Arterio-Enteric Fistula after Irreversible Electroporation

Lundy, Megan; Garland-Kledzik, Mary; Shen, Perry

doi:10.1177/000313481908500128

Cited by 10 publications

(4 citation statements)

References 4 publications

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“…[57][58][59] Moreover, reports of fistula formation after irreversible electroporation are abundant in the oncology literature, which raises the question of whether PFA can actually eliminate the risk of AEF. [60][61][62][63][64][65][66][67][68] As such, the importance of technologies that may reduce this dreaded complication remains high.…”

Section: Discussionmentioning

confidence: 99%

Multicenter analysis of atrioesophageal fistula rates before and after adoption of active esophageal cooling during atrial fibrillation ablation

Sánchez

Woods²,

Zagrodzky³

et al. 2023

Preprint

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Background: Active esophageal cooling reduces the incidence of endoscopically identified severe esophageal lesions during radiofrequency (RF) catheter ablation of the left atrium for the treatment of atrial fibrillation. No atrioesophageal fistula (AEF) has been reported to date with active esophageal cooling, and only one pericardio-esophageal fistula has been reported; however, a formal analysis of the AEF rate with active esophageal cooling has not previously been performed. Methods: Atrial fibrillation ablation procedure volumes before and after adoption of active cooling using a dedicated esophageal cooling device (ensoETM, Attune Medical) were determined across 25 hospital systems with the highest total use of esophageal cooling during RF ablation. The number of AEFs occurring in equivalent time frames before and after adoption of cooling were then determined, and AEF rates were compared using generalized estimating equations robust to cluster correlation. Results: Throughout the 25 hospital systems, which included a total of 30 separate hospitals, 14,224 patients received active esophageal cooling during RF ablation, with the earliest adoption beginning in March 2019 and the most recent beginning in March 2022. In the time frames prior to adoption of active cooling, a total of 10,962 patients received primarily luminal esophageal temperature (LET) monitoring during their RF ablations. In this pre-adoption cohort a total of 16 AEFs occurred, for an AEF rate of 0.146%, in line with other published estimates of <0.1% to 0.25%. No AEFs were found in the cohort treated after adoption of active esophageal cooling, yielding an AEF rate of 0% (P<0.0001). Conclusion: Adoption of active esophageal cooling during RF ablation of the left atrium for the treatment of atrial fibrillation was associated with a significant reduction in AEF rate.

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Section: Discussionmentioning

confidence: 99%

Multicenter analysis of atrioesophageal fistula rates before and after adoption of active esophageal cooling during atrial fibrillation ablation

Sánchez

Woods²,

Zagrodzky³

et al. 2023

Preprint

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“…While many PEF therapies, including NK-IRE, are considered to be nonthermal 6,7,9,52-54 due to their induction of cell death via mechanisms that are not dependent on local tissue temperatures, 55,56 these treatments have the potential to induce deleterious thermal transients 18 that could result in thermal injury to adjacent tissues. 19 Local tissue temperatures are generally not measured or accounted for in clinical treatments and rare examples of coagulative necrosis, 18 abscesses, 57 fistulas, 58 and thrombosis 59…”

Section: Discussionmentioning

confidence: 99%

Thermochromic Tissue Phantoms for Evaluating Temperature Distribution in Simulated Clinical Applications of Pulsed Electric Field Therapies

Sano

DeWitt

2020

Bioelectricity

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Background: Irreversible electroporation (IRE) induces cell death through nonthermal mechanisms, however, in extreme cases, the treatments can induce deleterious thermal transients. This study utilizes a thermochromic tissue phantom to enable visualization of regions exposed to temperatures above 60°C. Materials and Methods: Poly(vinyl alcohol) hydrogels supplemented with thermochromic ink were characterized and processed to match the electrical properties of liver tissue. Three thousand volt high-frequency IRE protocols were administered with delivery rates of 100 and 200 ls/s. The effect of supplemental internal applicator cooling was then characterized. Results: Baseline treatments resulted thermal areas of 0.73 cm 2 , which decreased to 0.05 cm 2 with electrode cooling. Increased delivery rates (200 ls/s) resulted in thermal areas of 1.5 and 0.6 cm 2 without and with cooling, respectively. Conclusions: Thermochromic tissue phantoms enable rapid characterization of thermal effects associated with pulsed electric field treatments. Active cooling of applicators can significantly reduce the quantity of tissue exposed to deleterious temperatures.

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“…28 The cardiac (and likely also the noncardiac) effects of PFA are dependent on both the parameters of the electrical field (voltage, pulse shape and duration, number and frequency of pulses) and the properties of the cells with pronounced differences in tissue sensitivity to electroporation. 23,[31][32][33] The effect of this complex interplay of electrical field and tissue properties (that may be different for individual PFA systems) has-to our knowledge-not been studied specifically for esophageal and periesophageal tissue but most likely is relevant to explain the improved esophageal safety profile of PFA compared with thermal ablation.…”

Section: Biophysics Of Lesion Generationmentioning

confidence: 99%

Pulsed‐field ablation does not induce esophageal and periesophageal injury—A new esophageal safety paradigm in catheter ablation of atrial fibrillation

Grosse Meininghaus,

Freund,

Koerber

et al. 2023

Cardiovasc electrophysiol

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IntroductionEsophageal injury is one of the most serious complications of pulmonary vein isolation (PVI) with thermic energy sources. Better tissue selectivity of primarily non‐thermic pulsed field ablation (PFA) may eliminate collateral injury, particularly the risk of atrio‐esophageal fistula (AEF).ObjectiveTo compare the incidence of any (peri)‐esophageal injury following PVI using PFA to thermic energy sources.MethodsUsing endoscopy, endoscopic ultrasound, and electrogastrography before and after PVI, esophageal and periesophageal injury (mucosal lesions, food retention, periesophageal edema, or vagal nerve injury) were assessed following PFA and radiofrequency (RF)‐ or cryoballoon (CB)‐PVI.ResultsBetween December 2022 and February 2023, 20 patients (67 ± 10 years, 53% male) undergoing PFA (Farapulse, Boston Scientific) for atrial fibrillation (AF) were studied and compared with a previous cohort of 57 patients who underwent thermic PVI (CB: n = 33; RF: n = 24). Following PFA‐PVI, none of the patients had mucosal lesions, food retention, or ablation‐induced vagal nerve injury; four patients showed periesophageal edema. Following thermic ablation, 33/57 patients (58%) showed esophageal and/or periesophageal injury (CB: 21/33 [64%], RF: 12/24 [50%]), in detail 4/57 mucosal lesions, 18/57 food retention, 17/57 vagal nerve injury, and 20/52 edema. Midterm success rates were similar for all energy sources.ConclusionIn contrast to thermic ablation tools, PFA is not associated with relevant esophageal and periesophageal injury, and might, therefore, reduce or eliminate the risk of potentially lethal AEF in interventional treatment of AF. The etiology of ablation‐induced periesophageal edema is unknown but has not been shown to be related to lesion progression.

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Arterio-Enteric Fistula after Irreversible Electroporation

Cited by 10 publications

References 4 publications

Multicenter analysis of atrioesophageal fistula rates before and after adoption of active esophageal cooling during atrial fibrillation ablation

Multicenter analysis of atrioesophageal fistula rates before and after adoption of active esophageal cooling during atrial fibrillation ablation

Thermochromic Tissue Phantoms for Evaluating Temperature Distribution in Simulated Clinical Applications of Pulsed Electric Field Therapies

Pulsed‐field ablation does not induce esophageal and periesophageal injury—A new esophageal safety paradigm in catheter ablation of atrial fibrillation

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