Computed Tomographic Analysis of the Anatomy of the Left Atrium and the Esophagus

Lemola, Kristina; Sneider, Michael; Desjardins, Benoı̂t; Case, Ian; Han, Jihn; Good, Eric; Tamirisa, Kamala; Tsemo, Ariane; Chugh, Aman; Bogun, Frank; Pelosi, Frank; Kazerooni, Ella A.; Morady, Fred; Oral, Hakan

doi:10.1161/01.cir.0000149714.31471.fd

Cited by 276 publications

(201 citation statements)

References 22 publications

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“…19,20 The VN and its branches innervate most of the UGI system. The right and left VN descend alongside the esophagus into the abdomen, and their course in the posterior mediastinum is variable.…”

Section: Discussionmentioning

confidence: 99%

Effect of Atrial Fibrillation Ablation on Gastric Motility

Lakkireddy

Reddy

Atkins

et al. 2015

Circ: Arrhythmia and Electrophysiology

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Background-Collateral damage to the vagal nerve and the upper gastrointestinal (UGI) system during atrial fibrillation ablation has not been systematically evaluated. Methods and Results-We performed a prospective, observational study assessing the effect of atrial fibrillation ablation on the function of the vagus nerve/UGI system. All patients underwent esophageal manometry, gastric emptying study, and sham-feeding test (corresponding to esophageal, gastric, and small intestinal function evaluation, respectively) before ablation (baseline) and subsequently at 24 hours, 90 days, and 180 days after the procedure. In addition, UGI symptom assessment using the patient assessment of upper gastrointestinal disorders-symptom severity index (PAGI-SYM) questionnaire was performed at baseline and during each of the subsequent evaluations. Of the 27 patients enrolled in the study, 9 (33%) patients had abnormal UGI function at baseline; defined as at least one of the 3 abnormal tests. At 24 hours after the radiofrequency catheter ablation, 20 (74%) patients had at least 1 new abnormality on the UGI function tests (P<0.001). New onset esophageal dysmotility, delayed gastric emptying time, and abnormal sham-feeding tests were observed in 13 (48%), 13 (48%), and 9 (33%) patients, respectively. Mean PAGI-SYM scores increased from 7.78±6.6 at baseline to 15.56±13.4 (P=0.002) at 24 hours. New onset abnormalities persisted in 9 (33%) patients at 3 months and normalized in all patients at 6 months. Conclusions-Atrial fibrillation ablation results in functional impairment of the UGI system, including the esophagus, stomach, and small intestine. This impairment is transient and is probably mediated by the injury to the components of the vagal nerve. Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique Identifier: NCT01396356.

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Section: Discussionmentioning

confidence: 99%

Effect of Atrial Fibrillation Ablation on Gastric Motility

Lakkireddy

Reddy

Atkins

et al. 2015

Circ: Arrhythmia and Electrophysiology

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“…45 To avoid an atrio-esophageal fistula, understanding the relationship between the esophagus and LA is paramount. Lenola et al 46 reported the topographic anatomy of the esophagus and posterior LA by using a 16-row multidetector CT scanner in patients with AF undergoing a percutaneous catheter ablation procedure. They identified that the esophagus and posterior LA were in close contact over a large area with an intervening fat layer of 0.9±0.2 mm, suggesting the potential risk of heat injury to the esophagus.…”

Section: Atrio-esophageal Fistulamentioning

confidence: 99%

Complications in the Catheter Ablation of Atrial Fibrillation

Takahashi

Kuwahara

Takahashi

2009

Circ J

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Circ J 2009; 73: 221 -226 ince the discovery of the main role of pulmonary vein (PV) foci in the initiation of atrial fibrillation (AF), 1 radiofrequency (RF) catheter ablation, basically targeting the PVs, has been developed as an effective treatment for recurrent, drug-resistant AF. [2][3][4] Moreover, various types of ablation strategies, such as extensive circumferential PV isolation including the atrial tissue in the adjacent left atrium (LA), 5-12 linear ablation [13][14][15][16] and complex fractionated electrogram-guided ablation, [17][18][19][20][21] have been used to achieve a high efficacy for all types of AF. However, these extensive and complex ablation strategies are associated with a relatively higher incidence of complications, 22,23 compared with ablation of other arrhythmias. Moreover, devastating complications, such as atrio-esophageal fistulas, have been reported, 24,25 caused by extracardiac penetration of the ablative energy, which is 1 of the unsolved safety issues concerning AF ablation. Incidence of ComplicationsComplications of AF ablation include vascular access accidents, cardiac perforation/tamponade, thromboembolic events, PV stenosis, extracardiac injury such as to the esophagus, nerve damage, and atypical atrial flutter. In a worldwide survey of 8,745 patients who underwent AF ablation reported by Cappato et al, 22 major complications occurred in 524 patients (6%), including 4 periprocedural deaths (0.05%) from massive cerebral thromboembolism in 2, extrapericardial PV perforation in 1, and an unknown cause in 1 patient. The incidence of cardiac tamponade was 1.2%, and significant PV stenosis >50%, stroke and atypical atrial flutter of new onset occurred in 1.31%, 0.28% and 3.7% of the patients, respectively. A large, prospective, multicenter Italian investigation of ablation-related complications recently reported that in 1,011 AF patients complications occurred in 40 (3.9%): 4 (0.4%) had a stroke, 6 (0.6%) had cardiac tamponade, and 4 (0.4%) had significant PV stenosis >50%. 23 Among our 1,600 patients who underwent extensive encircling isolation of both of the ipsilateral PVs guided by fluoroscopy between 2003 and 2008, overall complications occurred in 23 patients (1.4%): 4 (0.25%) had stroke, 10 (0.6%) had cardiac tamponade, 3 (0.19%) had damage to the peri-esophageal vagal plexus and 6 (0.38%) had transient phrenic nerve (PN) injury; however, there were no cases of significant PV stenosis >50% or atrio-esophageal fistula.Predictors of complications in AF ablation have been reported by some investigators, such as coronary disease, 23 advanced age, 26,27 and female gender. 27 Spragg et al found that the complication rates were higher during the first 100 cases (9%) than during the subsequent 541 cases (4.3%), indicating the salutary effect of institutional or individual operator experience. 27 ThromboembolismThe incidence of thromboembolism caused by AF ablation is 0.28-2.8%. 9,13,22,23,28-32 A worldwide survey reported periprocedural deaths because of massive cerebral thr...

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“…7 In the present study, direct contact of the esophagus with the LAPW was demonstrated in 14 of 24 patients (58%) and the difference might be related to the methodology used, in which the geometry constructed in our study represented the endocardial surface or lumen of the organs and the wall thickness of the LAPW and esophagus were not taken into account, whereas the outer surfaces of the esophagus and LAPW are demonstrated in the CT image. Sanchez-Quintana et al, however, reported that the esophageal wall was a distance of over 5 mm from the endocardium of the LAPW in the analysis of their specimens.…”

Section: Relationship Between the Esophagus And The Lapwmentioning

confidence: 54%

“…5,6 In all, recognition of the location of the esophagus relative to the LAPW is an inevitable initial step. Although preprocedural computed tomography (CT) and magnetic resonance imaging (MRI) have been reported as useful for recognizing this relationship, 7 the esophagus is mobile and thus the location at the time of imaging might not be the same as that during the ablation procedure, 8 so real-time 3-dimensional (D) visualization of the 2 organs during the RF ablation has been anticipated.…”

mentioning

confidence: 99%

Real-Time 3-Dimensional Imaging of the Esophagus and Left Atrium With a Noncontact Mapping System

Miyamoto¹,

Tsuchiya²,

Ashikaga³

et al. 2009

Circ J

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Background:Recognizing the relative location of the esophagus to the left atrial posterior wall (LAPW) is required to avoid esophageal injury during atrial fibrillation ablation. Methods and Results:The 24 patients undergoing circumferential pulmonary vein isolation (CPVI) each had the geometry of their left atrium (LA) and esophagus constructed by a noncontact mapping system with EnSite version 6.0J. The esophageal course relative to the LAPW was found to be to the left in 12, middle in 8, right in 2, and obliquely left-to-right in 2 patients, and in 13 patients (54%) it was located on or near either the left or right CPVI line. The mean distance between the esophagus and LAPW was shorter at the bottom line of the LAPW connecting both inferior pulmonary veins (3±3 mm) than at the LA roof line connecting both superior pulmonary veins (6±6 mm, P<0.01). Conclusions:The location of the esophagus relative to the LAPW varies with the patient, but a close location to either CPVI line was found in approximately 50% and a close location between the esophagus and LAPW was found in the inferior and middle locations in most patients.

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Computed Tomographic Analysis of the Anatomy of the Left Atrium and the Esophagus

Cited by 276 publications

References 22 publications

Effect of Atrial Fibrillation Ablation on Gastric Motility

Effect of Atrial Fibrillation Ablation on Gastric Motility

Complications in the Catheter Ablation of Atrial Fibrillation

Real-Time 3-Dimensional Imaging of the Esophagus and Left Atrium With a Noncontact Mapping System

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