Relationship between the posterior atrial wall and the esophagus: esophageal position during atrial fibrillation ablation

Relationship between the posterior atrial wall and the esophagus: esophageal position and temperature measurement during atrial fibrillation ablation (AWESOME-AF). A randomized controlled trial

BACKGROUND

Pulmonary vein isolation (PVI) implies unavoidable ablation lesions to the left atrial posterior wall, which is closely related to the esophagus, leading to several potential complications. This study evaluates the usefulness of the esophageal fingerprint in avoiding temperature rises during paroxysmal atrial fibrillation (PAF) ablation.

METHODS

Isodistance maps of the atrio-esophageal relationship (esophageal fingerprint) were derived from the preprocedural computerized tomography. Patients were randomized (1:1) into two groups: (1) PRINT group, the PVI line was modified according to the esophageal fingerprint; (2) CONTROL group, standard PVI with operator blinded to the fingerprint. The primary endpoint was temperature rise detected by intraluminal esophageal temperature probe monitoring. Ablation settings were as specified on the Ablate BY-LAW study protocol.

RESULTS

Sixty consecutive patients referred for paroxysmal AF ablation were randomized (42 (70%) men, mean age 60 ± 11 years). Temperature rise (> 39.1 °C) occurred in 5 (16%) patients in the PRINT group vs. 17 (56%) in the CONTROL group (p < 0.01). Three AF recurrences were documented at a mean follow-up of 12 ± 3 months (one (3%) in the PRINT group and 2 (6.6%) in the CONTROL group, p = 0.4).

CONCLUSION

The esophageal fingerprint allows for a reliable identification of the esophageal position and its use for PVI line deployment results in less frequent esophageal temperature rises when compared to the standard approach. Further studies are needed to evaluate the impact of PVI line modification to avoid esophageal heating on long-term outcomes. The development of new imaging-derived tools could ultimately improve patient safety (NCT04394923).