Odynophagia After Atrial Fibrillation Ablation

Abstract

A 74-year-old man with hypertrophic cardiomyopathy and paroxysmal atrial fibrillation, requiring multiple cardioversions for unstable rapid ventricular rates, was referred for electric isolation of his pulmonary veins. Wide-area circumferential ablations, combined with targeting of pulmonary vein potentials, were used to electrically isolate all 4 pulmonary veins.Before ablation, a transesophageal echocardiogram was performed after induction of general anesthesia. Ablation was performed with a closed, irrigated 4-mm tip (Chilli catheter, Boston Scientific, Natick, MA) with power levels of 30 W on the anterior left atrial wall and 20 W posteriorly. The temperature was limited to 40°C. An esophageal temperature probe was inserted for continuous monitoring but was difficult to advance to its proper location. Ablation was guided by a 3-dimensional representation of a contrast-enhanced cardiac computed tomography (CT) scan (Ensite Fusion, St Jude Medical, Minnetonka, MN). Intravenous heparin was administered to maintain the activated clotting time at 350 to 400 seconds.Six hours after the procedure, the patient resumed intravenous heparin per protocol. Soon after recovering from anesthesia, the patient had midsternal chest pain on swallowing and was unable to eat. A CT scan without contrast and a barium swallow study were obtained; they revealed a large intramural esophageal hematoma extending from the level of the pulmonary artery to the gastroesophageal junction, which compressed the esophageal lumen with obstruction proximal to the hematoma (Figure, left). There was no evidence of an atrioesophageal fistula. The patient was treated conservatively by halting his oral intake for 1 week and then slowly advancing his diet thereafter. His anticoagulation was also initially withheld, but then was resumed after the first week. Repeat CT scan and barium swallow study showed a resolving hematoma (Figure, right), and the patient fully recovered without recurrence of his atrial fibrillation or hematoma over the next several months. CommentaryEsophageal injury is a known complication of catheter ablation for atrial fibrillation, typically in the form of atrioesophageal fistulas. A case of fatal esophageal perforation from a transesophageal echocardiogram has been reported during the course of a catheter ablation. 1 Intramural esophageal hematomas are rare, and only 1 other case during catheter ablation has been reported in the literature, thought to be due to postoperative emesis in the setting of anticoagulation. 2 It is notable that serious esophageal injury during catheter ablation is extremely rare, despite various esophageal instrumentations with intubation, transesophageal echocardiogram, and esophageal temperature probe, coupled with extensive anticoagulation and risks of postoperative emesis. Nevertheless, esophageal injury or hematoma should be considered in the differential for postoperative nonpleuritic, retrosternal chest pain, particularly if accompanied by odynophagia, dysphagia, or hematemesis. 3 Furthermore, d...

Esophageal Hematoma After Atrial Fibrillation Ablation

“…[1][2][3] Transesophageal echo (TEE) is used commonly at the time of AF ablation procedures to exclude left atrial thrombus, define cardiac function, and in some centers to guide transseptal puncture. [4][5][6][7] Recently, Nguyen et al 8 reported a case of an esophageal hematoma as a complication after an AF ablation. This was attributed to the use of TEE during the procedure.…”

A Rare Cause for Acute Chest Pain in the Emergency Setting That Is Hard to Swallow

“…McCall and Thomas felt that the esophageal hematoma likely occurred due to postanesthesia emesis during the recovery period in the setting of anticoagulation and was unlikely caused by unintentional thermal injury [12]. The second case, presented by Nguyen and colleagues, concluded that the esophageal hematoma was a result of local trauma from the preprocedural transesophageal echocardiogram and was exacerbated by anticoagulation therapy [13]. Of note, the more serious and more common esophageal complication from cardiac ablation is atrioesophageal fistulas which is thought to be a direct result from thermal injury [14].…”

Examining the Risks and Benefits of Transesophageal Echocardiogram Imaging During Catheter Ablation for Atrial Fibrillation

“…Because this is a relatively recently reported complication, 16 despite many thousands of ablative outcome data in the literature, the true incidence and risk factors are unknown. In all cases, a TEE probe was inserted.…”

“…In all cases, a TEE probe was inserted. In the image by Nguyen et al, 16 a TEE was used at the start of the case to examine the left atrial appendage and then removed. In this case report, there are no comments provided regarding the difficulty with TEE insertion or the degree of probe manipulation.…”