Characteristics of Esophageal Injury in Ablation of Atrial Fibrillation Using a High-Power Short-Duration Setting

Abstract

Background - The mechanism of esophageal thermal injury (ETI; esophageal mucosal injury and periesophageal nerve injury leading to gastric hypomotility) remains unknown when using a high-power short-duration (HP-SD) setting. This study sought to evaluate the characteristics of esophageal injuries in atrial fibrillation (AF) ablation using a high-power short-duration (HP-SD) setting. Methods - After exclusion of 5 patients with their esophagus at the right portion of left atrium (LA) and 21 patients with additional ablations such as box isolation and/or low voltage ablation in LA posterior wall, 271 consecutive patients (62 ± 10 years, 56 women) who underwent pulmonary vein isolation (PVI) by radiofrequency catheter ablation were analyzed. In the 101 patients, a HP-SD setting at 45-50 W with an Ablation Index module® was used (HP-SD group). In the remaining 170 patients before introduction of the HP-SD setting, a conventional power setting of 20-30 W with contact force monitoring was used (Conventional group). We performed esophagogastroduodenoscopy after PVI in all patients and investigated the incidence and characteristics of ETI. Results - Although the incidence of ETI was significantly higher in the HP-SD group compared to the Conventional group (37% vs. 22%, P = 0.011), the prevalence of esophageal lesions did not differ between the groups (7% vs. 8%). Multivariate logistic regression analysis revealed that the use of the HP-SD setting (odds ratio: 6.09, P < 0.001), and the parameters that suggest anatomical proximity surrounding the esophagus, were independent predictors of ETI. However, the majority of ETI in the HP-SD group was gastric hypomotility, and the thermal injury was limited to the shallow layer of the periesophageal wall using the HP-SD setting. Conclusions - Although the use of the HP-SD setting was a strong predictor of ETI, it could avoid deeper thermal injuries that reach the esophageal mucosal layer.

Procedural efficacy and safety of standardized, Ablation Index guided fixed 50W high power short duration pulmonary vein isolation and substrate modification using the CLOSE protocol

“…While the overall incidence of EDEL was identical in the standard and HPSD ablation approach, lesion characteristics differed significantly, with most of the HPSD lesions consisting of small ulcerations or only superficial mucosal detachments that are poorly characterized in the currently used classification of EDEL 11 . These findings support the above mentioned biophysical considerations and are in line with previous publications of HPSD lesions 18 . In the present trial, all patients received post-procedural esophagoscopy and were followed up until the lesions resolved, or showed healing tendency.…”

Safety and Efficacy of High Power Shorter Duration Ablation Guided by Ablation Index or Lesion Size Index in Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis

“…There were no significant differences in procedural complications between the two groups (RR: 0.58; 95% CI: 0.20−1.69, I 2 = 0%, P =0.32) ( Figure 4 ). Esophageal lesions were evaluated by esophagogastroduodenoscopy in two trials [ 18 , 19 ]. There were no significant differences in esophageal lesions between the two groups (RR: 0.84; 95% CI: 0.43–1.61, I 2 = 0%, P =0.59) ( Figure 4 ).…”

“…No additional studies were added through manual search. us, 7 studies were finally selected in this meta-analysis [10][11][12][13][17][18][19].…”

“…ere is no consensus about the power and AI or LSI for HPSD; in our study, energy levels at or above 40 W are considered as high power. e target ablation lesion index was reached: LSI ≥ 4 or AI ≥ 350 in sites on the LA posterior wall and LSI ≥ 5 or AI ≥ 400 in others [10][11][12][13][17][18][19]. In the case of esophageal heating >38.5°or 39°, the AI target of the entire posterior ostium of that vein was lowered to ≥300 [17,18].…”

High‐power short‐duration ablation of atrial fibrillation: A contemporary review

“…Esophagogastroduodenoscopy after PVI in 271 patients demonstrated a higher incidence of gastric hypomotility in the HPSD group (45-50 W with an AI module) versus conventional ablation using 20-30 W (30% vs. 14%, p = .011). 55 The thermal injury pattern with HPSD ablation seems to be limited to the shallow periesophageal layer avoiding deep thermal injury reaching the esophageal mucosa.…”