Procedural time reduction associated with active esophageal cooling during pulmonary vein isolation

Abstract

Background Active esophageal cooling is increasingly utilized as an alternative to luminal esophageal temperature (LET) monitoring for protection against thermal injury during pulmonary vein isolation (PVI) when treating atrial fibrillation (AF). Published data demonstrate the efficacy of active cooling in reducing thermal injury, but impacts on procedural efficiency are not as well characterized. LET monitoring compels pauses in ablation due to heat stacking and temperature overheating alarms that in turn delay progress of the PVI procedure, whereas active esophageal cooling allows avoidance of this phenomenon. Our objective was to measure the change in PVI procedure duration after implementation of active esophageal cooling as a protective measure against esophageal injury. Methods We performed a retrospective review under IRB approval of patients with AF undergoing PVI between January 2018 and February 2020. For each patient, we recorded age, gender, and total procedure time. We then compared procedure times before and after the implementation of active esophageal cooling as a replacement for LET monitoring. Results A total of 373 patients received PVI over the study period. LET monitoring using a multi-sensor probe was performed in 198 patients, and active esophageal cooling using a dedicated device was performed in 175 patients. Patient characteristics did not significantly differ between groups (mean age of 67 years, and gender 37.4% female). Mean procedure time was 146 ± 51 min in the LET-monitored patients, and 110 ± 39 min in the actively cooled patients, representing a reduction of 36 min, or 24.7% of total procedure time (p < .001). Median procedure time was 141 [IQR 104 to 174] min in the LET-monitored patients and 100 [IQR 84 to 122] min in the actively cooled patients, for a reduction of 41 min, or 29.1% of total procedure time (p < .001). Conclusions Implementation of active esophageal cooling for protection against esophageal injury during PVI was associated with a significantly large reduction in procedure duration.

Multicenter analysis of atrioesophageal fistula rates before and after adoption of active esophageal cooling during atrial fibrillation ablation

“…[21][22][23] Active esophageal cooling using a dedicated esophageal cooling device is a newer technique that has shown benefits in preclinical studies, mathematical modeling, and clinical studies. [24][25][26][27][28][29][30][31][32][33][34] An international multicenter randomized controlled trial is currently underway (NCT04577859), but this study relies on the surrogate endpoint of endoscopically detected esophageal lesion (EDEL) reduction. Because an event rate of <1% requires an extremely large sample size, no study to date has evaluated the effectiveness of any strategy in reducing AEFs.…”

Assessment of Esophageal Shifts during Catheter Ablation of Atrial Fibrillation Using Intracardiac Ultrasound Integrated with 3-Dimensional Electroanatomical Mapping System

“…Among the tools aiming to increase safety of RFCA regarding esophageal injuries, an active cooling tool (ensoETM, Attune Medical, Chicago, IL, USA) has been tested in single center and multicenter trials showing better safety and outcomes, and shorter duration procedure over a control group, with the limitations of requiring general anesthesia [22][23][24][25].…”

How to ablate the septo-pulmonary bundle: a case-based review of percutaneous ablation strategies to achieve roof line block

“…Different methods have been proposed for this purpose which broadly may be considered ‘reactive’ (apply in response to an elevated oesophageal temperature) or ‘proactive’ cooling (pre-emptively cool prior to any risk of thermal injury). 35 Reduced procedure time, 36 fluoroscopy, 37 and overall cost 38 and no reduction in ablation efficacy, efficiency, and safety 39 were some of the benefits highlighted for dedicated active cooling devices. In turn, a recent systematic review and meta-analysis found that oesophageal cooling did not reduce the overall risk of any oesophageal injury compared to control.…”