Temporary Esophageal Stenting Allows Healing of Esophageal Perforations Following Atrial Fibrillation Ablation Procedures

Kuwahara

2009

Circ J

Circ J 2009; 73: 221 -226 ince the discovery of the main role of pulmonary vein (PV) foci in the initiation of atrial fibrillation (AF), 1 radiofrequency (RF) catheter ablation, basically targeting the PVs, has been developed as an effective treatment for recurrent, drug-resistant AF. [2][3][4] Moreover, various types of ablation strategies, such as extensive circumferential PV isolation including the atrial tissue in the adjacent left atrium (LA), 5-12 linear ablation [13][14][15][16] and complex fractionated electrogram-guided ablation, [17][18][19][20][21] have been used to achieve a high efficacy for all types of AF. However, these extensive and complex ablation strategies are associated with a relatively higher incidence of complications, 22,23 compared with ablation of other arrhythmias. Moreover, devastating complications, such as atrio-esophageal fistulas, have been reported, 24,25 caused by extracardiac penetration of the ablative energy, which is 1 of the unsolved safety issues concerning AF ablation. Incidence of ComplicationsComplications of AF ablation include vascular access accidents, cardiac perforation/tamponade, thromboembolic events, PV stenosis, extracardiac injury such as to the esophagus, nerve damage, and atypical atrial flutter. In a worldwide survey of 8,745 patients who underwent AF ablation reported by Cappato et al, 22 major complications occurred in 524 patients (6%), including 4 periprocedural deaths (0.05%) from massive cerebral thromboembolism in 2, extrapericardial PV perforation in 1, and an unknown cause in 1 patient. The incidence of cardiac tamponade was 1.2%, and significant PV stenosis >50%, stroke and atypical atrial flutter of new onset occurred in 1.31%, 0.28% and 3.7% of the patients, respectively. A large, prospective, multicenter Italian investigation of ablation-related complications recently reported that in 1,011 AF patients complications occurred in 40 (3.9%): 4 (0.4%) had a stroke, 6 (0.6%) had cardiac tamponade, and 4 (0.4%) had significant PV stenosis >50%. 23 Among our 1,600 patients who underwent extensive encircling isolation of both of the ipsilateral PVs guided by fluoroscopy between 2003 and 2008, overall complications occurred in 23 patients (1.4%): 4 (0.25%) had stroke, 10 (0.6%) had cardiac tamponade, 3 (0.19%) had damage to the peri-esophageal vagal plexus and 6 (0.38%) had transient phrenic nerve (PN) injury; however, there were no cases of significant PV stenosis >50% or atrio-esophageal fistula.Predictors of complications in AF ablation have been reported by some investigators, such as coronary disease, 23 advanced age, 26,27 and female gender. 27 Spragg et al found that the complication rates were higher during the first 100 cases (9%) than during the subsequent 541 cases (4.3%), indicating the salutary effect of institutional or individual operator experience. 27 ThromboembolismThe incidence of thromboembolism caused by AF ablation is 0.28-2.8%. 9,13,22,23,28-32 A worldwide survey reported periprocedural deaths because of massive cerebral thr...

Section: Atrio-esophageal Fistulamentioning

confidence: 99%

Complications in the Catheter Ablation of Atrial Fibrillation

Kuwahara

2009

Circ J

Circ: Arrhythmia and Electrophysiology

“…[6][7][8][9][10] Alternatively, successful stenting of an esophageal perforation without communication with the atrium or the pericardium has been described. 11 Advantages from stenting arise from quick establishment of a barrier that minimizes air and solid material embolism without the risks of esophageal surgery. However, other reports describe fatal complications caused by air insufflation during upper gastrointestinal endoscopy or stent dislocation leading to insecurities of adapting this approach in patients with esophageal perforations.…”

Section: Clinical Perspective On P 681mentioning

confidence: 99%

“…However, only patients with isolated perforation without pericardial or atrial communication have been successfully treated with this approach. 11,25,26 In patients with esophagopericardial and esophagoatrial fistulas, fatal courses or the necessity of combining stenting with surgery have been described. 6,12,24,27 Besides this, there is growing experience with esophageal stenting in the context of iatrogenic perforations because of endoscopic procedures.…”

Section: Treatment Of Esophagopericardial Fistulasmentioning

confidence: 99%

Successful Nonsurgical Treatment of Esophagopericardial Fistulas After Atrial Fibrillation Catheter Ablation

Eitel¹,

Rolf²,

Zachäus³

et al. 2013

Background-Esophageal perforations are a rare but devastating complication of atrial fibrillation catheter ablation. Rapid treatment is crucial to avoid permanent disabilities and death. Surgical treatment is considered the treatment of choice. Alternatively, single case reports describe successful esophageal stenting, but others discourage this approach because of fatal consequences. Methods and Results-We present 3 patients who developed esophagopericardial fistulas after radiofrequency catheter ablation of atrial fibrillation. Diagnosis and management with pericardial drainage and esophageal stenting, as well as long-term follow-up are described. Esophagopericardial fistulas occurred 26, 9, and 18 days after the ablation procedure. Symptoms leading to admission were recurrence of atrial fibrillation (n=1), elective control endoscopy for thermal lesion (n=1), and pain with swallowing (n=1). Computed tomography revealed esophagopericardial fistulas with pericardial effusion in all patients, while contrast leakage and air in the left atrium could be excluded. Broad-spectrum antibiotics were initialized, and minimally invasive pericardial drainage and esophageal stenting were performed. Stent dislocation occurred in 2 patients and was resolved by repositioning and clipping of the proximal stent end. After 45, 22, and 28 days, respectively, fistulas appeared closed and stents were removed. During follow-up, no embolic or septic events occurred. However, 2 patients underwent dilation of symptomatic esophageal stenosis in the formerly stented region. Conclusions-An early minimally invasive approach consisting of pericardial drainage and esophageal stenting proved effective in treating patients with esophagopericardial fistulas. However, constant interdisciplinary communication and attention is needed to recognize and manage potential evolving complications promptly. (Circ Arrhythm Electrophysiol. 2013;6:675-681.)

Circ: Arrhythmia and Electrophysiology

“…If I-MRI is clinically used, its use may reduce the AF recurrence rate (currently 10% to 30%) after ablation procedures. [11][12][13][14] I-MRI may also reduce complications, such as unwanted heating of adjacent organs, perforation of the esophagus, 15 PV stenosis, or clot formation. 16 -18 In an earlier study, 19 an EAM mapping system for use inside an MR scanner was presented.…”

Section: Clinical Perspective On P 704mentioning

confidence: 99%

Electroanatomic Mapping and Radiofrequency Ablation of Porcine Left Atria and Atrioventricular Nodes Using Magnetic Resonance Catheter Tracking

Schmidt

Mallozzi

Thiagalingam

et al. 2009

Background-The MRI-compatible electrophysiology system previously used for MR-guided left ventricular electroanatomic mapping was enhanced with improved MR tracking, an MR-compatible radiofrequency ablation system and higher-resolution imaging sequences to enable mapping, ablation, and ablation monitoring in smaller cardiac structures. MR-tracked navigation was performed to the left atrium (LA) and atrioventricular (AV) node, followed by LA electroanatomic mapping and radiofrequency ablation of the pulmonary veins (PVs) and AV node. Methods and Results-One ventricular ablation, 7 PV ablations, 3 LA mappings, and 3 AV node ablations were conducted.Three MRI-compatible devices (ablation/mapping catheter, torqueable sheath, stimulation/pacing catheter) were used, each with 4 to 5 tracking microcoils. Transseptal puncture was performed under x-ray, with all other procedural steps performed in the MRI. Preacquired MRI roadmaps served for real-time catheter navigation. Simultaneous tracking of 3 devices was performed at 13 frames per second. LA mapping and PV radiofrequency ablation were performed using tracked ablation catheters and sheaths. Ablation points were registered and verified after ablation using 3D myocardial delayed enhancement and postmortem gross tissue examination. Complete LA electroanatomic mapping was achieved in 3 of 3 pigs, Right inferior PV circumferential ablation was achieved in 3 of 7 pigs, with incomplete isolation caused by limited catheter deflection. During AV node ablation, ventricular pacing was performed, 3 devices were simultaneously tracked, and intracardiac ECGs were displayed. 3D myocardial delayed enhancement visualized node injury 2 minutes after ablation. AV node block succeeded in 2 of 3 pigs, with 1 temporary block. Conclusions-LA mapping, PV radiofrequency ablation, and AV node ablation were demonstrated under MRI guidance.Intraprocedural 3D myocardial delayed enhancement assessed lesion positional accuracy and dimensions. Key Words: catheter ablation Ⅲ MRI Ⅲ electrophysiology mapping T he current state-of-the-art electrophysiology (EP) practice for treatment of atrial fibrillation (AF) uses registration of preacquired CT or MRI of the atrium and pulmonary veins (PVs) with an electroanatomic monitoring (EAM) system to guide diagnostic catheterization and radiofrequency ablation (RFA). 1,2 Recent results suggest that MRI may also have utility after left atrial RFA in the assessment of ablation lesions 3,4 and may prove useful in determining circumferential ablation gaps that can contribute to the recurrence of AF. 5 Clinical Perspective on p 704The growing use of preinterventional and postinterventional imaging suggests that interventional MRI (I-MRI) may provide additional benefits. I-MRI may permit more precise EAM mapping because I-MRI provides up-to-date anatomic scans and does not require coregistration with a scan performed hours or days previously. 5 I-MRI also offers direct visualization of ablation injuries, through methods such as T2-weighted imaging and 3D myocardial...