15, and 0.2 representing the amount of missing 
data in both VOM and PVAI arms.   At look k, let the success rate in the VOM arm be 𝑝𝑝1𝑘𝑘 and 
the success rate in the PVAI arm be  𝑝𝑝2𝑘𝑘,  𝑛𝑛1𝑘𝑘 and 𝑛𝑛2𝑘𝑘 the number of patients accrued in the 
VOM and PVAI arms, 𝑛𝑛1𝑘𝑘
𝑚𝑚= 𝑛𝑛1𝑘𝑘𝑃𝑃𝑚𝑚 and  𝑛𝑛2𝑘𝑘
𝑚𝑚= 𝑛𝑛2𝑘𝑘𝑃𝑃𝑚𝑚  the number of patients in VOM and PVAI 
arms with missing outcome data, and  𝑛𝑛1𝑘𝑘
0 = 𝑛𝑛1𝑘𝑘−𝑛𝑛1𝑘𝑘
𝑚𝑚  and 𝑛𝑛2𝑘𝑘
0 = 𝑛𝑛2𝑘𝑘−𝑛𝑛2𝑘𝑘
𝑚𝑚 the number of 
patients in VOM and PVAI arms without missing outcomes.  Next, for VOM patients with missing 


Protocol V7.2 15FEB2016 
 
 
39 
 
outcomes, simulate the number of successes by taking random draws of a binomial variate with 
parameters (𝑛𝑛1𝑘𝑘
𝑚𝑚, 𝑝𝑝2) , and the number of successes among PVAI patients with missing 
outcomes as 𝐵𝐵(𝑛𝑛2𝑘𝑘
𝑚𝑚, 𝑝𝑝1).  Note that the random draws of binomial variates are based on the 
success rate in the opposing arm, which enforces a high level of conservatism.   A test statistic 
(unpooled variance) at the bth iteration is  
𝑍𝑍𝑘𝑘
(𝑏𝑏) =
𝑝𝑝̂1𝑘𝑘−𝑝𝑝̂2𝑘𝑘
ට
𝑝𝑝ො1𝑘𝑘(1−𝑝𝑝ො1𝑘𝑘)
𝑛𝑛1𝑘𝑘
+ 
𝑝𝑝ො2𝑘𝑘(1−𝑝𝑝ො2𝑘𝑘)
𝑛𝑛2𝑘𝑘
, 
where 𝑝𝑝̂1𝑘𝑘=[𝑛𝑛1𝑘𝑘
0 𝑝𝑝1𝑘𝑘+ 𝐵𝐵(𝑛𝑛1𝑘𝑘
𝑚𝑚, 𝑝𝑝2)]/𝑛𝑛1𝑘𝑘 is the unobserved success rate among VOM patients with 
and without missing data, and 𝑝𝑝̂2𝑘𝑘=[𝑛𝑛2𝑘𝑘
0 𝑝𝑝2𝑘𝑘+ 𝐵𝐵(𝑛𝑛2𝑘𝑘
𝑚𝑚, 𝑝𝑝1)]/𝑛𝑛2𝑘𝑘.   The power of the test is equal to 
the proportion of rejections among the B iterations, given in the form 
 
𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃=
#{𝑏𝑏: 𝑍𝑍𝑘𝑘
(𝑏𝑏)>1.96}
𝐵𝐵
. 
The tables below present power as a function of VOM and PVAI success rates, and the 
proportion of patients with missing data for the VENUS and MARS trials. 
 
VENUS 33% 
  
(n1=60,n2=52) 
PVAI Success 
VOM Success 
Missing 
0.28 
0.33 
0.38 
0.43 
0.48 
0.46 
0 
1.000 
0.000 
0.000 
0.000 
0.000 
0.05 
0.778 
0.055 
0.000 
0.000 
0.000 
0.1 
0.462 
0.054 
0.002 
0.000 
0.000 
0.15 
0.247 
0.051 
0.003 
0.000 
0.000 
0.2 
0.197 
0.052 
0.007 
0.001 
0.000 
0.51 
0 
1.000 
1.000 
0.000 
0.000 
0.000 
0.05 
1.000 
0.584 
0.059 
0.000 
0.000 
0.1 
0.855 
0.461 
0.045 
0.001 
0.000 
0.15 
0.601 
0.213 
0.043 
0.002 
0.000 
0.2 
0.445 
0.159 
0.042 
0.008 
0.001 
0.56 
0 
1.000 
1.000 
1.000 
0.000 
0.000 
0.05 
1.000 
1.000 
0.476 
0.060 
0.000 
0.1 
1.000 
0.854 
0.459 
0.049 
0.001 
0.15 
0.907 
0.514 
0.218 
0.040 
0.003 
0.2 
0.709 
0.397 
0.154 
0.045 
0.011 
0.61 
0 
1.000 
1.000 
1.000 
1.000 
0.000 
0.05 
1.000 
1.000 
1.000 
0.477 
0.058 
0.1 
1.000 
1.000 
0.860 
0.452 
0.053 
0.15 
0.990 
0.879 
0.510 
0.227 
0.034 
0.2 
0.901 
0.696 
0.383 
0.146 
0.049 
0.66 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
0.478 
0.1 
1.000 
1.000 
1.000 
0.868 
0.434 


Protocol V7.2 15FEB2016 
 
 
40 
 
0.15 
1.000 
0.991 
0.866 
0.513 
0.233 
0.2 
0.982 
0.905 
0.682 
0.367 
0.153 
VENUS 66% 
(n1=120,n2=104) 
  
PVAI Success 
VOM Success 
Missing 
0.28 
0.33 
0.38 
0.43 
0.48 
0.46 
0 
1.000 
1.000 
0.000 
0.000 
0.000 
0.05 
1.000 
0.766 
0.008 
0.000 
0.000 
0.1 
0.976 
0.473 
0.024 
0.000 
0.000 
0.15 
0.777 
0.243 
0.018 
0.000 
0.000 
0.2 
0.532 
0.159 
0.020 
0.001 
0.000 
0.51 
0 
1.000 
1.000 
1.000 
0.000 
0.000 
0.05 
1.000 
1.000 
0.770 
0.007 
0.000 
0.1 
1.000 
0.976 
0.476 
0.025 
0.000 
0.15 
0.981 
0.745 
0.227 
0.019 
0.000 
0.2 
0.860 
0.487 
0.148 
0.020 
0.001 
0.56 
0 
1.000 
1.000 
1.000 
1.000 
0.000 
0.05 
1.000 
1.000 
1.000 
0.770 
0.003 
0.1 
1.000 
1.000 
0.971 
0.429 
0.022 
0.15 
1.000 
0.978 
0.700 
0.214 
0.018 
0.2 
0.983 
0.834 
0.468 
0.131 
0.022 
0.61 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
0.768 
0.1 
1.000 
1.000 
1.000 
0.969 
0.466 
0.15 
1.000 
1.000 
0.978 
0.698 
0.198 
0.2 
1.000 
0.981 
0.812 
0.483 
0.129 
0.66 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
1.000 
0.1 
1.000 
1.000 
1.000 
1.000 
0.979 
0.15 
1.000 
1.000 
1.000 
0.981 
0.710 
0.2 
1.000 
0.999 
0.980 
0.821 
0.479 
VENUS 100% 
(n1=180,n2=156) 
PVAI Success 
VOM Success 
Missing 
0.28 
0.33 
0.38 
0.43 
0.48 
0.46 
0 
1.000 
1.000 
0.000 
0.000 
0.000 
0.05 
1.000 
0.994 
0.086 
0.000 
0.000 
0.1 
1.000 
0.811 
0.072 
0.000 
0.000 
0.15 
0.979 
0.594 
0.069 
0.001 
0.000 
0.2 
0.827 
0.363 
0.048 
0.002 
0.000 
0.51 
0 
1.000 
1.000 
1.000 
0.000 
0.000 
0.05 
1.000 
1.000 
0.993 
0.083 
0.000 
0.1 
1.000 
1.000 
0.781 
0.059 
0.000 
0.15 
1.000 
0.973 
0.572 
0.061 
0.001 
0.2 
0.987 
0.808 
0.335 
0.047 
0.002 


Protocol V7.2 15FEB2016 
 
 
41 
 
0.56 
0 
1.000 
1.000 
1.000 
1.000 
0.000 
0.05 
1.000 
1.000 
1.000 
0.992 
0.081 
0.1 
1.000 
1.000 
0.999 
0.781 
0.057 
0.15 
1.000 
1.000 
0.966 
0.540 
0.063 
0.2 
1.000 
0.984 
0.787 
0.321 
0.048 
0.61 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
0.991 
0.1 
1.000 
1.000 
1.000 
0.999 
0.795 
0.15 
1.000 
1.000 
1.000 
0.966 
0.552 
0.2 
1.000 
1.000 
0.983 
0.784 
0.329 
0.66 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
1.000 
0.1 
1.000 
1.000 
1.000 
1.000 
1.000 
0.15 
1.000 
1.000 
1.000 
1.000 
0.970 
0.2 
1.000 
1.000 
1.000 
0.985 
0.800 
MARS 33% 
(n1=11,n2=11) 
PVAI Success 
VOM Success 
Missing 
0.32 
0.37 
0.42 
0.47 
0.52 
0.66 
0 
1.000 
0.000 
0.000 
0.000 
0.000 
0.05 
0.109 
0.127 
0.000 
0.000 
0.000 
0.1 
0.108 
0.126 
0.000 
0.000 
0.000 
0.15 
0.107 
0.132 
0.020 
0.026 
0.000 
0.2 
0.108 
0.015 
0.021 
0.026 
0.000 
0.71 
0 
1.000 
1.000 
0.000 
0.000 
0.000 
0.05 
0.518 
0.108 
0.124 
0.000 
0.000 
0.1 
0.517 
0.108 
0.121 
0.000 
0.000 
0.15 
0.357 
0.108 
0.129 
0.018 
0.023 
0.2 
0.087 
0.107 
0.015 
0.019 
0.024 
0.76 
0 
1.000 
1.000 
1.000 
0.000 
0.000 
0.05 
0.483 
0.521 
0.420 
0.113 
0.124 
0.1 
0.482 
0.522 
0.102 
0.113 
0.000 
0.15 
0.314 
0.356 
0.102 
0.121 
0.015 
0.2 
0.312 
0.084 
0.103 
0.093 
0.015 
0.81 
0 
1.000 
1.000 
1.000 
1.000 
0.000 
0.05 
1.000 
1.000 
0.530 
0.472 
0.097 
0.1 
1.000 
0.489 
0.529 
0.089 
0.098 
0.15 
0.554 
0.311 
0.357 
0.094 
0.111 
0.2 
0.270 
0.313 
0.194 
0.095 
0.092 
0.86 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
0.545 
0.588 
0.1 
1.000 
1.000 
0.499 
0.544 
0.517 
0.15 
0.659 
0.613 
0.309 
0.358 
0.277 
0.2 
0.660 
0.265 
0.310 
0.232 
0.080 


Protocol V7.2 15FEB2016 
 
 
42 
 
MARS 66% 
(n1=22,n2=22) 
PVAI Success 
VOM Success 
Missing 
0.32 
0.37 
0.42 
0.47 
0.52 
0.66 
0 
1.000 
1.000 
1.000 
0.000 
0.000 
0.05 
1.000 
0.584 
0.141 
0.000 
0.000 
0.1 
0.799 
0.445 
0.154 
0.026 
0.000 
0.15 
0.643 
0.363 
0.152 
0.042 
0.006 
0.2 
0.252 
0.112 
0.050 
0.052 
0.012 
0.71 
0 
1.000 
1.000 
1.000 
1.000 
0.000 
0.05 
1.000 
1.000 
0.588 
0.134 
0.000 
0.1 
1.000 
0.799 
0.448 
0.151 
0.023 
0.15 
0.887 
0.642 
0.362 
0.147 
0.038 
0.2 
0.461 
0.251 
0.119 
0.114 
0.046 
0.76 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
0.603 
0.128 
0.1 
1.000 
1.000 
0.805 
0.447 
0.141 
0.15 
0.859 
0.890 
0.647 
0.359 
0.140 
0.2 
0.702 
0.459 
0.248 
0.120 
0.116 
0.81 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
1.000 
0.1 
1.000 
1.000 
1.000 
0.815 
0.449 
0.15 
1.000 
0.868 
0.897 
0.655 
0.359 
0.2 
0.908 
0.710 
0.464 
0.336 
0.235 
0.86 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
1.000 
0.1 
1.000 
1.000 
1.000 
1.000 
0.830 
0.15 
1.000 
1.000 
1.000 
0.906 
0.667 
0.2 
1.000 
0.914 
0.718 
0.465 
0.380 
MARS 100% 
(n1=33,n2=33) 
PVAI Success  
VOM Success 
Missing 
0.32 
0.37 
0.42 
0.47 
0.52 
0.66 
0 
1.000 
1.000 
1.000 
0.000 
0.000 
0.05 
1.000 
1.000 
0.703 
0.181 
0.000 
0.1 
1.000 
0.928 
0.414 
0.183 
0.005 
0.15 
0.742 
0.501 
0.319 
0.056 
0.019 
0.2 
0.515 
0.371 
0.115 
0.061 
0.028 
0.71 
0 
1.000 
1.000 
1.000 
1.000 
0.000 
0.05 
1.000 
1.000 
1.000 
0.859 
0.177 
0.1 
1.000 
1.000 
0.931 
0.414 
0.179 
0.15 
0.973 
0.863 
0.499 
0.316 
0.118 
0.2 
0.661 
0.513 
0.372 
0.126 
0.056 
0.76 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
0.867 


Protocol V7.2 15FEB2016 
 
 
43 
 
0.1 
1.000 
1.000 
1.000 
0.934 
0.414 
0.15 
1.000 
0.975 
0.896 
0.502 
0.315 
0.2 
0.934 
0.660 
0.517 
0.372 
0.231 
0.81 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
1.000 
0.1 
1.000 
1.000 
1.000 
1.000 
0.941 
0.15 
1.000 
1.000 
0.977 
0.903 
0.619 
0.2 
0.984 
0.939 
0.734 
0.516 
0.369 
0.86 
0 
1.000 
1.000 
1.000 
1.000 
1.000 
0.05 
1.000 
1.000 
1.000 
1.000 
1.000 
0.1 
1.000 
1.000 
1.000 
1.000 
1.000 
0.15 
1.000 
1.000 
1.000 
0.981 
0.913 
0.2 
1.000 
0.986 
0.944 
0.852 
0.619 
 
           
D) Stopping rules. The trials will be stopped if one of the following occurs: 
a. Futility/efficacy boundaries reached. As illustrated in Figures S1 and S2, if the upper or 
lower boundary is reached at the 1/3 or 2/3 data assessment for beneficial efficacy or 
futility respectively, the trial will be evaluated for early termination. 
b. Safety. Events will be reported to FDA, NHLBI, and DSMB according to FDA/OHRP 
requirements and NHLBI adverse event and unanticipated problem reporting policy.  
Expedited reporting will occur within 7 days of initial receipt of information for fatal or life-
threatening unexpected serious reactions and within 15 calendar days for non-fatal, non-
life threatening unexpected events.  The DSMB will otherwise evaluate overall safety 
events on a bi-annual basis. An excess of procedural adverse events attributable to 
study procedure will be evaluated for early termination.  Procedural adverse events 
include those that occur within 24 hours of the procedure or those that may be delayed 
but procedure-related (atrio-esophageal fistula or delayed pericardial effusion).  The 
following are expected to be rare.  One event may occur by chance in either treatment 
groups.  Two of the same events in either arm will trigger consideration for study 
termination after detailed case review: 
• 
Mortality.  
• 
Stroke-Transient ischemic attack or systemic embolus.  
• 
Pericardial effusion requiring drainage 
  
1. Raghunathan, T. E., J. M. Lepkowski, J. Van Hoewyk, and P. Solenberger. 2001. A multivariate 
technique for multiply imputing missing values using a sequence of regression models. Survey 
Methodology 27: 85–95. 
2. Rubin, D. B. 1987. Multiple Imputation for Nonresponse in Surveys. New York: Wiley. 
3. van Buuren, S. 2007. Multiple imputation of discrete and continuous data by fully conditional 
specification. Statistical Methods in Medical Research 16: 219–242. 
4. Proschan, MA, McMahon, RP, Shih, JH, Hunsberger, SA, Geller, NL, Knatterud, G, Wittes, J.  
2001.  Sensitivity analysis using an imputation method for missing binary data in clinical trials.   J. 
Statistical Planning and Inference.  96: 155-165. 
.


 
 
 
44 
 
 
7.0 
STUDY ORGANIZATION 
7.1  
SCHEDULE OF EVENTS 
Visit ID 
1 
2 
3 
4 
5 
6 
7 
8 
9 
Procedure 
screen/ 
baseline 
procedure 
day 0 
prior to 
discharge 
  
7 days  
(± 3) 
30 day FU 
(±10) 
1mo 
90 day FU 
(±30d) 
3mo 
180 day FU 
(±60d) 
6mo 
9 mo FU 
(±30d) 
 
360 day FU 
(±60d) 
12 mos. 
Informed Consent (prior to study specific 
procedures 
X 
 
 
 
 
 
 
 
 
Eligibility Checklist (PMH, medications, verification 
of Inclusion and exclusion criteria) 
X 
 
 
 
 
 
 
 
 
General Medical History  & Cardiovascular 
History with CHADS2-VASC Score) 
X 
 
 
 
 
 
 
 
 
LAA thrombus exclusion Transesophageal 
Echocardiogram (within 48 hours) or 
anticoagulation/LAA exclusion) 
X(l) 
 
 
 
 
 
 
 
 
Cardiac MRI or CT or Echocardiogram (showing 
structure & function within 1 year) 
X(m) 
 
 
 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
 
 
 
Targeted Physical Exam 
X 
 
 
 
X 
X 
X 
X 
X 
12 lead EKG 
X 
X pre-
procedure 
X 
 
X 
X 
X 
X 
X 
Laboratory: CBC, Serum creatinine, and INR –
(INR only if patient is taking warfarin(g)) 
X 
 
 
 
 
 
 
 
 
AF Quality of Life Questionnaire (AFEQT) 
X 
 
 
 
 
 
X 
X 
X 
Pre-procedure 3D Mapping(b)(j) 
 
X 
 
 
 
 
 
 
 
VOM Procedure w/ ETOH Injection and Post 
ethanol map 
 
X(i) 
 
 
 
 
 
 
 
PVAI Procedure 
 
X 
 
 
 
 
 
 
 
Post Procedure 3 D Mapping 
 
X(c,j) 
 
 
 
 
 
 
 
Follow-Up Phone Call(f) 
 
 
 
X 
 
 
 
 
 
3-4 Week EKG (Event Monitor)(d,n) 
 
 
 
 
 
 
X 
 
X 
Echocardiogram , Central Reader (Dr. Nagueh) 
 
 
 
 
 
 
 
 
X(k) 
Repeat Procedure allowed (e) 
 
 
 
 
 
X 
X 
X 
 
AAD Therapy  
If appl. 
If appl. 
If appl. 
If appl. 
If appl. 
Stop AAD(a) 
 
 
 
Anticoagulation 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 


 
 
 
45 
 
 
Footnote Key 
(a) Must be in sinus rhythm prior to stopping AAD, may stop if clinically indicated 
(b) Required for both VENUS-AF and MARS-AF groups. For subjects in VENUS-AF, there should be little to no 
scarring for first procedure.  For subjects in MARS-AF group and study patients requiring repeat procedures, 
maps will assess pre-existing extent of previous ablation lesions and presence or absence of PV reconnection. 
(c) To delineate extent of scar in both PVAI alone and PVAI/VOM groups. 
(d) Continuous 4 week EKG monitoring, will take place at month 6, and 12  
(e) Repeat procedures will be allowed if certain criteria met 
(f) Seven day follow-up phone call to assess post procedure symptoms. 
(g) Baseline INR must be within 24 hours prior to procedure for patients taking warfarin;  
(h) Not applicable.  
(i) 
 For patients randomized to receive VOM ethanol infusion, and who have a vein of Marshall that can be 
cannulated. 
(j) 
For subjects who undergo repeat on-study procedures, mapping will be done a second time 
(k) Echocardiogram for LA Strain will be performed at study end at 12 months, and read centrally by core lab. 
(l) 
Imaging prior to enrollment is required to rule out the presence of LA appendage thrombus. Ruling out LAA 
thrombus can be performed by the following: TEE within 48 hours of the procedure; at least one month of oral 
anticoagulation prior to the procedure; or documented prior procedures of LAA occlusion or ligation.  
(m) Imaging prior to enrollment is required to rule out structural heart disease. For ruling out structural heart disease, 
either a cardiac MRI or CT or transthoracic echocardiogram within 1 year prior to participation in the study is 
sufficient. 
(n) Options for continuous EKG monitoring include: event monitoring include: external event monitor, implanted 
miniaturized rhythm monitor, or implanted pacemaker. 
 
 


 
 
 
46 
 
7.2  
PATIENT RECRUITMENT, PROCEDURES AND FOLLOW-UP 
Patients will be recruited from Cardiac Electrophysiology consultation services at all sites. 
Qualified, trained investigators will perform the procedures at the centers. These investigators 
will be unblinded. Patients will be followed up by qualified and trained at each study center. 
The clinicians will follow the patients and evaluate adverse events and clinical primary 
endpoints.   
7.3  
CLINICAL RESEARCH NURSES/COORDINATORS 
Each site will have designated research nurses and/or study support staff.  Coordinating center 
may provide research nurse and/or study support staff as needed to conduct the trial efficiently. 
All study staff will keep in close communication with the Project Manager at the coordinating 
center, in order to ensure the study process runs smoothly. The coordinating center will train all 
study coordinators in the same manner. 
7.4  
DATA COORDINATING CENTER (DCC)  
A DCC has been set up at the Dan L. Duncan Institute for Clinical and Translational Research 
at Baylor College of Medicine. Coordinators at each site will use a web-based data entry and 
collection system, which is capable of image collection (including maps) and FISMA-compliant. 
Methodist coordinating center will oversee data collection, integrity and quality. A statistician 
with extensive experience handling large data sets has been recruited to independently lead 
data analysis.  He will meet periodically with DCC and lead blinded data analysis of the 
proposed endpoints and SAEs. Data will be reported to the DSMB with pre-specified criteria for 
stopping the trial if safety and futility boundaries are reached. See below in “Protection of 
Human Subjects”. 
The DCC will design, develop and maintain the secure, web-based electronic database systems 
for this trial. The electronic data management system (EDC) is a secure, web-based system 
which will require the participants to have an internet-accessible computer/tablet with an Internet 
browser.  This electronic data management system will have logical checks and audit logs built 
into the system to ensure data correctness and data integrity.  All automated alerts and 
notifications requested by the project team will be implemented in this electronic data 
management system. This system will also have reports and queries that are requested by the 
project team and the DSMB to monitor and manage the study.  Also provided will be backend 
access to statistical software with data connectivity to facilitate data analyses. At various time 
points in the study, as requested by the study team, snapshots and locking of the database will 
occur, and clean data sets will be provided to the study team for review and data analyses. 
 
 


 
 
 
47 
 
7.5  
STUDY DRUG 
Investigational Product: The VOM injections will be performed using Dehydrated Alcohol 
Injection, USP, (multiple manufacturers).  The product is commercially available and is 
indicated for therapeutic neurolysis in a number of medical situations, mainly for chronic 
pain. 
Supply: The alcohol will be obtained commercially by the each site, and stored in a locked, 
limited access area under the appropriate temperature conditions.  The number of ml used 
in each procedure will be documented in the surgical record by the surgeon.  Site specific 
handling and accountability procedures, if different than above, shall be approved by the 
sponsor and outlined in the Clinical Trial Management Plan. 
Labeling and accountability:  The supply obtained for this study will be clearly marked for 
Investigational use per the FDA requirements, regardless of its approval status.  Records 
will be kept of the date, patient use, and lot # of study drug used from this supply. No 
unused study drug will be retained.  After opening, used and unused product will be 
destroyed on site per institutional policy.  No drug supplies shall be returned to the sponsor. 
Storage and Maintenance: Study drug will be stored in a cool place away from a heat 
source, as indicated on package insert. 
Administration and Dosing: Study drug is administered intravenously. Dosing is 
dependent upon the surgeon achievement of sufficient neurolysis for successful ablation (up 
to 4 injections of 1cc ethanol. 
7.6  
BLINDING 
Patients and personnel involved in data analysis, will be blinded to the treatment provided. 
Upon enrollment, the operators will be informed of the randomization outcome. After the 
procedure is performed, data will be collected and analyzed with treatment groups as the 
only identifier. The DSMB will receive the data identification for their assessment.  
The primary endpoint of freedom from AF as determined by electrocardiographic monitoring 
by either external monitors or implanted devices will be adjudicated in an independent and 
blinded manner by the external EKG monitoring laboratory, respectively.  
 


 
 
 
48 
 
7.7  
CORE LABORATORIES: ECHOCARDIOGRAPHY, AND EKG MONITORING 
Electrocardiographic monitoring will be performed by continuous 3-4 week monitors as 
described. We have secured a commitment from a qualified vendor to provide with storage 
of continuous data (i.e. e. all the heart beats) for the 3-4 week monitoring time that will allow 
precise determination of the AF burden (percentage of time in AF). Data will be reviewed by 
technicians unaware of the treatment mode, thus AF occurrence and AF burden 
quantification will be blinded. Additionally, analysis such as heart rate variability may be 
performed: If VOM ethanol causes effective vagal denervation, and vagal innervation 
modulates dynamics of heart rate variability123 then we expect differences between the two 
treatment groups. The core echocardiographic laboratory is a national leader in 
echocardiography with particular expertise in LA function.114b LA volumes, ejection fraction 
and strain will be collected as described and reviewed and analyzed in the 
echocardiography core laboratory at Houston Methodist Hospital.114ab 
Alternate rhythm monitoring 
Certain patients may be eligible for implantation of a miniaturized subcutaneous recording 
device (Medtronic LinQ device) or other equivalent implanted permanent monitoring 
devices. These implanted devices provide continuous electrocardiographic monitoring for up 
to 3 years including data on atrial fibrillation or flutter burden, episode duration per day and 
other quantified data.  For patients that choose to have this kind of monitoring, AF data will 
be quantified for the primary and secondary endpoints using this device as opposed to 3-4 
week electrocardiographic monitoring.  
Certain patients may already have an implanted pacemaker previously inserted prior to 
study enrollment. These devices yield interrogation reports that provide sufficient data on 
atrial fibrillation or flutter burden, episode duration per day and other quantified data.  For 
patients that already undergo this kind of monitoring, AF data will be quantified for the 
primary and secondary endpoints using these devices as opposed to 3-4 week 
electrocardiographic monitoring. 
7.8  
SAFETY CONSIDERATIONS 
Ethanol infusion for the treatment of hypertrophic cardiomyopathy has been used for more 
than a decade.124 Complications derive from collateral damage (i.e. e. AV block) or spillage 
of ethanol in unintended arterial branches.124 VOM infusion is retrograde, and spilled ethanol 
drains via the CS into the right atrium to be diluted to non-damaging concentrations. Ethanol 
passage into the systemic circulation via the LA, albeit seemingly dangerous, is necessary 
for its ablative effects in the atrial myocardium. In order to achieve rapid dilution and avoid 
systemic effects, a slow infusion rate is critical. Mixed blood ethanols have been 
undetectable. VOM venograms performed after VOM ethanol infusion can show varying 
degrees of myocardial staining, but macroscopic extravasation into the epicardial space has 
not occurred. Adverse events of the VOM procedure included one CS dissection, which had 
no clinical consequences. Two patients developed sub-acute pericardial effusion 4 and 6 
weeks after the procedure, respectively. The role of VOM ethanol is unclear, since this 
complication is also well described in conventional ablation.56 No systemic effects were 


 
 
 
49 
 
detected at the doses tested (total 4 ml). This is an FDA Investigational New Drug (IND # 
105083) project, which will continue.  
Added procedure and fluoroscopy times in our previous experience average 45 and 8 
minutes, respectively. Reported fluoroscopy times of conventional ablation can be up to 
100-120 minutes,125, 126 so 8 minutes do not represent a major fluoroscopy time increase. 
Given that VOM ethanol may lead to ablation of otherwise targeted tissue (including LIPV 
isolation),1 and facilitate perimitral block,3 it may reduce the need of RF ablation in these 
areas. Thus VOM ethanol may potentially save procedure and fluoroscopy times 
downstream.  
7.8.1  Adverse Event Reporting 
The adverse event reporting period for this trial begins at the time the subjects sign the 
informed consent form, and will continue through the final month follow-up visit or withdrawal 
from the study.  Reportable events will be reported per institution specific IRB policy. 
Only AE’s related to the catheter ablation procedure, ethanol ablation, and disease 
process will be captured.  
Anticipated (Expected) Adverse Events (AE’s) 
Patients may experience certain clinical events that are attributable to the ablation 
procedure or the disease process of the patient. The following list of AE’s are 
expected based on previous clinical and research experience. 
• 
Atrial Arrhythmias 
• 
Chest pain or Angina 
• 
Standard of care cardioversions for arrhythmias  
• 
Headache 
• 
Minor bleeding 
• 
Hypertension or hypotension 
• 
Vasovagal reactions  
• 
self-limiting pericarditis attributable to the ablation procedure defined as pleuritic 
chest discomfort with or without pericardial rub 
• 
pacemaker implantation for nodal dysfunction rhythms (sick sinus syndrome, sinus 
bradycardia, sinus arrest or AV blocks) that resulted in symptomatic bradycardia 
(unrelated to the ablation procedure or related to pre-existing disease state) 
• 
Incision site pain/soreness 
• 
Incision site infection 
• 
Inadvertent AV block: Second or third degree heart block 
• 
Palpitations 
• 
Pulmonary edema 
• 
ECG changes that did not require additional hospitalization 
• 
Pericarditis 
• 
Anxiety 
• 
Hematoma 


 
 
 
50 
 
 
7.8.2  Serious Adverse Events (SAE) Reporting 
An adverse event that meets one or more of the following criteria/outcomes will be 
classified as serious: These events will be treated accordingly and reported per local & 
federal regulations and institutional policies & requirements.  
• 
Results in a life-threatening illness or injury. 
• 
Results in permanent impairment of a body structure or a body function. 
• 
Requires inpatient hospitalization ≥ 24 hours (other than the ablation procedure) or 
prolongation of existing hospitalization. 
• 
Requires a medical or surgical intervention to prevent permanent impairment to body 
structure. 
• 
Death  
SAE’s will be reported in accordance with current institutional policies. 
NOTE: Unexpected serious adverse events deemed related, probably or possibly 
related to the VOM study procedure will warrant a hold on the study until further 
review and approval by the IRB and DSMB. 
Screen Failure AEs will be documented as follows: Adverse events that occur for 
subjects prior to the intervention, will be documented in the study record and will not be 
reported to the IRB or sponsor (HMRI) unless unexpected or the PI determines the event 
should be reported to the IRB as non-study intervention related event. Subjects who are 
deemed screen failures and experience an event that meets the general SAE criteria will 
be followed until resolution of the event and those events will be reported to HMRI as the 
sponsor of the IND, and to the IRB per institutional policies for reporting SAE’s.    
7.8.3 Data Safety and Monitoring Plan 
Data Safety Monitoring Board (DSMB) 
A study-specific DSMB has been created by the NHLBI (National Heart, Lung, and Blood 
Institute) which is funding this clinical trial (R01 HL115003). None of the members of the 
DSMB are listed on the protocol as sub-investigators or have conflicting interests in the 
trial results. The DSMB is made up of electrophysiology consultants familiar with ablation 
procedures that will have insights into the specific clinical scenarios that can occur in AF 
ablation. Additionally, the DSMB will have a dedicated statistician. The NHLBI will 
administer the DSMB with the assistance of the project manager and data center. 
Data Reports to DSMB 
Specific data reports will be supplied to the DSMB Executive Secretary at the NHLBI for 
reporting to the DSMB for review on a semi-annual basis or as requested. The reports 


 
 
 
51 
 
will contain un-blinded data in order to properly ascertain adverse events attributable to 
the VOM procedure. The DSMB reports and voting results will subsequently be provided 
to the IRB and the FDA as part of the IND oversight process.  
7.8.4  Minimization of Other Risks 
Procedural Risks: There are known risks to the conventional pulmonary vein ablation 
procedure, and they remain present for every patient undergoing ablation of AF. 
Additional risks specific to the Vein of Marshall procedure are listed in the consent and 
expected outcomes are fully explained to each consented subject. Standard safety 
precautions will be taken to minimize risk. The Principal Investigator of the study is 
very familiar with the risks of catheter ablation procedures and is experienced in its 
resolution and treatment. 
Risks to PHI: All data will be de-identified and only the research personnel will have 
access to subjects protected health information; all source documents will be kept onsite 
and stored with the principal investigator. The CRFs for this Study will be created by the 
PI as hard copy (paper) and as electronic CRFs. If electronic CRFs are used, the source 
document will be the electronic CRF, with appropriate password controls. The forms are 
designed to record observations and other data pertinent to the Study on each 
participant enrolled in the Study. The CRFs will be completed by the Investigator and/or 
designated staff. All data will be entered into a computer and stored in a secure 
database, accessible to approved personnel only. All hardcopies will be stored in a 
secure location and will be only accessible to approved personnel. 
 
8.0 
STUDY ADMINISTRATION & OVERSIGHT 
8.1  
PI OVERSIGHT 
Principal Investigator, Dr. Miguel Valderrábano, will have general and scientific oversight 
of the project. Dr. Valderrábano will oversee the quality of clinical measurements 
obtained in the study and ensuring adherence to the protocol. Additionally, he will be 
responsible for patient recruitment, which includes site start-up activities and training for 
all site personnel. 
8.2  
COORDINATING CENTER 
Houston Methodist Research Institute d/b/a The Methodist Hospital Research Institute  
will serve as the coordinating center for this study, led by the project PI, Dr. Miguel 
Valderrábano. A trial administrator-manager at HMRI will oversee day-to-day operations 
of the clinical study as it relates to participant enrollment, clinical site administration, and 
data administration.  
8.3  
SCIENTIFIC ADVISORY BOARD 


 
 
 
52 
 
Constituted by outside experts in clinical research, autonomic nervous system and 
evidence-based medicine research, or the use of ethanol ablation, this board will have 
the following functions: 
1. Reviewing the operational conduct of the study, including adherence to the 
study protocol. The board will assist in facilitating resolution of problems that 
may arise concerning these issues. 
2. Reviewing and rendering advice concerning potential changes to the 
protocol. Such changes would require approval by the DSMB. 
3. Recommending publication policies, as well as overseeing the publications 
and presentations review process. This includes reviewing scientific reports, 
analysis, ancillary study proposals, and publications resulting from data that 
are obtained during the study; review and approval of any revisions to the 
publication guidelines for the study; and determination of data analyses, not 
currently included in the protocol, for the purpose of furthering scientific 
understanding in the field. 
4. Reviewing recommendations from the DSMB and providing advice and 
guidance regarding potential study issues. 
 
8.4  
DATA SAFETY MONITORING BOARD (DSMB) 
An NIH-based, study-specific DSMB will oversee safety issues for the study as 
described in section 7.7.3 Data Safety Monitoring Plan. 
9.0  
TRIAL MANAGEMENT 
9.1  
STATISTICAL MANAGEMENT 
The primary functions of the individuals in the statistical core laboratory from Houston 
Methodist Hospital will be to contribute to data analysis and to create systems for 
randomization. Data from the Data Coordinating Center (see below) will be available for 
blinded statistical analysis for interim analysis, applicable DSMB or FDA reports, and 
prior to publications or presentations. 
9.2  
DATA MANAGEMENT 
Data Coordinating Center 
Data Coordinating Center (DCC) will be responsible for the integrity of data collection –
blinded to the specific treatment provided. Statistical analysis will be provided by HMRI 
statistics team, who will have access to the DCC data. Clinical analysis will be handled 
by an expert EP researcher from Methodist. 
Data flow From Remote Sites 
The Investigator at each investigative site is responsible for the completion and timely 
web-based submission of case report forms (CRFs) for each patient according to visit 


 
 
 
53 
 
requirements as detailed in the Schedule of Events.   All electronic data will be stored as 
a HIPAA-compliant limited data set in a password-protected database. Research nurses 
at each site will be responsible for entering the data in the system.  
Data collection and record-keeping   
An electronic Case Report Form (EDC) will be completed for each subject enrolled into 
the clinical study. The investigator will review, approve and sign/date each completed 
patient case report record; the investigator’s signature serving as attestation of the 
investigator’s responsibility for ensuring that all clinical and laboratory data entered on 
the EDC are complete, accurate and authentic.   
Source Data are the clinical findings and observations, laboratory and test data, and 
other information contained in Source Documents.  Source Documents are the original 
records (and certified copies of original records); including, but not limited to, hospital 
medical records, physician or office charts, physician or nursing notes, subject diaries or 
evaluation checklists, pharmacy dispensing records, recorded data from automated 
instruments, x-rays, etc.  When applicable, information recorded on the CRF shall match 
the Source Data recorded on the Source Documents.   
           Study Records Access 
The investigator will maintain all records in accordance with Good Clinical Practice 
guidelines.  Regulatory documents are maintained in a locked file cabinet in the AOCT 
office, with limited access.  Sponsor personnel viewing any site-related PHI will follow all 
rules of the institution and regulations regarding protection of PHI. 
Case report forms will not contain any subject identifiers and will be labeled with only 
subject ID numbers. Study data is recorded on a secure, limited-access electronic 
database constructed by the DCC, and compliant with all electronic data regulations.   
Any paper records, such as consent forms, that contain direct subject identifiers (e.g., 
name, social security number) will be stored in a separate locked filing cabinet in the 
study coordinator’s office. Only the study coordinator and the Investigator will have 
access to this information.    
           Missing data processing plan 
Critical data fields are those variables necessary for final study analysis.  They will be 
agreed upon by the PI and the Clinical Data Manager, and detailed within the Data 
Management Plan. For those critical fields that are discrepant or not completed on the 
case report form (CRF), a query will be issued to the investigative site.  Missing or 
overdue patient CRFs will also be queried. 
9.3  
STUDY MONITORING 
The study sponsor will provide or contract a clinical study monitor to monitor the clinical 
trial. Monitoring visits will begin as soon as subjects are consented and enrolled and will 


 
 
 
54 
 
continue until all subjects have been taken off of the clinical trial and the trial has been 
terminated.  Monitoring visits will include review of informed consent process, eligibility, 
adherence to the clinical protocol, and adverse events. Safety issues and/or trends in 
data errors or deviations will be managed by the administrative study team (principal 
investigator, project manager, IND sponsor representative, et. al). The monitoring 
process is outlined in the clinical monitoring plan which will be maintained by the 
coordinating center. 
9.4  
PROJECT MANAGEMENT 
HMRI will have a project manager who will coordinate the sites with regard to regulatory 
set-up and maintenance, IRB, DSMB and other committee approvals and submissions, 
case report form completion, problem solving, and timeline enforcement as appropriate. 
Management of the trial and oversight is delineated in the Clinical Trial Management 
Plan. 
Non Local Clinical Trial Sites 
The organization of this trial is centralized at HMRI, which will act as a coordinating 
center for other clinical sites. Additional eligible, experienced AF treatment sites will be 
contracted to enroll patients and receive reimbursement on a per-patient basis. Sites will 
be trained on the protocol prior to initiation to minimize protocol deviations, avoid 
breaches of blinding procedures and other violations. Sites should be structured with 3 
levels of personnel: operators, blinded clinicians that would follow the primary endpoints; 
and research nurses. This process and training is explained in the Clinical Trial 
Management Plan. 
 
 
 
 


 
 
 
55 
 
10.0  GUIDE TO ACRONYMS / DEFNITIONS 
AAD 
Antiarrhythmic Drug 
 
CS 
Coronary Sinus 
 
DCC 
Data Coordinating Center.  This is Dan L. Duncan Institute for Clinical and 
Translational Research (ICTR).  Will be referred to as DCC 
 
DSMB 
Data Safety Monitoring Board 
 
ECG/EKG 
Electrocardiogram 
 
EDC 
Electronic Data Capture (also, electronic case report form) 
 
HMRI 
Houston Methodist Hospital doing business as Houston Methodist Research 
Institute or The Methodist Hospital Research Institute (IND Sponsor) 
 
LA 
Left Atrium 
 
MARS 
Vein of Marshall Alcohol in Repeat ablation of perSistent Atrial Fibrillation. 
 
NIH 
National Institutes of Health (sponsor of this study) 
 
Persistent AF: continuous AF that is sustained beyond seven days. Episodes of AF in which a 
decision is made to electrically or pharmacologically cardiovert the patient after  
48 hours of AF, but prior to 7 days, should also be classified as persistent AF 
episodes. 
PMF 
Perimitral Flutter 
 
PVAI 
Pulmonary Vein Antrum Isolation (traditional A. Fib. Procedure) 
 
RF 
Radiofrequency 
 
VENUS 
VENUS-AF. Vein of Marshall Ethanol iNfusion in Untreated perSistent Atrial 
Fibrillation. 
 
VOM 
Vein of Marshall 
 
VOM-PV 
Vein of Marshall infusion plus conventional PVAI. Also VOM+PVAI 
 
 


 
 
 
56 
 
11.0 CLASSES OF ANTI-ARRHYTHMIC DRUGS (VAUGHN-WILLIAMS CLASSIFICATION)127 
Class 
Known as 
Examples 
Mechanism 
Clinical uses in cardiology [2] 
Ia 
fast-channel 
blockers-
affect QRS 
complex 
• 
Quinidine 
• 
Procainamide 
• 
Disopyramide 
(Na+) channel block 
(intermediate 
association/dissociation) 
• 
Ventricular arrhythmias 
• 
prevention of paroxysmal recurrent atrial 
fibrillation (triggered by vagal over activity) 
• 
procainamide in Wolff-Parkinson-White 
syndrome 
Ib 
Do not affect 
QRS complex 
• 
Lidocaine 
• 
Phenytoin 
• 
Mexiletine 
• 
Tocainide 
(Na+) channel block (fast 
association/dissociation) 
• 
treatment and prevention during and 
immediately after myocardial infarction, though 
this practice is now discouraged given the 
increased risk of systole 
• 
ventricular tachycardia 
Ic 
 
• 
Encainide 
• 
Flecainide 
• 
Propafenone 
• 
Moricizine 
(Na+) channel block (slow 
association/dissociation) 
• 
prevents paroxysmal atrial fibrillation 
• 
treats recurrent tachyarrhythmias of 
abnormal conduction system. 
• 
contraindicated immediately post-myocardial 
infarction. 
II 
Beta-blockers 
• 
Propranolol 
• 
Esmolol 
• 
Timolol 
• 
Metoprolol 
• 
Atenolol 
• 
Bisoprolol 
beta blocking 
Propranolol also shows some 
class I action 
• 
decrease myocardial infarction mortality 
• 
prevent recurrence of tachyarrhythmias 
III 
 
• 
Amiodarone 
• 
Sotalol 
• 
Ibutilide 
• 
Dofetilide 
• 
Dronedarone 
• 
E-4031 
K+ channel blocker 
Sotalol is also a beta 
blocker[3] Amiodarone has Class 
I, II, III & IV activity 
• 
In Wolff-Parkinson-White syndrome 
• 
(sotalol:) ventricular tachycardias and atrial 
fibrillation 
• 
(Ibutilide:) atrial flutter and atrial fibrillation 
IV 
slow-channel 
blockers 
• 
Verapamil 
• 
Diltiazem 
Ca2+ channel blocker 
• 
prevent recurrence of paroxysmal 
supraventricular tachycardia 
• 
reduce ventricular rate in patients with atrial 
fibrillation 
V 
 
• 
Adenosine 
• 
Digoxin 
• 
Magnesium 
Sulfate 
Work by other or unknown 
mechanisms (Direct nodal 
inhibition). 
Used in supraventricular arrhythmias, especially in 
Heart Failure with Atrial Fibrillation, contraindicated 
in ventricular arrhythmias. Or in the case of 
Magnesium Sulfate, used in Torsades de Pointes. 
 


 
 
 
57 
 
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