Esophageal imaging and strategies for avoiding injury during left atrial ablation for atrial fibrillation

Ren, Jian-Fang; Lin, David; Marchlinski, Francis E.; Callans, David J.; Patel, Vickas V.

doi:10.1016/j.hrthm.2006.06.006

Cited by 88 publications

(60 citation statements)

References 13 publications

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“…13 The variability of the thickness of the posterior LA wall and the esophageal wall may play an important role in esophageal heating and development of thermal damages.…”

Section: Clinical Perspective On P 159mentioning

confidence: 99%

Damage to the Esophagus After Atrial Fibrillation Ablation

Zellerhoff¹,

Ullerich²,

Lenze³

et al. 2010

Circ: Arrhythmia and Electrophysiology

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Background-Radiofrequency catheter ablation is increasingly used in the treatment of atrial fibrillation. Esophageal wall changes varying from erythema to ulcers have been described by endoscopy in up to 47% of patients following pulmonary vein isolation (PVI). Although esophageal changes are frequently reported, the development of a left atrial (LA)-esophageal fistula is fortunately rare. Nevertheless, mucosal changes may just represent "the tip of the iceberg." The aim of this study was, therefore, to investigate the more subtle changes of and injuries to the posterior wall of the LA, the periesophageal and mediastinal connective tissue, and the whole wall of the esophagus, including mucosal changes by esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS). Methods and Results-Twenty-nine patients (7 females; mean age, 57.7Ϯ10.5 years [range, 23-75 years]) underwent EGD and EUS before and after PVI within 48 hours. PVI was performed as a circumferential antral isolation of the septal and lateral pulmonary veins guided by a decapolar circular mapping catheter using a 3-dimensional mapping system with the integration of a preprocedurally acquired computed tomography scan of the left atrium. The maximum power applied was 30 W, with an open-irrigated catheter using a maximum flow rate of 30 mL/min. In all patients, the esophagus was reconstructed using the same computed tomography scan and displayed during the ablation procedure. In case of newly detected periesophageal changes, EGD and EUS were repeated 1 week after the PVI. In all patients, a regular contact area between the LA and the esophagus could be demonstrated before PVI. The mean vertical contact length was 4.4Ϯ1.5 cm (range, 2-10 cm); and the mean distance between the anterior wall of the esophagus and the endocardium was 2.6Ϯ0.8 mm (range, 1.4 -4.0 mm). After PVI, morphological changes of the periesophageal connective tissue and the posterior wall of the LA were diagnosed by endosonography in 8 patients (27%; 95% confidence interval, 12.73-47.24). No mucosal changes of the esophagus in terms of erythema or ulcers were found. In all but one patient (who refused the control), all periesophageal and atrial changes had resolved within 1 week. No atrioesophageal fistula occurred during follow-up (mean follow-up, 294Ϯ110 days [range, 36 -431 days]). Conclusions-Mucosal changes of the esophagus after PVI-like ulcers or erythema could not be demonstrated, yet structural changes of the mediastinum, which were only visible by endosonography, occurred in 27% of patients in the present study. This may indicate a higher than expected periesophageal injury because of PV ablation. Endosonography might prove to be a sensitive and reliable tool in the follow-up after PVI. (Circ Arrhythm Electrophysiol. 2010;3:155-159.)

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“…13 The variability of the thickness of the posterior LA wall and the esophageal wall may play an important role in esophageal heating and development of thermal damages.…”

Section: Clinical Perspective On P 159mentioning

confidence: 99%

Damage to the Esophagus After Atrial Fibrillation Ablation

Zellerhoff¹,

Ullerich²,

Lenze³

et al. 2010

Circ: Arrhythmia and Electrophysiology

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“…These include limiting the duration and power of lesion application to the posterior LA wall adjacent to the oesophagus. 7 Intraprocedural monitoring of the course of the esophagus in relation to the left atrium has also been suggested and includes continuous ICE monitoring of esophagus location, 8 intraprocedural barium swallow and placement of an oesophageal thermistor. 9 Reliance on the anatomical relationships from a preprocedural CT scan is recognized as being less accurate as the range of esophageal motion during a catheter ablation for AF has been shown to be greater than 2cm.…”

Section: Discussionmentioning

confidence: 99%

Esophageal Dilatation Post - Gastric Banding and Catheter Ablation for Atrial Fibrillation: A Case Report

Phillips¹,

Townsend²,

James³

et al. 2009

J.A.F.I.B

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Esophageal injury is a potential serious complication of catheter ablation for atrial fibrillation (AF). We report a case of significant esophageal dilatation following previous laproscopic gastric banding (LGB) in a patient undergoing pulmonary vein isolation (PVI) for atrial fibrillation. Case ReportA 53 year male with a 2 year history of permanent atrial fibrillation and a prior history of laproscopic gastric banding (LGB) for obesity underwent a pre-procedure planning cardiac CT scan. Moderate esophageal dilatation was demonstrated on the cardiac CT with the esophageal diameter reaching a maximum of 42mm level with the posterior left atrial wall (Fig 1). A barium swallow showed normal esophageal motility but with markedly slowed emptying times (Fig 2).A catheter ablation procedure was performed which included wide pulmonary vein antral electrical isolation guided by a cardiac navigational system (Ensite, St Jude Medical) and intra-cardiac echocardiography (ICE).The position of the esophagus was delineated on the integrated CT navigational map and on fluoroscopy by placement of an esophageal thermistor probe. Radiofrequency energy was delivered through an open irrigated tip catheter and titrated to maximum 25W and 40°C for lesions applied to the left atrial posterior wall. Esophageal temperature rises were only seen in association with lesions applied to the right inferior pulmonary vein and energy applications here were limited to avoid esophageal temperatures >38.5°C.At 6 months follow-up the patient remains in sinus rhythm with no complications. DiscussionThe potential for esophageal injury following ab- AbstractEsophageal injury is a potential serious complication of catheter ablation for atrial fibrillation. We report a case of significant esophageal dilatation following previous laparascopic gastric banding in a patient with permanent atrial fibrillation undergoing a pulmonary vein isolation procedure.

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“…Thus, it might be beneficial to segmentally apply RF energy with/without titrating it under microbubble monitoring. 6 Real-time monitoring of the esophagus with either intracardiac echocardiography 25 or continuous esophagraphy 8 would further improve the safety of PVAI.…”

Section: Discussionmentioning

confidence: 99%

“…As has been previously described, the PV ostium was angiographically defined as the region where the outline from the LA to PV curves with a maximum angle, 15 whereas the PV antrum was defined as the intervening area between the venous tube and the widely opened LA, which was identified angiographically as the gradually widening region around the PV ostium. PV mapping was performed using a steerable circular catheter with a diameter of either 15,20,25 or 30 mm equipped with 20 1-mm electrodes in a loop made of shape-retaining material orthogonal to the shaft (Lasso, Biosense Webster, Diamond Bar, CA, USA). In the Group 1 patients, we mapped and ablated the PV ostium according to the conventional method, 1,7 using a standard Lasso catheter (15 or 20 mm in diameter), whereas larger sized Lasso catheters (diameter of 25 or 30 mm) were used for mapping the PV antrum in the Group 2 patients.…”

Section: Mapping Techniquesmentioning

confidence: 99%

Segmental Pulmonary Vein Antrum Isolation Using the "Large-Size" Lasso Catheter in Patients With Atrial Fibrillation

Yamane

Date

Kanzaki

et al. 2007

Circ J

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lthough the efficiency of ostial pulmonary vein isolation (OPVI) to suppress the occurrence of atrial fibrillation (AF) is well established, 1 the relatively frequent recurrence of AF 2 and the appearance of pulmonary vein (PV) stenosis 3 have recently been highlighted as major limitations of this approach. Because the isolation of the PVs, together with their surrounding tissue, might overcome these problems, at least in part, several approaches using linear ablation techniques, such as circumferential linear ablation using electroanatomical mapping 4 or circumferential 2×2 PV isolation (PVI), 5 have so far been developed; however, there have only been a few reports describing the effects of segmental radiofrequency (RF) application outside the PV ostium. 6 In this report, we describe the feasibility and efficiency of performing segmental PV antrum isolation (PVAI) using large-sized Lasso catheters compared with the conventional OPVI method. Methods Patient PopulationThis study included 187 consecutive patients who underwent PV mapping and ablation for multidrug-resistant AF (paroxysmal AF: 120 patients; persistent AF: 67 patients) and thereafter were observed for at least 12 months Circulation Journal Vol.71, May 2007 (Table 1). We defined persistent AF as an episode of AF that lasted for more than 14 days and required cardioversion to restore sinus rhythm (SR). Cases of long-lasting persistent AF for more than 12 months were not included. The study group comprised 144 males and 43 females with a mean age of 55±8 years. Forty-five patients had evidence of cardiovascular diseases: 32 had hypertension, 9 had coronary artery disease, 5 had dilated cardiomyopathy, and 3 had mitral valve regurgitation. Two types of mapping and ablation techniques were used for PVI. In Group 1, which comprised the first 70 consecutive patients (52 males, mean age: 52.0±10.3 years), each PV was disconnected from the left atrium (LA) at its ostium. In Group 2, which included the subsequent 117 patients (92 males, mean age: 53.2±9.8 years), PVI was performed at its antrum, targeting not only the PV itself but also the surrounding tissues. All patients underwent the ablation procedure and subsequent observaCirc J 2007; 71: 753 -760 (Received October 20, 2006; revised manuscript received January 24, 2007; accepted February 22, 2007 Background The limited efficacy and complications of segmental ostial pulmonary vein isolation (PVI) for treating atrial fibrillation (AF) have been discussed so, in the present study the feasibility and efficiency of performing segmental pulmonary vein (PV) antrum isolation to treat AF were assessed. Methods and Results A total of 187 patients with drug-refractory AF (paroxysmal 120, persistent 67) underwent segmental PVI guided by circumferential 20-electrode catheters (Lasso). Radiofrequency (RF) current was delivered either at the ostium using a regular Lasso (15-20 mm in diameter, 70 patients: Group 1) or at the antrum using a larger Lasso (25-30 mm in diameter, 117 patients: Group 2). A significantly ...

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Esophageal imaging and strategies for avoiding injury during left atrial ablation for atrial fibrillation

Cited by 88 publications

References 13 publications

Damage to the Esophagus After Atrial Fibrillation Ablation

Damage to the Esophagus After Atrial Fibrillation Ablation

Esophageal Dilatation Post - Gastric Banding and Catheter Ablation for Atrial Fibrillation: A Case Report

Segmental Pulmonary Vein Antrum Isolation Using the "Large-Size" Lasso Catheter in Patients With Atrial Fibrillation

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