Incidence of oesophageal wall injury post-pulmonary vein antrum isolation for treatment of patients with atrial fibrillation

Schmidt, Martin; Nölker, Georg; Marschang, Harald; Gutleben, Klaus; Schibgilla, Volker; Rittger, Harald; Sinha, Anil M.; Ritscher, Guido; Dirk, Mayer; Brachmann, Johannes; Marrouche, Nassir F.

doi:10.1093/europace/eun001

Cited by 149 publications

(118 citation statements)

References 26 publications

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“…The absence of mucosal changes in the present study is possibly due to a different ablation strategy and the use of conscious sedation rather than general anesthesia or deep sedation. Schmidt et al 11 reported esophageal wall changes in 47% of their patients using either an 8-mm solid-tip ablation catheter or a 3.5-mm tip open irrigated catheter with a maximum power setting of 50 W. This high power, compared with our study, may lead to deeper ablation lesions affecting also the esophageal mucosa. Mediastinal changes were not investigated in that study.…”

Section: Zellerhoff Et Al Esophageal and Mediastinal Changes After Pvimentioning

confidence: 41%

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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Section: Zellerhoff Et Al Esophageal and Mediastinal Changes After Pvimentioning

confidence: 41%

Damage to the Esophagus After Atrial Fibrillation Ablation

Zellerhoff¹,

Ullerich²,

Lenze³

et al. 2010

Circ: Arrhythmia and Electrophysiology

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“…Some of the well-identified UGI system complications, including atrioesophageal fistulae, esophageal ulcerations, gastroesophageal reflux, acute pyloric spasm, and gastric hypomotility, are at least partially a consequence of VN injury. [3][4][5][6][7][8][9][10][11] Because the consequences of UGI injury can be catastrophic, the importance of understanding the effect of AF ablation on VN injury cannot be overstated.…”

Section: Discussionmentioning

confidence: 99%

“…Some of the reported UGI complications resulting from AF ablation include atrioesophageal fistulae, esophageal mucosal ulcerations with or without bleeding, gastroesophageal reflux, pyloric spasm, and gastric hypomotility. [3][4][5][6][7][8][9][10][11] The exact mechanism of these injuries is not known; however, injury to the vagus nerve (VN) and its components are proposed to be one of the major players in many of these complications. 5,10 The VN because of its close proximity to the posterior wall of the LA is susceptible to the thermal injury from RFA.…”

mentioning

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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“…Therefore, it is possible that microbubble formation is not a consistent marker of tissue overheating (68). Microbubble formation may even have the same problem as luminal temperature monitoring by a latency time too long to stop energy delivery and prevent EU, especially when showers of microbubbles occur (28,66). In contrast to another study published, we did not show any increased risk of general anesthesia versus deep sedation (2.7% vs. 2.2%) (61).…”

Section: Identification Of a High-risk Population For Esophageal Injucontrasting

confidence: 71%

“…In addition, power does not correlate with esophagus temperature, and overheating even occurs when the ablation site is quite distant (31). The additional usage of intracardiac echocardiography (ICE) gives divergent study results (28,63,66). Cummings et al (63) reported good correlation of microbubble formation and esophageal temperature increase.…”

Section: Identification Of a High-risk Population For Esophageal Injumentioning

confidence: 99%

New aspects of ablation treatment for atrial fibrillation

Bencsik¹

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Incidence of oesophageal wall injury post-pulmonary vein antrum isolation for treatment of patients with atrial fibrillation

Abstract: A significant number of patients experienced oesophageal wall injury post PVAI. Initiating PPIs in this group of patients might facilitate recovery of oesophageal wall injuries caused by radio-frequency energy delivery.

Cited by 149 publications

References 26 publications

Damage to the Esophagus After Atrial Fibrillation Ablation

Damage to the Esophagus After Atrial Fibrillation Ablation

Effect of Atrial Fibrillation Ablation on Gastric Motility

New aspects of ablation treatment for atrial fibrillation

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