Background: Active esophageal cooling reduces the incidence of endoscopically identified severe esophageal lesions during radiofrequency (RF) catheter ablation of the left atrium for the treatment of atrial fibrillation. No atrioesophageal fistula (AEF) has been reported to date with active esophageal cooling, and only one pericardio-esophageal fistula has been reported; however, a formal analysis of the AEF rate with active esophageal cooling has not previously been performed. Methods: Atrial fibrillation ablation procedure volumes before and after adoption of active cooling using a dedicated esophageal cooling device (ensoETM, Attune Medical) were determined across 25 hospital systems with the highest total use of esophageal cooling during RF ablation. The number of AEFs occurring in equivalent time frames before and after adoption of cooling were then determined, and AEF rates were compared using generalized estimating equations robust to cluster correlation. Results: Throughout the 25 hospital systems, which included a total of 30 separate hospitals, 14,224 patients received active esophageal cooling during RF ablation, with the earliest adoption beginning in March 2019 and the most recent beginning in March 2022. In the time frames prior to adoption of active cooling, a total of 10,962 patients received primarily luminal esophageal temperature (LET) monitoring during their RF ablations. In this pre-adoption cohort a total of 16 AEFs occurred, for an AEF rate of 0.146%, in line with other published estimates of <0.1% to 0.25%. No AEFs were found in the cohort treated after adoption of active esophageal cooling, yielding an AEF rate of 0% (P<0.0001). Conclusion: Adoption of active esophageal cooling during RF ablation of the left atrium for the treatment of atrial fibrillation was associated with a significant reduction in AEF rate.
We enjoyed reading "Atrioesophageal fi stula: A rare complication of catheter ablation for atrial fi brillation," by Sarah Jones, PA-C, and Areeba Kara, MD, MS, in the June issue. We would like to commend the authors for this informative report, and add further background and data on the topic, particularly with regard to the area of prevention, because as the authors point out, atrioesophageal fi stula has a mortality up to 80%, and cases often present with chest pain and undifferentiated sepsis, making diagnosis diffi cult.Focusing on the prevention of esophageal injuries such as atrioesophageal fi stula is ideal. Growing data have supported the use of active esophageal cooling, as opposed to luminal esophageal temperature (LET) monitoring. For example, recent randomized studies have shown greater esophageal injury with LET monitoring than without. 1 On the other hand, the impact study showed a reduction of 83% in esophageal injury with active esophageal cooling compared with LET monitoring. 2 Rapid adoption of this practice has resulted in the accumulation of data showing a range of ancillary benefi ts as well. For example, use of active esophageal cooling has been shown to have a signifi cant reduction in fl uoroscopy requirements. 3 In addition, our group and others recently presented data showing reduced procedure times as well as improvement in long-term freedom from dysrhythmia with cooling, presumably due to the improved ability to perform point-topoint ablation without interruption from local overheating. 4 JAAPA
Introduction: The use of active esophageal cooling instead of traditional luminal esophageal temperature (LET) monitoring during left atrial ablation for the treatment of atrial fibrillation (AF) allows contiguous lesion placement with fewer partially-formed lesions and less catheter repositioning than required with LET monitoring. As a consequence, fewer electrical reconnections, and a lower rate of atrial arrhythmia recurrence, may result. We aimed to determine the association between esophageal protective strategy and recurrence of arrhythmia at one-year. Methods: We performed an IRB-approved review of an existing hospital registry to measure the association between recurrence of arrhythmia at one year follow-up and the use of active esophageal cooling as opposed to LET monitoring. Data were collected from ablations performed between 2017 and 2020. For each patient we recorded the type of esophageal temperature management, rhythm status at one-year follow-up, ejection fraction, and CHA 2 DS 2 -VASc score. Results: Data from a total of 247 ablations were collected. There were 95 ablations that occurred in the actively cooled group and 152 in the LET monitored group. Among those in the actively cooled group, the average CHA 2 DS 2 -VASc score was 1.8, and the average ejection fraction was 61%. In the LET monitored group, the average CHA 2 DS 2 -VASc score was 1.2 and the average ejection fraction was 61%. In the LET monitored group, there were 36 patients who had atrial arrhythmias at one-year follow-up, representing a 24% recurrence rate. In the actively cooled group, 11 patients had recurrence of arrhythmia at one-year, representing a 12% recurrence rate (P=0.02). Conclusions: Patients treated with active esophageal cooling during left atrial ablation had a significantly lower atrial arrhythmia recurrence rate at one-year follow-up when compared to patients provided with traditional LET monitoring during left atrial ablation procedures.
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