Clinical investigation of esophageal injury from cryoballoon ablation of persistent atrial fibrillation

Abstract

Background The cryoballoon (CB) can be utilized for extra pulmonary vein (PV) ablation such as for a left atrial (LA) posterior wall (LAPW) isolation. However, scrutiny of the esophageal injuries during the LAPW isolation has never been performed. We sought to thoroughly investigate the esophageal lesions (ELs) and gastric hypomotility (GH) caused by an LAPW isolation using a CB. Methods A total of 101 persistent atrial fibrillation patients who underwent an LAPW isolation using a CB were enrolled. The CB was applied on the roof and bottom area of the LAPW after a PV isolation. The luminal esophageal temperature (LET) was monitored by a thermistor probe during the CB applications. When the LET reached 15°C, the freezing application was prematurely interrupted. Esophagogastroscopy was performed on the next day following the ablation. Results All PVs were successfully isolated in all patients. A successful LAPW isolation solely with CB ablation was performed in 72 (71.3%) patients. Cryofreezing applications were prematurely interrupted due to low LETs in 49 (48.5%) patients predominantly during the LA bottom line ablation. ELs and GH were observed in 11 (10.9%) and 16 patients (15.8%), respectively. The nadir LET tended to be lower in patients with ELs and GH than in those without (ELs: 14.8 ± 4.5°C vs 17.4 ± 6.0°C, P = 0.17; GH: 15.5 ± 4.5°C vs 17.5 ± 6.1°C, P = 0.23, respectively). Conclusions Esophageal complications such as ELs and GH occur during the LAPW isolation with a CB. There was no reliable predictor of those adverse events.

Clinical investigation of the durability of the lesions created by left atrial linear ablation with a cryoballoon

“…Although the PVI is a standard established therapeutic strategy in AF ablation, the clinical outcome after an ablation procedure with only a PVI is still unsatisfactory, especially in non‐paroxysmal patients with AF. Recently, the second generation CB has been applied for linear ablation on the LAPW with a high success rate and without any serious complications including esophageal injury 6–9,13 . In this cohort, we were able to draw the clinical implications of the linear ablation on the LAPW with the CB from the result of a low arrhythmia recurrence rate (24.1%).…”

“…Recently, the second generation CB has been applied for linear ablation on the LAPW with a high success rate and without any serious complications including esophageal injury. [6][7][8][9]13 In this cohort, we were able to draw the clinical implications of the linear ablation on the LAPW with the CB from the result of a low arrhythmia recurrence rate (24.1%). In the re-do ablation cohort (n = 47), in 12 patients solely using a CB application failed to create a complete conduction block at the LAPW bottom line and included one patient who underwent a touch-up RF ablation, and the RF delivery was prematurely terminated due to an esophageal temperature rise.…”

Severe hypoperistalsis caused by a 3-min single shot cryoballoon ablation for paroxysmal atrial fibrillation: A case report

“…The value of monitoring the intra-esophageal temperature to prevent such complications is controversial [3,5]. In the reports about esophageal complications after cryoballoon ablation, a longer or repetitive cryo-application would be a risk factor for these complications [6]. It was also reported [3,5] that non-symptomatic, not clinically relevant gastroparesis has occurred in 17.3-32.5%.…”

Response to the letter to the editor entitled “A dangerous and risky relationship: Esophagus and left atrium”

“…We greatly appreciate Dr. Celebi's interest in our article regarding esophageal complications after a left atrial posterior wall isolation (LAPW) utilizing the cryoballoon (CB). Shigeta et al highlighted a contentious issue regarding reliable predictors of esophageal injury from cryoballoon applications to the left atrial tissue, rightly indicating that esophageal complications, such as esophageal lesions (ELs) and gastric hypomobility (GH), occur during LAPW isolation with a CB without identifying reliable predictors of those adverse events …”