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Kistler PM, Sanders P, Amarena JV, Bain CR, Chia KM, Choo WK, Eslick AT, Hall T, Hopper IK, Kotschet E, Lim HS, Ling LH, Mahajan R, Marasco SF, McGuire MA, McLellan AJ, Pathak RK, Phillips KP, Prabhu S, Stiles MK, Sy RW, Thomas SP, Toy T, Watts TW, Weerasooriya R, Wilsmore BR, Wilson L, Kalman JM. 2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation. Heart Lung Circ 2024; 33:828-881. [PMID: 38702234 DOI: 10.1016/j.hlc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 05/06/2024]
Abstract
Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.
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Affiliation(s)
- Peter M Kistler
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia.
| | - Prash Sanders
- University of Adelaide, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Chris R Bain
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Karin M Chia
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Wai-Kah Choo
- Gold Coast University Hospital, Gold Coast, Qld, Australia; Royal Darwin Hospital, Darwin, NT, Australia
| | - Adam T Eslick
- University of Sydney, Sydney, NSW, Australia; The Canberra Hospital, Canberra, ACT, Australia
| | | | - Ingrid K Hopper
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Emily Kotschet
- Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia
| | - Han S Lim
- University of Melbourne, Melbourne, Vic, Australia; Austin Health, Melbourne, Vic, Australia; Northern Health, Melbourne, Vic, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia
| | - Rajiv Mahajan
- University of Adelaide, Adelaide, SA, Australia; Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Silvana F Marasco
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | | | - Alex J McLellan
- University of Melbourne, Melbourne, Vic, Australia; Royal Melbourne Hospital, Melbourne, Vic, Australia; St Vincent's Hospital, Melbourne, Vic, Australia
| | - Rajeev K Pathak
- Australian National University and Canberra Heart Rhythm, Canberra, ACT, Australia
| | - Karen P Phillips
- Brisbane AF Clinic, Greenslopes Private Hospital, Brisbane, Qld, Australia
| | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Martin K Stiles
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Raymond W Sy
- Royal Prince Alfred Hospital, Sydney, NSW, Australia; Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Stuart P Thomas
- University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia
| | - Tracey Toy
- The Alfred Hospital, Melbourne, Vic, Australia
| | - Troy W Watts
- Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Rukshen Weerasooriya
- Hollywood Private Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia
| | | | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Vic, Australia; Royal Melbourne Hospital, Melbourne, Vic, Australia
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2
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Shehadeh M, Wan EY, Biviano A, Mollazadeh R, Garan H, Yarmohammadi H. Esophageal injury, perforation, and fistula formation following atrial fibrillation ablation. J Interv Card Electrophysiol 2024; 67:409-424. [PMID: 38038816 DOI: 10.1007/s10840-023-01708-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Esophageal perforation and fistula formation are rare but serious complications following atrial fibrillation ablation. In this review article, we outline the incidence, pathophysiology, predictors, and preventative strategies of this dreaded complication. METHODS We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles reporting complications following atrial fibrillation ablation, including esophageal injury and fistula formation, were included for systematic review. RESULTS A total of 130 manuscripts were identified for the final review process. The overall incidence of esophageal injury following atrial fibrillation ablation was significantly higher with thermal ablation modalities (radiofrequency 5-40%, cryoballoon 3-25%, high-intensity focused ultrasound < 10%) as opposed to non-thermal ablation modalities (no cases reported to date). The incidence of esophageal perforation and fistula formation with the use of thermal ablation modalities is estimated to occur in less than 0.25% of all atrial fibrillation ablation procedures. The use of luminal esophageal temperature monitoring probe and mechanical esophageal deviation showed protective effect toward reducing the incidence of this complication. The prognosis is very poor for patients who develop atrioesophageal fistula, and the condition is rapidly fatal without surgical intervention. CONCLUSIONS Esophageal perforation and fistula formation following atrial fibrillation ablation are rare complications with poor prognosis. Various strategies have been proposed to protect the esophagus and reduce the incidence of this fearful complication. Pulsed field ablation is a promising new ablation technology that may be the future answer toward reducing the incidence of esophageal complications.
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Affiliation(s)
- Malik Shehadeh
- Division of Cardiology, Mount Sinai Heart Institute, Columbia University, Miami, FL, USA
| | - Elaine Y Wan
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Irving Medical Center, New York, NY, USA
| | - Angelo Biviano
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Irving Medical Center, New York, NY, USA
| | - Reza Mollazadeh
- Department of Cardiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Hasan Garan
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Irving Medical Center, New York, NY, USA
| | - Hirad Yarmohammadi
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Irving Medical Center, New York, NY, USA.
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Pereira R, Pisani C, Aiello V, Cestari I, Oyama H, Santos O, Otubo J, Moura D, Scanavacca M. Safety of an esophageal deviator for atrial fibrillation catheter ablation. Heart Rhythm O2 2023; 4:565-573. [PMID: 37744938 PMCID: PMC10513920 DOI: 10.1016/j.hroo.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Esophageal thermal injury is a complication of atrial fibrillation (AF) ablation, and it can be avoided by esophageal deviation during left atrial posterior wall radiofrequency catheter ablation. Objective This study aimed to evaluate the safety of a nitinol-based mechanical esophageal displacement device (MEDD) and its performance. Methods This preclinical safety study was conducted on 20 pigs, with 10 undergoing radiofrequency AF ablation using the MEDD and 10 serving as a control group under anticoagulation but without radiofrequency application. Esophageal traumatic injuries were classified from 0 to 4 and were grouped as absent (grade 0), minor (grade 1 or 2), moderate (grade 3), or major risk lesions (grade 4) by anatomopathological study. Grades 1 and 2 were considered acceptable. Fluoroscopy was used to measure displacement. Results Five (25%) pigs developed traumatic lesions, 4 with grade 1 and 1 with grade 2 (2-mm superficial ulcer). There was no difference in lesion occurrence between the radiofrequency and control groups (30% and 20%, respectively; P = .43). Under rightward displacement, the right edge moved 23.9 (interquartile range [IQR] 21.3-26.3) mm and the left edge moved 16.3 (IQR 13.8-18.4) mm (P < .001) from baseline. Under leftward displacement, the right edge moved 13.5 (IQR 10.9-15.3) mm and the left edge moved 16.5 (IQR 12.3-18.5) mm (P = .07). A perforation to the pharyngeal diverticulum occurred in 1 pig, related to an accidental extubation. Conclusion In pigs, the MEDD demonstrated safety in relation to esophageal tissue, and successful deviation. Esophageal traumatic injuries were acceptable, but improper manipulation led to pharyngeal lesion.
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Affiliation(s)
- Renner Pereira
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Cristiano Pisani
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Vera Aiello
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Idágene Cestari
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Helena Oyama
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Osmar Santos
- Department of Materials and Processes, Aeronautics Institute of Technology, São José dos Campos, Brazil
| | - Jorge Otubo
- Department of Materials and Processes, Aeronautics Institute of Technology, São José dos Campos, Brazil
| | - Daniel Moura
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Mauricio Scanavacca
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
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4
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Leung LWM, Akhtar Z, Hayat J, Gallagher MM. Protecting Against Collateral Damage to Non-cardiac Structures During Endocardial Ablation for Persistent Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e15. [PMID: 35990104 PMCID: PMC9376833 DOI: 10.15420/aer.2021.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/13/2022] [Indexed: 11/04/2022] Open
Abstract
Injury to structures adjacent to the heart, particularly oesophageal injury, accounts for a large proportion of fatal and life-altering complications of ablation for persistent AF. Avoiding these complications dictates many aspects of the way ablation is performed. Because avoidance involves limiting energy delivery in areas of interest, fear of extracardiac injury can impede the ability of the operator to perform an effective procedure. New techniques are becoming available that may permit the operator to circumvent this dilemma and deliver effective ablation with less risk to adjacent structures. The authors review all methods available to avoid injury to extracardiac structures to put these developments in context.
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Affiliation(s)
- Lisa WM Leung
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Zaki Akhtar
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Jamal Hayat
- Department of Gastroenterology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
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5
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Innovations in atrial fibrillation ablation. J Interv Card Electrophysiol 2022; 66:737-756. [PMID: 35411440 DOI: 10.1007/s10840-022-01215-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Catheter-based ablation to perform pulmonary vein isolation (PVI) has established itself as a mainstay in the rhythm control strategy of atrial fibrillation. This review article aims to provide an overview of recent advances in atrial fibrillation ablation technology. METHODS We reviewed the available literature and clinical trials of innovations in atrial fibrillation ablation technologies including ablation catheter designs, alternative energy sources, esophageal protection methods, electroanatomical mapping, and novel ablation targets. RESULTS Innovative radiofrequency (RF) catheter designs maximize energy delivery while avoiding overheating associated with conventional catheters. Single-shot balloon catheters in the form of cryoballoons, radiofrequency, and laser balloons have proven effective at producing pulmonary vein isolation and improving procedural efficiency and reproducibility. Pulsed field ablation (PFA) is a highly anticipated novel nonthermal energy source under development, which demonstrates selective ablation of the myocardium, producing durable lesions while also minimizing collateral damage. Innovative devices for esophageal protection including esophageal deviation and cooling devices have been developed to reduce esophageal complications. Improved electroanatomical mapping systems are being developed to help identify additional non-pulmonary triggers, which may benefit from ablation, especially with persistent atrial fibrillation. Lastly, the vein of Marshall alcohol ablation has been recently studied as an adjunct therapy for improving outcomes with catheter ablation for persistent atrial fibrillation. CONCLUSIONS Numerous advances have been made in the field of atrial fibrillation ablation in the past decade. While further long-term data is still needed for these novel technologies, they show potential to improve procedural efficacy and safety.
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Leung LWM, Akhtar Z, Sheppard MN, Louis-Auguste J, Hayat J, Gallagher MM. Preventing esophageal complications from atrial fibrillation ablation: A review. Heart Rhythm O2 2022; 2:651-664. [PMID: 34988511 PMCID: PMC8703125 DOI: 10.1016/j.hroo.2021.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Atrioesophageal fistula is a life-threatening complication of ablation treatment for atrial fibrillation. Methods to reduce the risk of esophageal injury have evolved over the last decade, and diagnosis of this complication remains difficult and therefore challenging to treat in a timely manner. Delayed diagnosis leads to treatment occurring in the context of a critically ill patient, contributing to the poor prognosis associated with this complication. The associated mortality risk can be as high as 70%. Recent important advances in preventative techniques are explored in this review. Preventative techniques used in current clinical practice are discussed, which include high-power short-duration ablation, esophageal temperature probe monitoring, cryotherapy and laser balloon technologies, and use of proton pump inhibitors. A lack of randomized clinical evidence for the effectiveness of these practical methods are found. Alternative methods of esophageal protection has emerged in recent years, including mechanical deviation of the esophagus and esophageal temperature control (esophageal cooling). Although these are fairly recent methods, we discuss the available evidence to date. Mechanical deviation of the esophagus is due to undergo its first randomized study. Recent randomized study on esophageal cooling has shown promise of its effectiveness in preventing thermal injuries. Lastly, novel ablation technology that may be the future of esophageal protection, pulsed field ablation, is discussed. The findings of this review suggest that more robust clinical evidence for esophageal protection methods is warranted to improve the safety of atrial fibrillation ablation.
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Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Zaki Akhtar
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Mary N Sheppard
- Cardiac Pathology Unit, St. George's University of London, London, United Kingdom
| | - John Louis-Auguste
- Department of Gastroenterology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Jamal Hayat
- Department of Gastroenterology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark M Gallagher
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
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7
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Leung LWM, Bajpai A, Zuberi Z, Li A, Norman M, Kaba RA, Akhtar Z, Evranos B, Gonna H, Harding I, Sohal M, Al-Subaie N, Louis-Auguste J, Hayat J, Gallagher MM. Randomized comparison of oesophageal protection with a temperature control device: results of the IMPACT study. Europace 2021; 23:205-215. [PMID: 33205201 PMCID: PMC7868886 DOI: 10.1093/europace/euaa276] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/13/2020] [Accepted: 08/18/2020] [Indexed: 02/04/2023] Open
Abstract
Aims Thermal injury to the oesophagus is an important cause of life-threatening complication after ablation for atrial fibrillation (AF). Thermal protection of the oesophageal lumen by infusing cold liquid reduces thermal injury to a limited extent. We tested the ability of a more powerful method of oesophageal temperature control to reduce the incidence of thermal injury. Methods and results A single-centre, prospective, double-blinded randomized trial was used to investigate the ability of the ensoETM device to protect the oesophagus from thermal injury. This device was compared in a 1:1 randomization with a control group of standard practice utilizing a single-point temperature probe. In the protected group, the device maintained the luminal temperature at 4°C during radiofrequency (RF) ablation for AF under general anaesthesia. Endoscopic examination was performed at 7 days post-ablation and oesophageal injury was scored. The patient and the endoscopist were blinded to the randomization. We recruited 188 patients, of whom 120 underwent endoscopy. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 vs. 2/60; P = 0.008), with a trend toward reduction in gastroparesis (6/60 vs. 2/60, P = 0.27). There was no difference between groups in the duration of RF or in the force applied (P value range= 0.2–0.9). Procedure duration and fluoroscopy duration were similar (P = 0.97, P = 0.91, respectively). Conclusion Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared with standard care. This method of oesophageal protection is safe and does not compromise the efficacy or efficiency of the ablation procedure.
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Affiliation(s)
- Lisa W M Leung
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Abhay Bajpai
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Zia Zuberi
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Anthony Li
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Mark Norman
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Riyaz A Kaba
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Zaki Akhtar
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Banu Evranos
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Hanney Gonna
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Idris Harding
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Manav Sohal
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Nawaf Al-Subaie
- Anesthetic Department, Anesthesia and Intensive Care Medicine, Kuwait Oil Company Ahmadi Hospital, Kuwait
| | - John Louis-Auguste
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, St. George's, London, UK
| | - Jamal Hayat
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, St. George's, London, UK
| | - Mark M Gallagher
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
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8
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Romero J, Patel K, Lakkireddy D, Alviz I, Velasco A, Rodriguez D, Karpenos J, Zhang XD, Natale A, Di Biase L. Epicardial access complications during electrophysiology procedures. J Cardiovasc Electrophysiol 2021; 32:1985-1994. [PMID: 33993576 DOI: 10.1111/jce.15101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/12/2021] [Accepted: 04/14/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Percutaneous epicardial access (EA) was first described more than two decades ago. Since its initial introduction, indications for its utilization in the field of electrophysiology have expanded dramatically. DISCUSSION Epicardial mapping and ablation in patients with ventricular tachycardia is routinely performed in tertiary electrophysiology centers around the world. Although limited by lack of randomized controlled trials, epicardial ablation for atrial fibrillation has been suggested as a conjunctive strategy in patients who have failed an initial endocardial catheter ablation attempt, and it is necessary for placement of some left atrial appendage occlusion devices as well. An accurate understanding of the cardiac anatomy is crucial to avoid complications such as inadvertent right ventricular puncture, injury to the coronary arteries, abdominal viscera, phrenic nerves, and esophagus during both EA and catheter ablation. CONCLUSION The aim of this review is to provide a comprehensive overview of the cardiac anatomy, technical aspects to optimize the safety of epicardial puncture, recognize and avoid potential complications.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kavisha Patel
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.,Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA.,Kansas City Heart Rhythm Institute at HCA Midwest Health, Overland Park, Kansas, USA
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute at HCA Midwest Health, Overland Park, Kansas, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel Rodriguez
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.,Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA.,Kansas City Heart Rhythm Institute at HCA Midwest Health, Overland Park, Kansas, USA
| | - Joseph Karpenos
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Xiao-Dong Zhang
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Houmsse M, Daoud EG. Protection of the esophagus during catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:2824-2829. [PMID: 33556991 DOI: 10.1111/jce.14934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 12/27/2022]
Abstract
Esophageal injury still occurs with high frequency during ablation of atrial fibrillation (AF). The purpose of this study is to provide a review of methods to protect the esophagus from injury during AF ablation. Despite advances in imaging and ablation, the potential risk of esophageal injury during AF ablation remains an important concern with a high occurrence of esophageal injury (≈15%). There have been numerous studies evaluating varied techniques for esophageal protection including active cooling and displacement of the esophagus. These techniques are reviewed in this manuscript as well as the role of esophageal protection in managing patients undergoing AF ablation procedure.
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Affiliation(s)
- Mahmoud Houmsse
- Division of Cardiology, Department of Medicine, Richard M. Ross Heart Hospital, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Division of Cardiology, Department of Medicine, Richard M. Ross Heart Hospital, The Ohio State University Medical Center, Columbus, Ohio, USA
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10
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Gianni C, Della Rocca DG, MacDonald BC, Mohanty S, Quintero Mayedo A, Sahore Salwan A, Trivedi C, Natale A. Prevention, diagnosis, and management of atrioesophageal fistula. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:640-645. [DOI: 10.1111/pace.13938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/29/2020] [Accepted: 05/06/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia InstituteSt. David's Medical Center Austin Texas United States
| | | | - Bryan C. MacDonald
- Texas Cardiac Arrhythmia InstituteSt. David's Medical Center Austin Texas United States
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia InstituteSt. David's Medical Center Austin Texas United States
- Dell Medical SchoolUniversity of Texas Austin Texas United States
| | - Angel Quintero Mayedo
- Texas Cardiac Arrhythmia InstituteSt. David's Medical Center Austin Texas United States
| | - Anu Sahore Salwan
- Texas Cardiac Arrhythmia InstituteSt. David's Medical Center Austin Texas United States
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia InstituteSt. David's Medical Center Austin Texas United States
| | - Andrea Natale
- Texas Cardiac Arrhythmia InstituteSt. David's Medical Center Austin Texas United States
- HCA National Medical Director of Cardiac Electrophysiology United States
- Interventional ElectrophysiologyScripps Clinic La Jolla California United States
- MetroHealth Medical CenterCase Western Reserve University School of Medicine Cleveland Ohio United States
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11
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Bhardwaj R, Koruth JS, Reddy VY. Current Status of Esophageal Protection. Card Electrophysiol Clin 2020; 12:247-257. [PMID: 32451108 DOI: 10.1016/j.ccep.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Catheter ablation of atrial fibrillation necessitates ablation on the posterior left atrium. The anterior esophagus touches the posterior left atrium, although its course is highly variable. The proximity of the left atrium to the esophagus confers risk of injury with radiofrequency and cryoablation owing to the heat transfer that occurs with thermal ablation. Early detection of esophageal temperature changes with probes may decrease the extent of damage to the esophagus, but evidence is mixed. Avoiding ablation on the esophagus with esophageal deviation and modifying ablation approaches may decrease the risk of injury.
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Affiliation(s)
- Rahul Bhardwaj
- Loma Linda University, 11234 Anderson Street, Room 4404, Loma Linda, CA 92354, USA
| | - Jacob S Koruth
- Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Suite 1030, New York, NY 10029, USA
| | - Vivek Y Reddy
- Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Suite 1030, New York, NY 10029, USA.
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12
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El Moheb MN, Refaat MM. Protecting the esophagus during catheter ablation: Evaluation of a novel vacuum suction-based retractor. J Cardiovasc Electrophysiol 2020; 31:1670-1671. [PMID: 32369252 DOI: 10.1111/jce.14530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Mohamad N El Moheb
- Division of Trauma Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Marwan M Refaat
- Division of Cardiology Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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13
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Houmsse M, Daoud EG, Joseph M, Weiss R, Essandoh M. Evaluation of a novel esophageal retractor utilizing vacuum suction and mechanical force for deviating the esophagus. J Cardiovasc Electrophysiol 2020; 31:1661-1669. [PMID: 32369243 DOI: 10.1111/jce.14529] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/27/2020] [Accepted: 04/06/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deviation of the esophagus prevents esophageal injury during atrial fibrillation ablation. OBJECTIVES This study is to evaluate, in animals, safety and effectiveness of a novel esophageal retractor that utilizes vacuum suction and mechanical force to deviate the esophagus. METHODS Following general anesthesia, a radiopaque ruler was placed behind the animal perpendicular to the esophagus. The esophageal retractor was inserted and esophagram was completed. Suction force (280-300 mm Hg) was applied to the distal aspect of the device that resulted in adherence of the esophagus in a circumferential manner. Then movement of a deflecting arm was used to deviate the esophagus. Four animal studies completed: (a) deviation distance and presence of trailing edge; (b) effect of 1 hour continuous suction and deviation upon esophageal cellular architecture; (c) impact on luminal esophageal temperature (LET) during high power ablation; and (d) compatibility of esophageal retractor with electroanatomic mapping system. RESULTS The distance of deviation to the right (26.6 ± 2.5 mm) was higher than to the left (18.7 ± 2.3 mm; P < .01). There was no esophageal trailing edge in 65/68 deviations (96%). With continuous suction for 1 hour, pathology revealed small, <1mm, circular area of hyperemia in the esophageal mucosa. During high power ablation, the maximum increase in LET was 0.2°C. Finally, there was no interference between the device and electro-anatomical mapping system. CONCLUSION In animal models, the esophageal retractor utilizing vacuum suction was successful at deviating the esophagus without significant trailing edge and with minor (1 mm) injury with prolonged continuous suction.
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Affiliation(s)
- Mahmoud Houmsse
- Division of Cardiolovascular Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Emile G Daoud
- Division of Cardiovascular Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew Joseph
- Davis Heart and Lung Research Institute, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raul Weiss
- Division of Cardiovascular Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael Essandoh
- Division of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio
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14
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Assis FR, Shah R, Narasimhan B, Ambadipudi S, Bhambhani H, Catanzaro JN, Calkins H, Tandri H. Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies. J Cardiovasc Electrophysiol 2020; 31:1364-1376. [PMID: 32323383 DOI: 10.1111/jce.14513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 01/19/2023]
Abstract
Catheter ablation has become an important element in the management of atrial fibrillation. Several technical advances allowed for better safety profiles and lower recurrence rates, leading to an increasing number of ablations worldwide. Despite that, major complications are still reported, and esophageal thermal injury remains a significant concern as atrioesophageal fistula (AEF) is often fatal. Recognition of the mechanisms involved in the process of esophageal lesion formation and the identification of the main determinants of risk have set the grounds for the development and improvement of different esophageal protective strategies. More sensitive esophageal temperature monitoring, safer ablation parameters and catheters, and different energy sources appear to collectively reduce the risk of esophageal thermal injury. Adjunctive measures such as the prophylactic use of proton-pump inhibitors, as well as esophageal cooling or deviation devices, have emerged as complementary methods with variable but promising results. Nevertheless, as a multifactorial problem, no single esophageal protective measure has proven to be sufficiently effective to eliminate the risk, and further investigation is still warranted. Early screening in the patients at risk and prompt intervention in the cases of AEF are important risk modifiers and yield better outcomes.
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Affiliation(s)
- Fabrizio R Assis
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rushil Shah
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bharat Narasimhan
- Department of Internal Medicine, Mount Sinai St. Lukes-Roosevelt, New York, New York
| | - Sravya Ambadipudi
- Department of Medicine, Division of Cardiology, Purdue University College of Pharmacy, West Lafayete, Indiana
| | - Hrithika Bhambhani
- Department of Biological Sciences, University of Southern California, Los Angeles, California
| | - John N Catanzaro
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harikrishna Tandri
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Wang L, Milman S, Ng T. Reply to Hysi and Fabre. Eur J Cardiothorac Surg 2020; 57:411. [PMID: 31168613 DOI: 10.1093/ejcts/ezz170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/09/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lily Wang
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Steven Milman
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Thomas Ng
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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16
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Marashly Q, Chelu MG. Ablation Approaches and Imaging Modalities to Lower Risk of Atrioesophageal Injury During Catheter Ablation for Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2020. [DOI: 10.1007/s12170-019-0635-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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17
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Weber HP, Schaur P, Sagerer-Gerhardt M. Use of Light Sensor and Focused Local Atrial Electrogram Recordings for the Monitoring of Thermal Injury to the Esophagus and Lungs During Laser Catheter Ablation of the Posterior Atrial Walls: Preclinical In Vitro Porcine and In Vivo Canine Experimental Studies. J Innov Card Rhythm Manag 2019; 10:3723-3731. [PMID: 32477739 PMCID: PMC7252753 DOI: 10.19102/icrm.2019.100703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/26/2018] [Indexed: 11/17/2022] Open
Abstract
During the catheter ablation of atrial fibrillation, thermal damages to the esophagus may have deleterious effects. The use of the SensoLas light sensor (SLLS; LasCor GmbH, Taufkirchen, Germany) and focused local atrial electrograms (LEGs) were tested as means for the assessment of thermal effects on the esophagus during laser catheter ablation. A total of 32 transcatheter in vitro and in vivo 1064-nm laser impacts were aimed at porcine (n = 16) and canine (n = 16) atrial endocardia. Photons scattering through the atrial and esophageal walls were captured by the SLLS, transmitted via an optical fiber to a diode, and converted to power displayed on a monitor. The laser was stopped automatically when the power measurement reached values beyond the preset upper limit. During in vivo laser applications, bipolar LEGs were recorded via the miniature electrodes of the laser catheter. Thermal damage to the esophagus was avoided when the power measurement was limited to 150 μW or less and the diode current was 60 μA or less, regardless of the energy setting used and regardless of the thicknesses of the atrial and esophageal walls. Laser energy applied for eight seconds to 13 seconds (average: 10 seconds) abolished the electrical potentials permanently. In conclusion, the control of laser light via the SLLS and of atrial potential amplitudes in the LEGs can prevent thermal esophageal and lung injury during laser catheter ablation.
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Affiliation(s)
- Helmut P. Weber
- Section of Research and Development, CCEP Centre Taufkirchen, Taufkirchen, Germany
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18
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Frankel DS. Mechanical Esophageal Deviation During Atrial Fibrillation Ablation: I Like to Move it, Move it. JACC Clin Electrophysiol 2018; 4:1031-1032. [PMID: 30139484 DOI: 10.1016/j.jacep.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/03/2018] [Indexed: 11/17/2022]
Affiliation(s)
- David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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19
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Bhardwaj R, Naniwadekar A, Whang W, Mittnacht AJ, Palaniswamy C, Koruth JS, Joshi K, Sofi A, Miller M, Choudry S, Dukkipati SR, Reddy VY. Esophageal Deviation During Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2018; 4:1020-1030. [DOI: 10.1016/j.jacep.2018.04.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/05/2018] [Accepted: 04/05/2018] [Indexed: 11/28/2022]
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20
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Romero J, Avendano R, Grushko M, Diaz JC, Du X, Gianni C, Natale A, Biase LD. Oesophageal Injury During AF Ablation: Techniques for Prevention. Arrhythm Electrophysiol Rev 2018; 7:24-31. [PMID: 29636969 PMCID: PMC5889811 DOI: 10.15420/aer.2017.46.2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/15/2018] [Indexed: 11/04/2022] Open
Abstract
Atrial fibrillation remains the most common arrhythmia worldwide, with pulmonary vein isolation (PVI) being an essential component in the treatment of this arrhythmia. In view of the close proximity of the oesophagus with the posterior wall of the left atrium, oesophageal injury prevention has become a major concern during PVI procedures. Oesophageal changes varying from erythema to fistulas have been reported, with atrio-oesophageal fistulas being the most feared as they are associated with major morbidity and mortality. This review article provides a detailed description of the risk factors associated with oesophageal injury during ablation, along with an overview of the currently available techniques to prevent oesophageal injury. We expect that this state of the art review will deliver the tools to help electrophysiologists prevent potential oesophageal injuries, as well as increase the focus on research areas in which evidence is lacking.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
| | - Ricardo Avendano
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
| | - Michael Grushko
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
| | - Juan Carlos Diaz
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
| | - Xianfeng Du
- Department of Cardiology, Ningbo First HospitalZhejiang Sheng, China
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St David’s Medical CenterAustin, USA
| | - Andrea Natale
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
- Texas Cardiac Arrhythmia Institute, St David’s Medical CenterAustin, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
- Texas Cardiac Arrhythmia Institute, St David’s Medical CenterAustin, USA
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21
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Marar D, Muthusamy V, Krishnan SC. Avoiding oesophageal injury during cardiac ablation: insights gained from mediastinal anatomy. Europace 2017; 20:466-471. [DOI: 10.1093/europace/eux024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/26/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Devan Marar
- The Department of Medicine, University of California at Irvine School of Medicine, Irvine, CA, USA
| | - Venkatraman Muthusamy
- The Department of Medicine, University of California at Irvine School of Medicine, Irvine, CA, USA
| | - Subramaniam C Krishnan
- The Department of Medicine, University of California at Irvine School of Medicine, Irvine, CA, USA
- Arrhythmia Services, Sutter Medical Group, 2800 L Street, 6th floor, Sacramento, CA 95819, USA
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22
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Mateos JCP, Mateos EIP, Peña TGS, Lobo TJ, Mateos JCP, Vargas RNA, Pachón CTC, Acosta JCZ. Simplified method for esophagus protection during radiofrequency catheter ablation of atrial fibrillation--prospective study of 704 cases. Braz J Cardiovasc Surg 2016; 30:139-47. [PMID: 26107444 PMCID: PMC4462958 DOI: 10.5935/1678-9741.20150009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/02/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction Although 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. Objective This 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. Methods Seven 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. Results The 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. Conclusion Mechanical 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.
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23
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Manouchehri N, Turner SR, Lockwood E, Sterns LD, Bédard EL. Esophageal perforation after radiofrequency ablation for atrial fibrillation. Asian Cardiovasc Thorac Ann 2014; 22:1116-8. [PMID: 24887888 DOI: 10.1177/0218492313504767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 69-year-old man underwent left atrial radiofrequency ablation for atrial fibrillation. After 10 minutes, the procedure was terminated due to pericardial tamponade secondary to perforation during mapping. Pericardiocentesis resolved the tamponade. Ablation was completed one week later, and the patient was discharged. Two days later, he presented with odynophagia. Computed tomography demonstrated small bilateral pleural effusions. He was judged to be stable and was discharged again, but returned 2 days later with chest pain. He was found to have esophageal perforation with empyema, which was repaired using a muscle patch and esophageal stenting, successfully treating the lesion with minimal morbidity.
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Affiliation(s)
- Namdar Manouchehri
- Department of Surgery, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada
| | - Simon R Turner
- Department of Surgery, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada
| | - Evan Lockwood
- Department of Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada
| | | | - Eric Lr Bédard
- Department of Surgery, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada
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24
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Liu E, Shehata M, Liu T, Amorn A, Cingolani E, Kannarkat V, Chugh SS, Wang X. Prevention of esophageal thermal injury during radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol 2012; 35:35-44. [PMID: 22717996 DOI: 10.1007/s10840-011-9655-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 12/16/2011] [Indexed: 11/30/2022]
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25
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KORUTH JACOBS, REDDY VIVEKY, MILLER MARCA, PATEL KALPESHK, COFFEY JAMESO, FISCHER AVI, GOMES JANTHONY, DUKKIPATI SRINIVAS, D’AVILA ANDRE, MITTNACHT ALEXANDER. Mechanical Esophageal Displacement During Catheter Ablation for Atrial Fibrillation. J Cardiovasc Electrophysiol 2011; 23:147-54. [DOI: 10.1111/j.1540-8167.2011.02162.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Kanjwal K, Yeasting R, Maloney JD, Baptista C, Elsamaloty H, Sheikh M, Elahinia M, Anderson W, Maloney JD. Retro-cardiac esophageal mobility and deflection to prevent thermal injury during atrial fibrillation ablation: an anatomic feasibility study. J Interv Card Electrophysiol 2010; 30:45-53. [DOI: 10.1007/s10840-010-9524-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 10/15/2010] [Indexed: 11/29/2022]
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27
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Macedo PG, Kapa S, Mears JA, Fratianni A, Asirvatham SJ. Correlative anatomy for the electrophysiologist: ablation for atrial fibrillation. Part II: regional anatomy of the atria and relevance to damage of adjacent structures during AF ablation. J Cardiovasc Electrophysiol 2010; 21:829-36. [PMID: 20158560 DOI: 10.1111/j.1540-8167.2010.01730.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ablation procedures for atrial fibrillation have become an established and increasingly used option for managing patients with symptomatic arrhythmia. The anatomic structures relevant to the pathogenesis of atrial fibrillation and ablation procedures are varied and include the pulmonary veins, other thoracic veins, the left atrial myocardium, and autonomic ganglia. Exact regional anatomic knowledge of these structures is essential to allow correlation with fluoroscopy and electrograms and, importantly, to avoid complications from damage of adjacent structures within the chest. We present this information as a series of 2 articles. In a prior issue, we have discussed the thoracic vein anatomy relevant to paroxysmal atrial fibrillation. In the present article, we focus on the atria themselves, the autonomic ganglia, and anatomic issues relevant for minimizing complications during atrial fibrillation ablation.
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Affiliation(s)
- Paula G Macedo
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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28
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Nakahara S, Ramirez RJ, Buch E, Michowitz Y, Vaseghi M, de Diego C, Boyle NG, Mahajan A, Shivkumar K. Intrapericardial balloon placement for prevention of collateral injury during catheter ablation of the left atrium in a porcine model. Heart Rhythm 2009; 7:81-7. [PMID: 19914143 DOI: 10.1016/j.hrthm.2009.09.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 09/14/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Catheter ablation of the left atrium (LA) is associated with potential collateral injury to surrounding structures, especially the esophagus and the right phrenic nerve (PN). OBJECTIVES The purpose of this study was to evaluate the efficacy and feasibility of intrapericardial balloon placement (IPBP) for the protection of collateral structures adjacent to the LA. METHODS Electroanatomic mapping was performed in porcine hearts using a transseptal endocardial approach in eight swine weighing 40-50 kg. An intrapericardial balloon was inflated in the oblique sinus, via percutaneous epicardial access, to displace the esophagus. Similarly, with the balloon positioned in the transverse sinus, IPBP was used to displace the right PN. Esophageal temperature was monitored while endocardial radiofrequency (RF) energy was delivered to the distal inferior PV. RESULTS In all cases, balloon placement was successful with no significant effects on hemodynamic function. Balloon inflation increased the distance between the esophagus and posterior LA by 12.3 +/- 4.0 mm. IPBP significantly attenuated increases in luminal esophageal temperature during endocardial RF application (6.1 +/- 2.4 degrees C vs. 1.2 +/- 1.1 degrees C; P<.0001). High-output endocardial pacing from the right superior pulmonary vein ostium stimulated PN activity. After displacement of the right PN with IPBP, PN capture was abolished in 30 (91%) of 33 sites. CONCLUSIONS These findings demonstrate that in an animal model, IPBP is feasible in the setting of catheter ablation procedures and has the potential to decrease the risk of collateral damage to the esophagus and PN during LA ablation.
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Affiliation(s)
- Shiro Nakahara
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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29
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HERWEG BENGT, ALI RIAS, KHAN NADIM, ILERCIL ARZU, BAROLD SS. Esophageal Contour Changes during Cryoablation of Atrial Fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:711-6. [DOI: 10.1111/j.1540-8159.2009.02356.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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Bahnson TD. Strategies to minimize the risk of esophageal injury during catheter ablation for atrial fibrillation. Pacing Clin Electrophysiol 2009; 32:248-60. [PMID: 19170916 DOI: 10.1111/j.1540-8159.2008.02210.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Esophageal injury is a rare but serious complication of catheter ablation for atrial fibrillation using radiofrequency energy. Recent studies have begun to identify variables that may determine heat transfer to and thermal injury of the esophagus. There is significant variability in the relationship between the esophagus and left atrium among individuals. New imaging techniques can facilitate assessment of esophagus position relative to intended ablation targets. Strategies to minimize the risk of esophageal injury include avoidance of ablation near the esophagus, titration of RF energy delivery at the posterior left atrial endocardium, and the use of alternative ablation methods.
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Affiliation(s)
- Tristram D Bahnson
- Division of Cardiology, Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke University Medical Center, Durham, North Carolina 27710, USA.
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31
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Chugh A, Rubenstein J, Good E, Ebinger M, Jongnarangsin K, Fortino J, Bogun F, Pelosi F, Oral H, Nostrant T, Morady F. Mechanical displacement of the esophagus in patients undergoing left atrial ablation of atrial fibrillation. Heart Rhythm 2009; 6:319-22. [DOI: 10.1016/j.hrthm.2008.12.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 12/03/2008] [Indexed: 11/28/2022]
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Intra-pericardial balloon retraction of the left atrium: a novel method to prevent esophageal injury during catheter ablation. Heart Rhythm 2008; 5:1473-5. [PMID: 18783994 DOI: 10.1016/j.hrthm.2008.06.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 06/25/2008] [Indexed: 11/23/2022]
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Lequerica JL, Berjano EJ, Herrero M, Hornero F. Reliability assessment of a cooled intraesophageal balloon to prevent thermal injury during RF cardiac ablation: an agar phantom study. J Cardiovasc Electrophysiol 2008; 19:1188-93. [PMID: 18554206 DOI: 10.1111/j.1540-8167.2008.01229.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED Cooled Balloon Prevents Thermal Injury During RF Ablation. INTRODUCTION The use of a cooled intraesophageal balloon has recently been proposed to minimize the risk of thermal injury in the esophagus during radiofrequency (RF) ablation of the left atrium. However, the capacity of this device to adequately protect the esophagus under different procedural and anatomical conditions remains unknown. METHODS AND RESULTS An agar phantom-based model was built that provided temperature readings not only on the cooled balloon (T(b)) but also at a hypothetical point between the esophageal lumen and myocardium at a distance of 2 mm (T(2-mm)). The RF ablations were conducted considering two anatomical factors (total distance between the electrode and balloon and flow rate around the electrode) and two procedural factors (angle and pressure between the electrode and agar surface). The results show that most of the parameters studied have no significant influence on the temperature measured on the cooled balloon (T(b)), the exception being a variation in the flow rate, which was found to influence the temperature. On the other hand, T(2-mm) was affected to a great extent by all the factors considered, the smallest influence being that of the contact pressure. The results also suggest that when an intraesophageal balloon is employed, the applied power is not a good predictor either of the temperature on the balloon or of the temperature measured at a distance 2 mm away. CONCLUSION The results suggest that a cooled intraesophageal balloon provides effective thermal protection of the esophageal lumen. However, under certain circumstances, the temperature reached at a distance 2 mm away could possibly put at risk the integrity of the inner layers of the esophagus.
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Affiliation(s)
- Juan L Lequerica
- Cardiac Research Laboratory, Instituto de Biomedicina, Spanish Council for Scientific Research, CSIC, Valencia, Spain
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34
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KENNEDY ROBERT, GOOD ERIC, ORAL HAKAN, HUETHER ELIZABETH, BOGUN FRANK, PELOSI FRANK, MORADY FRED, CHUGH AMAN. Temporal Stability of the Location of the Esophagus in Patients Undergoing a Repeat Left Atrial Ablation Procedure for Atrial Fibrillation or Flutter. J Cardiovasc Electrophysiol 2008; 19:351-5. [DOI: 10.1111/j.1540-8167.2007.01051.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pichardo S, Hynynen K. Circumferential lesion formation around the pulmonary veins in the left atrium with focused ultrasound using a 2D-array endoesophageal device: a numerical study. Phys Med Biol 2007; 52:4923-42. [PMID: 17671344 DOI: 10.1088/0031-9155/52/16/014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Atrial fibrillation (AF) is the most frequently sustained cardiac arrhythmia affecting humans. The electrical isolation by ablation of the pulmonary veins (PVs) in the left atrium (LA) of the heart has been proven as an effective cure of AF. The ablation consists mainly in the formation of a localized circumferential thermal coagulation of the cardiac tissue surrounding the PVs. In the present numerical study, the feasibility of producing the required circumferential lesion with an endoesophageal ultrasound probe is investigated. The probe operates at 1 MHz and consists of a 2D array with enough elements (114 x 20) to steer the acoustic field electronically in a volume comparable to the LA. Realistic anatomical conditions of the thorax were considered from the segmentation of histological images of the thorax. The cardiac muscle and the blood-filled cavities in the heart were identified and considered in the sound propagation and thermal models. The influence of different conditions of the thermal sinking in the LA chamber was also studied. The circumferential ablation of the PVs was achieved by the sum of individual lesions induced with the proposed device. Different scenarios of lesion formation were considered where ultrasound exposures (1, 2, 5 and 10 s) were combined with maximal peak temperatures (60, 70 and 80 degrees C). The results of this numerical study allowed identifying the limits and best conditions for controlled lesion formation in the LA using the proposed device. A controlled situation for the lesion formation surrounding the PVs was obtained when the targets were located within a distance from the device in the range of 26 +/- 7 mm. When combined with a maximal temperature of 70 degrees C and an exposure time between 5 and 10 s, this distance ensured preservation of the esophageal structures, controlled lesion formation and delivery of an acoustic intensity at the transducer surface that is compatible with existing materials. With a peak temperature of 70 degrees C, the device and setup presented here induced highly localized lesions with a lesion volume varying from 10 +/- 4 to 18 +/- 7 mm(3) for an ultrasound exposure between 5 and 10 s, respectively, while the intensity varied from 26 +/- 7 to 20 +/- 6 W cm(-2).
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Affiliation(s)
- Samuel Pichardo
- Imaging Research-Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room C713, Toronto, Ontario, Canada.
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