September 13, 2011Journal of Cardiovascular Electrophysiology104 citations
View Full PaperMechanical Esophageal Displacement During Catheter Ablation for Atrial Fibrillation
Key Result
Mechanical esophageal deviation during atrial fibrillation ablation was feasible, with 95% of patients showing no esophageal ulceration from thermal injury on post-procedural endoscopy.
Study Design
Type
Cohort (n=20)
Structured PICO
Does mechanical esophageal deviation prevent thermal injury in patients undergoing catheter ablation for atrial fibrillation?
P
Population
20 consecutive patients undergoing radiofrequency or laser balloon ablation of atrial fibrillation under general anesthesia.
E
Exposure
Mechanical esophageal deviation using an endotracheal stylet placed within a thoracic chest tube, after barium instillation
O
Outcome
Feasibility and safety of esophageal displacement (measured by deviation distance, luminal esophageal temperature, and upper GI endoscopy prior to discharge)safety
Mechanical esophageal deviation during AF ablation is feasible and prevents severe thermal injury, though minor instrumentation trauma is frequent.
Abstract
OBJECTIVE: To determine the feasibility and safety of esophageal displacement during atrial fibrillation (AF) ablation, to prevent thermal injury. BACKGROUND: Patients undergoing AF ablation are at risk of esophageal thermal injury, which ranges from superficial ulceration, to gastroparesis, to the rare but catastrophic atrioesophageal fistula. A common approach to avoid damage is luminal esophageal temperature (LET) monitoring; however, (1) temperature rises mandate interruptions in energy delivery that interrupt workflow and potentially decrease procedural efficacy, and (2) esophageal fistulas have been reported even with LET monitoring. METHODS: A cohort of 20 consecutive patients undergoing radiofrequency (RF) (16 patients) or laser balloon (4 patients) ablation of AF under general anesthesia. After barium instillation, the esophagus was deviated using an endotracheal stylet placed within a thoracic chest tube. LET monitoring was used during catheter ablation. Upper GI endoscopy was performed prior to discharge. RESULTS: At the pulmonary vein level, leftward deviation measured 2.8 ± 1.6 cm (range: 0.4-5.7) and rightward deviation 2.8 ± 1.8 cm (range: 0.5-4.9). The temperature rose to >38.5 °C in 3/20 (15%) patients. In these 3 patients, there was an average of 2 applications/patient that recorded temperatures >38.5 °C. No patient had a temperature rise > 40 °C. Endoscopy revealed no esophageal ulceration from thermal injury in 18/19 (95%) patients; the sole patient with a thermally mediated ulceration had an unusual esophageal diverticulum fully across the posterior left atrium. Twelve patients (63%) exhibited trauma related to instrumentation with no clinical sequelae. CONCLUSIONS: Mechanical esophageal deviation is feasible and allows for uninterrupted energy delivery along the posterior wall during catheter ablation of AF.