Unexpected High Incidence of Esophageal Injury Following Pulmonary Vein Isolation Using Robotic Navigation

Tilz, Roland Richard; Chun, Julian; Metzner, Andreas; Burchard, Andre; Wißner, Erik; Koektuerk, Buelent; Konstantinidou, Melanie; Nuyens, Dieter; Potter, Tom De; Neven, Kars; Fuernkranz, Alexander; Ouyang, Feifan; Schmidt, Boris

doi:10.1111/j.1540-8167.2010.01742.x

Cited by 73 publications

(56 citation statements)

References 25 publications

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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%

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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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Section: Discussionmentioning

confidence: 99%

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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“…Theoretically, measurement of contact force should also prevent excessively high force and wall perforation. One previous study found a relatively high incidence of esophageal lesions after robotic AF ablation 16 . Even though a different robotic system was used and no contact force was measured the results of the study by Tilz et al may at least in part apply to the RCS used in our protocol.…”

Section: Discussionmentioning

confidence: 99%

Robotic Ablation of Atrial Fibrillation

Wutzler

Wölber

Haverkamp

et al. 2015

JoVE

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Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 -40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

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“…65,66 While insufficient contact force may result in an ineffective lesion, excessive contact force may result in complications such as heart wall perforation, steam pops, thrombus formation or oesophageal injury. 54,67,68 From the foregoing we can safely propose that catheter contact sensors might allow the creation of more uniform ablation lesions and increase the safety of RF delivery. Less experienced electrophysiologists might ensure less variability in manipulations and avoid excessive contact force.…”

Section: Radiofrequency-based Pulmonary Vein Isolation By Contact Monmentioning

confidence: 99%

“…The use of power limit to 20 W along the posterior wall in combination with an oesophageal temperature limit of 41 degrees Celsius significantly reduced the risk of oesophageal injury. 54 Considering that remote navigation may provide higher stability and subsequent more predictable RF lesions, 55 it seems reasonable to limit application time at a single spot to 20 seconds, concomitantly to set up maximum power at 30 W and decrease it to 15-20 W when ablating on the posterior wall.…”

Section: Pulmonary Vein Isolation By Remote Navigationmentioning

confidence: 99%

The Future of Pulmonary Vein Isolation – Single-shot Devices, Remote Navigation or Improving Conventional Radiofrequency Delivery by Contact Monitoring and Lesion Characterisation?

Filgueiras-Rama¹,

Merino

2013

Arrhythmia &Amp; Electrophysiology Review

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59Atrial fibrillation (AF) is the most common sustained arrhythmia in the clinical practice. 1 The prevalence of the arrhythmia is progressively increasing in developed countries and moreover, it is expected to affect up to 12 million people only in the US by 2050.2 Antiarrhythmic drugs continue to represent the first-line of treatment in AF patients, either to restore sinus rhythm or to prevent recurrences.3 However, current antiarrhythmic drugs usually do not achieve complete elimination of the arrhythmia burden and do not have a wide safety profile.4,5 Surgical elimination of certain arrhythmogenic substrates such as AF may represent a therapeutic option. 6 However, nowadays catheter-based ablation is the most common alternative to treat symptomatic patients when antiarrhythmic drugs fail. 3 The cornerstone radiofrequency (RF) catheter-based procedure pioneered by Haïssaguerre and colleagues, of ablating ectopic triggers that arise from the pulmonary veins (PV) in paroxysmal AF, 7 has progressively evolved to new technical developments aiming to simplify pulmonary vein isolation and increase safety. 8 To reach such objectives it is essential to increase catheter stability, achieve predictable lesion formation, reduce procedure and X-ray exposure time, and make simple and automatic either different steps or the whole procedure by using an anatomically-based ablation approach.The so-called single-shot devices for PV isolation, robotic catheter navigation and ablation, contact force-controlled catheter ablation and new realtime imaging of endocardial ablation are the main available technological breakthroughs intending to overcome some of the conventional manual-guided RF delivery shortcomings. The present review is focused on compiling current clinical data, potential advantages and shortcomings of these new ablation strategies for PV isolation. Single-shot DevicesSeveral single-shot devices have been developed in recent years to facilitate PV isolation, based on the encouraging aim of achieving complete isolation of the vein after one single application (single-shot) using circular catheters or balloon-like ablation devices. Among these devices, high-intensity focused ultrasound (HIFU) applied via a balloon catheter (BC) integrates a 9 megahertz (MHz) ultrasound crystal, which generates a ring of ultrasound energy at the base of the balloon. The third generation of HIFU-BC (12 French of outer diameter) is steerable through a pull wire mechanism integrated in the handle of the catheter and is available in balloon sizes (sonication ring diameter) of 24 millimetres (mm) (20 mm), 27 mm (25 mm) and 32 mm (30 mm), respectively (ProRhythm Inc, Ronkonkoma, New York, US). The catheter also has a lumen for insertion of a hexapolar spiral mapping catheter to record PV potentials.Beyond the circumferential lesion design instead of point-by-point ablation, the technology has the potential benefit of not being critically dependent on balloon-to-tissue contact. Initial reports using first and second generation HIFU balloon c...

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Unexpected High Incidence of Esophageal Injury Following Pulmonary Vein Isolation Using Robotic Navigation

Cited by 73 publications

References 25 publications

Effect of Atrial Fibrillation Ablation on Gastric Motility

Effect of Atrial Fibrillation Ablation on Gastric Motility

Robotic Ablation of Atrial Fibrillation

The Future of Pulmonary Vein Isolation – Single-shot Devices, Remote Navigation or Improving Conventional Radiofrequency Delivery by Contact Monitoring and Lesion Characterisation?

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