Factors Associated With Periesophageal Vagal Nerve Injury After Pulmonary Vein Antrum Isolation

Abstract

BackgroundPeriesophageal vagal nerve injury is recognized as a rare complication in atrial fibrillation ablation procedures. We investigated the factors associated with the occurrence of symptomatic periesophageal vagal nerve injury after pulmonary vein antrum isolation.Methods and ResultsOverall, 535 consecutive patients who underwent sole pulmonary vein antrum isolation were included. Point‐by‐point radiofrequency applications were applied using irrigated‐tip catheters under minimal sedation without esophageal temperature monitoring. In the initial 165 patients, the ablation settings for the posterior left atrium were a maximum energy of 25 to 30 W and a duration of 30 seconds. In the subsequent 370 patients, the power was additionally limited to 20 to 25 W at specific parts of the posterior left atrium where the ablation line transversed the esophagus. Symptomatic gastric hypomotility was found in 13 patients, and all were observed during the initial period (7.9%). No other collateral damage was observed. Logistic regression analysis revealed that the body mass index was the only independent predictor for identifying patients with gastric hypomotility (odds ratio 0.770; 95% confidence interval 0.643 to 0.922; P=0.0045) during the initial period. The prevalence of gastric hypomotility was significantly higher in the initial study period than subsequently (0 of 370, 0%; P<0.0001). All except for 1 patient recovered completely with conservative treatment within 4 months after the procedure.ConclusionsPeriesophageal vagal nerve injury is more common collateral damage than direct esophageal injury in pulmonary vein antrum isolation procedures. Titrating the radiofrequency energy at specific areas where the ablation line transverses the esophagus and taking account of the body mass index might reduce occurrences not only of direct esophageal damage but also of periesophageal vagal nerve injury in pulmonary vein antrum isolation procedures.

Impact of esophageal temperature monitoring guided atrial fibrillation ablation on preventing asymptomatic excessive transmural injury

“…Most recently, we demonstrated that AF ablation with a lower-energy setting of 20 W strictly controlled by esophageal temperature monitoring (ETM) at 39 °C could reduce the esophageal injury even in patients with a BMI<24.9 kg/m 2 [11] . As for the incidence of peri-ENI, Miyazaki et al reported that BMI was the only independent predictor for identifying patients who would develop peri-ENI during RF applications to the LA posterior wall with a relatively higher setting of 25–30 W and a duration of 30 s (OR=0.77; 95% CI=0.64–0.92; p =0.0045) [12] . However, data comparing the incidence of ETI (including esophageal injury and peri-ENI) following AF ablation with and without ETM are still lacking.…”

Vagal schwannomas of the head and neck: A comprehensive review and a novel approach to preserving vocal cord innervation and function

“…Intraoperative cardiac effects of vagal stimulation, namely bradycardia, have been reported during vagal schwannoma resection, although no case reports described lasting cardiac complications . Vagus nerve injury has been reported following cardiac procedures such as radiofrequency catheter ablation and pulmonary vein antrum isolation . Ablation has the potential to injure the vagus nerve at the level of the esophagus, causing dysphagia, heart burn, gastrointestinal reflux disease, nausea, bloating, early satiety, weight loss, constipation, diarrhea, and decreased gastric motility .…”

“…Some reports suggest that these symptoms tend to resolve within 3‐6 months of the ablation procedure . Instances of periesophageal nerve injury have been associated with pulmonary vein atrium isolation procedures . In these cases, complications include gastric hypomotility, which tends to resolve over time …”

“…Instances of periesophageal nerve injury have been associated with pulmonary vein atrium isolation procedures . In these cases, complications include gastric hypomotility, which tends to resolve over time …”

Innovations in Clinical Cardiac Electrophysiology: Challenges and Upcoming Solutions in 2018 and Beyond

“…Additionally, the development of upper gastrointestinal motility complications from injury to the vagus nerve and its branches has been described. 55,56 Thrombus formation. Coagulation and tissue necrosisinduced thermal energy in RF is associated with a risk of thrombus formation.…”