Comparative study of strategies to prevent esophageal and periesophageal injury during atrial fibrillation ablation

Barbara D. de Oliveira; H. T. T. Oyama; Carina Hardy; Sissy Lara de Melo; Cristiano Pisani; Muhieddine Omar Chokr; Conrado Balbo; Francisco Darrieux; Denise Hachul; Dalton Chaves; Everson L. Artifon; Idágene A. Cestari; Paulo Sakai; Maurício Scanavacca

doi:10.1111/jce.14417

February 28, 2020Journal of Cardiovascular Electrophysiology

Comparative study of strategies to prevent esophageal and periesophageal injury during atrial fibrillation ablation

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Why the study?

To compare the prevalence of esophageal and periesophageal thermal injury during RF AF ablation using 8 mm tip catheters across three different esophageal protection strategies.

Does continuous esophageal cooling compared to temperature monitoring or power limitation prevent esophageal injury during atrial fibrillation ablation?

Structured PICO

Does continuous esophageal cooling compared to temperature monitoring or power limitation prevent esophageal injury during atrial fibrillation ablation?

P

Population

45 consecutive patients with paroxysmal or persistent atrial fibrillation undergoing their first radiofrequency ablation procedure

I

Intervention

Group III: Radiofrequency application in the left atrium posterior wall with fixed power of 50 W for 20 seconds during continuous esophageal cooling

C

Comparator

Group I: No protection/monitoring, RF limited to 30 W for 20 seconds; Group II: RF up to 50 W for 20 seconds limited by esophageal temperature monitoring

O

Outcome

Prevalence of esophageal and periesophageal thermal injury assessed by esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS) after pulmonary vein isolationsafety

Continuous esophageal cooling during AF ablation allowed for higher RF power delivery but was associated with a higher incidence of esophageal and periesophageal injuries compared to power limitation or temperature monitoring.

Implication

Esophageal protection strategies in RF AF ablation warrant caution; Level 5 data leaves open optimal approach selection.

Abstract

OBJECTIVE: To compare the prevalence of esophageal and periesophageal thermal injury in patients undergoing radiofrequency (RF) atrial fibrillation (AF) ablation using 8 mm tip catheters during three different esophageal protection strategies. METHODS: Forty-five consecutive patients with paroxysmal or persistent AF underwent first ablation procedure, besides esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS) performed before and after the pulmonary vein (PV) isolation. Before the procedure, patients were randomly assigned to one of three esophageal lesion protection strategies: group I-without any protective or monitoring dispositive and limiting RF applications to 30 W for 20 seconds, in left atrium posterior wall (LAPW); group II-power and time of RF delivery, up to 50 W for 20 seconds at LAPW, limited by esophageal temperature monitoring; group III-applications of RF in LAPW with fixed power application of 50 W for 20 seconds during continuous esophageal cooling. RESULTS: Baseline characteristics of patients were similar in all groups. The four PVs were isolated in 14 (93.3%), 13 (86.7%), and 15 (100%) patients, respectively in groups I, II, and III. The mean RF power was significantly higher (P < .001) in the posterior side of PVs in group III. Post-AF ablation EGD and EUS revealed two esophageal wall ulcerations and two periesophageal mediastinal edemas only in the esophageal cooling group (P = .008). CONCLUSION: Esophageal cooling balloon strategy resulted in a higher RF power energy delivery when ablating at the LA posterior wall, using 8 mm nonirrigated tip catheters under temperature mode control. Despite that, patients presented a relatively low incidence of esophageal and periesophaeal injuries.