Simplified Method for Esophagus Protection during Atrial Fibrillation Radiofrequency Catheter Ablation - Prospective Study of 704 Cases

Abstract

IntroductionAlthough rare, the atrioesophageal fistula is one of the most feared complications in radiofrequency catheter ablation of atrial fibrillation due to the high risk of mortality.ObjectiveThis is a prospective controlled study, performed during regular radiofrequency catheter ablation of atrial fibrillation, to test whether esophageal displacement by handling the transesophageal echocardiography transducer could be used for esophageal protection.MethodsSeven hundred and four patients (158 F/546M [22.4%/77.6%]; 52.8±14 [17-84] years old), with mean EF of 0.66±0.8 and drug-refractory atrial fibrillation were submitted to hybrid radiofrequency catheter ablation (conventional pulmonary vein isolation plus AF-Nests and background tachycardia ablation) with displacement of the esophagus as far as possible from the radiofrequency target by transesophageal echocardiography transducer handling. The esophageal luminal temperature was monitored without and with displacement in 25 patients.ResultsThe mean esophageal displacement was 4 to 9.1cm (5.9±0.8 cm). In 680 of the 704 patients (96.6%), it was enough to allow complete and safe radiofrequency delivery (30W/40ºC/irrigated catheter or 50W/60ºC/8 mm catheter) without esophagus overlapping. The mean esophageal luminal temperature changes with versus without esophageal displacement were 0.11±0.13ºC versus 1.1±0.4ºC respectively, P<0.01. The radiofrequency had to be halted in 68% of the patients without esophageal displacement because of esophageal luminal temperature increase. There was no incidence of atrioesophageal fistula suspected or confirmed. Only two superficial bleeding caused by transesophageal echocardiography transducer insertion were observed.ConclusionMechanical esophageal displacement by transesophageal echocardiography transducer during radiofrequency catheter ablation was able to prevent a rise in esophageal luminal temperature, helping to avoid esophageal thermal lesion. In most cases, the esophageal displacement was sufficient to allow safe radiofrequency application without esophagus overlapping, being a convenient alternative in reducing the risk of atrioesophageal fistula.

Distance between the left atrium and the vertebral body is predictive of esophageal movement in serial MR imaging

“…The mobility of the esophagus has been well described in previous studies, including an autopsy study which reported that the esophagus can move laterally between 2.7–5.5 cm by using the stylet probe extending to the gastro-esophageal (GE) junction[13]. Other studies have tried using this mobility to move the esophagus during ablation by moving the esophagus with a catheter or echo probe[14, 15]. Kobza et al[16] reported in a study of 18 patients that the esophagus moved more than 10 mm in 6 (33%) patients within 24 hrs.…”

A Strategy for Precise Treatment of Cardiac Malignant Neoplasms

“…Although there is no report thermal ablation for the treatment of cardiac malignant neoplasms up to this date, this technique has been proposed and tested for other heart-related anomalies. For instance, radiofrequency catheter ablation is a common treatment approach for atrial fibrillation1617. The major problem that faced surgeons in these procedures is that cardiac motility often led to unintended thermal damage to the proximal esophageal tissues.…”

Contact‐Force Catheters: Efficacy Versus Safety? Case Report of 2 Atrioesophageal Fistulae

“…Mateos et al . recently proposed a method for esophagus protection, which consisted of mechanical esophageal displacement using the TEE probe during ablation in order to remove the esophagus as far as possible from the ablation site . Also, power and duration of ablation on the posterior LA wall should be limited (targeting EGM signals attenuation and impedance drop rather than only focusing on FTI or CF) to prevent any esophageal damage.…”

“…Mateos et al recently proposed a method for esophagus protection, which consisted of mechanical esophageal displacement using the TEE probe during ablation in order to remove the esophagus as far as possible from the ablation site. 32 Also, power and duration of ablation on the posterior LA wall should be limited (targeting EGM signals attenuation and impedance drop rather than only focusing on FTI or CF) to prevent any esophageal damage. Concerning the use of proton pump inhibitors, there is a consensus for a shortterm use after AF ablation 33 despite low clinical evidence, since gastro-esophageal reflux (which is possibly majored by vagal fibers damage) may play a role by worsening mucosal injury after ablation, and these medications have a good safety profile.…”