Calculated parameters of luminal esophageal temperatures predict esophageal injury following conventional and high‐power short‐duration radiofrequency pulmonary vein isolation

Abstract

Background Luminal esophageal temperature (LET) monitoring is not associated with reduced esophageal injury following pulmonary vein isolation (PVI). Objective Detailed analysis of (the temporal and spatial gradients of) LET measurements may better predict the risk for esophageal injury. Methods Between January 2020 and December 2021, LET maxima, duration of LET rise above baseline, and area under the LET curve (AUC) were calculated offline and correlated with (endoscopy and endoscopic ultrasound detected) esophageal injury (i.e., mucosal esophageal lesions [ELs], periesophageal edema, and gastric motility disorders) following PVI using moderate‐power moderate‐duration (MPMD [25–30 W/25–30s]) and high‐power short‐duration (HPSD [50 W/13s]) radiofrequency (RF) settings. Results 63 patients (69 ± 9 years old, 32 male, 51 MPMD and 12 HPSD) were studied. The esophageal injury was frequent (40% in both groups), mucosal ELs were more common with MPMD, and edema was frequently observed following HPSD. RF‐duration, total RF‐energy at the left atrial (LA) posterior wall, and distance between LA and esophagus were not different between patients with/without esophageal injury. In contrast, to LET and LET duration above baseline, AUC was the best predictor and significantly increased in patients with esophageal injury (3422 vs. 2444 K.s). Conclusion For both ablation strategies, AUC of the LET curves best predicted esophageal injury. HPSD is associated with similar rates of esophageal injury when (mostly subclinical) periesophageal alterations (that are of unclear clinical relevance) are included. Whether integration of these calculated LET parameters is useful to prevent esophageal injury remains to be seen.

Asymptomatic esophageal perforation following high-power short-duration pulmonary vein isolation—A case of conservative cure

“…In a previous study, periesophageal edema but no esophageal lesions were seen with HPSD ablation. 12 In contrast, the same energy protocol resulted in esophageal perforation in the reported case. Whether periesophageal edema plays a role in progression to perforation/fistula or is just an unsuspicious thermic side effect not reaching the mucosa is not well understood.…”

“…In a previous study, periesophageal edema but no ELs were seen with HPSD ablation. 12 In contrast, the same energy protocol resulted in esophageal perforation in the reported case.…”

“…The distance of the ablation lesions to the esophagus has also not shown to be a reliable indicator of safety. 12 Only routine endoscopic surveillance following PVI detected this major complication, and as reported in another case 13 , closure of the perforation site by endoscopic clips, in analogy to the albeit different pathophysiological mechanism of perforation by esophageal instrumentation, was sufficient for the healing.…”

“…The distance of the ablation lesions to the esophagus has also not shown to be a reliable indicator of safety. 12 …”

“…Unfortunately, indicators for esophageal injury are not yet defined. Perhaps our recently reported tool of the calculated area-under-the-curve (AUC) of LET 12 (considering the temporal and spatial components in addition to temperature maximum) may be an initial step to limit the need for endoscopic workup.…”