Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies

Abstract

Catheter ablation has become an important element in the management of atrial fibrillation. Several technical advances allowed for better safety profiles and lower recurrence rates, leading to an increasing number of ablations worldwide. Despite that, major complications are still reported, and esophageal thermal injury remains a significant concern as atrioesophageal fistula (AEF) is often fatal. Recognition of the mechanisms involved in the process of esophageal lesion formation and the identification of the main determinants of risk have set the grounds for the development and improvement of different esophageal protective strategies. More sensitive esophageal temperature monitoring, safer ablation parameters and catheters, and different energy sources appear to collectively reduce the risk of esophageal thermal injury. Adjunctive measures such as the prophylactic use of proton-pump inhibitors, as well as esophageal cooling or deviation devices, have emerged as complementary methods with variable but promising results. Nevertheless, as a multifactorial problem, no single esophageal protective measure has proven to be sufficiently effective to eliminate the risk, and further investigation is still warranted.Early screening in the patients at risk and prompt intervention in the cases of AEF are important risk modifiers and yield better outcomes. K E Y W O R D S atrial fibrillation, atrioesophageal fistula, catheter ablation, esophageal cooling, esophageal lesion, esophageal protection, esophageal thermal damage 1366 | ASSIS ET AL. SUPPORTING INFORMATIONAdditional supporting information may be found online in the Supporting Information section.How to cite this article: Assis FR, Shah R, Narasimhan B, et al.Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies.

Radiofrequency Pulmonary Vein Isolation without Esophageal Temperature Monitoring: Contact-Force Characteristics and Incidence of Esophageal Thermal Damage

“…Deeper and transmural esophageal lesions are more susceptible to progress into an AEF [ 5 ]. The incidences of endoscopically detected esophageal lesions (EDEL) often exceeded 10% [ 5 , 6 , 7 ] and were reported in up to 47% [ 8 ] in previous studies. The formation of esophageal thermal lesions depends on many factors and in radiofrequency (RF) ablation, particularly on the applied energy, ablation duration and contact force [ 6 ].…”

“…The incidences of endoscopically detected esophageal lesions (EDEL) often exceeded 10% [ 5 , 6 , 7 ] and were reported in up to 47% [ 8 ] in previous studies. The formation of esophageal thermal lesions depends on many factors and in radiofrequency (RF) ablation, particularly on the applied energy, ablation duration and contact force [ 6 ]. In contrast, these parameters alone or as combined contact force indices are also determinants for the creation of effective ablation lesions [ 9 , 10 , 11 ], which requires a careful risk-benefit balance regarding a successful ablation without compromising safety.…”

Atrial‐esophageal fistula as a complication of AF ablation: A tough one to swallow

“…In the present issue of Journal of Cardiovascular Electrophysiology , Assis et al 3 present a state‐of‐the‐art review of esophageal injury during CA for AF. While recounting the features, risk factors, management, and potential preventative strategies for AEF, the authors also underscore the gaps in knowledge that have thwarted the ability to eradicate this complication.…”

Estudo piloto, prospectivo e randomizado sobre o efeito do monitoramento da temperatura esofágica com termômetro multipolar na incidência de lesões esofágicas após ablação do átrio esquerdo para tratamento da fibrilação atrial

“…Outros fatores foram associados ao risco de lesão esofágica durante ablação de FA. São eles: anestesia geral; uso de tubo nasogástrico; ingestão de contraste baritado; aplicações com potência de RF maiores que 30 W, com duração maior que 20 -30 segundos e força de contato maior que 15 -20 gramas; uso de cateter não irrigado; aumento do átrio esquerdo; índice de massa corporal menor que 26 kg/m²; número de lesões de RF na parede posterior do átrio esquerdo; e temperatura esofágica máxima acima de 38,5°C 73 .…”

“…Porém, como sexo não é fator de risco para lesões esofágicas, não é esperado qualquer impacto nos resultados do estudo como consequência dessa diferença e, além disso, nenhum outro dado clínico foi preditor de qualquer desfecho no estudo. A taxa de recorrência de FA foi semelhante entre os grupos e em linha com as taxas encontradas na literatura 69,73,[94][95][96] Os riscos associados à sua participação neste estudo, não acrescentam em nada os riscos inerentes ao próprio procedimento, uma vez que é rotina nos procedimentos de ablação realizados no nosso serviço, a realização do procedimento sob anestesia geral, bem como a passagem de sondas orogástricas após a anestesia.…”