Progression From Esophageal Thermal Asymptomatic Lesion to Perforation Complicating Atrial Fibrillation Ablation

Abstract

Postablation endoscopy seems to identify patients at high risk of esophageal perforating complications only occurring in patients with category 2 EDEL. One out of 10 postablation esophageal ulcers progressed to perforation, and no patient without esophageal thermal ulcers showed the occurrence of perforating esophageal complications.

Incidence of acute thermal esophageal injury after atrial fibrillation ablation guided by prespecified ablation index

“…EDEL have been identified in between 0% and up to 40% of patients after AF ablation depending on ablation energy, type of ablation catheter, use of catheter‐tip irrigation, use of temperature probes, and depending on the indication and timing of postprocedural endoscopy . Endoscopy is considered the gold standard for detecting thermal esophageal damage and category 2 EDEL are the endoscopic findings in patients with increased risk of perforating esophageal injury like atrioesophageal fistula.…”

“…Endoscopy is considered the gold standard for detecting thermal esophageal damage and category 2 EDEL are the endoscopic findings in patients with increased risk of perforating esophageal injury like atrioesophageal fistula. A recently published study found an incidence of atrioesopahgeal fistula and esophageal perforation of 0.6% in patients undergoing rigid postablation surveillance . Of note, esophageal thermal injury can be identified using endoscopy already during the ablation procedure and most EDEL heal off within 7 days after the initial thermal injury.…”

“…EE was performed by experienced operators (having performed over 1000 post AF–ablation endoscopies each) within 1 to 3 days after ablation to assess for the presence and extent of endoscopically detected esophageal lesions (EDEL). EDEL was defined as a typical endoscopical finding of the esophageal mucosa in an area neighboring the LA and was classified as either category 1 lesion (mild: erythema/erosion or small ulcers ≤5 mm diameter) or category 2 (severe) lesion (ulcer >5 mm diameter) as previously reported …”

“…All patients received proton pump inhibitors (PPI) (80 mg per day orally) for 6 weeks postprocedurally irrespective of endoscopy results. In case of any EDEL, endoscopy was repeated until confirmation of healing of the lesion as per institutional standard protocol . Patients with category 2 lesions received a liquid diet in addition to PPI until repeat endoscopy indicated remission of the lesion.…”

“…The incidence of perforating esophageal complications reported may be lower than the true incidence because of underdetection and underreporting. According to a worldwide survey and a registry study, the incidence of atrioesophageal fistula after AF ablation was below 0.2%, whereas a recently published study with rigid postablation endoscopy found an incidence of atrioesophageal fistula and esophageal perforation of up to 0.6% in patients …”