Damage to the Esophagus After Atrial Fibrillation Ablation

Abstract

Background-Radiofrequency catheter ablation is increasingly used in the treatment of atrial fibrillation. Esophageal wall changes varying from erythema to ulcers have been described by endoscopy in up to 47% of patients following pulmonary vein isolation (PVI). Although esophageal changes are frequently reported, the development of a left atrial (LA)-esophageal fistula is fortunately rare. Nevertheless, mucosal changes may just represent "the tip of the iceberg." The aim of this study was, therefore, to investigate the more subtle changes of and injuries to the posterior wall of the LA, the periesophageal and mediastinal connective tissue, and the whole wall of the esophagus, including mucosal changes by esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS). Methods and Results-Twenty-nine patients (7 females; mean age, 57.7Ϯ10.5 years [range, 23-75 years]) underwent EGD and EUS before and after PVI within 48 hours. PVI was performed as a circumferential antral isolation of the septal and lateral pulmonary veins guided by a decapolar circular mapping catheter using a 3-dimensional mapping system with the integration of a preprocedurally acquired computed tomography scan of the left atrium. The maximum power applied was 30 W, with an open-irrigated catheter using a maximum flow rate of 30 mL/min. In all patients, the esophagus was reconstructed using the same computed tomography scan and displayed during the ablation procedure. In case of newly detected periesophageal changes, EGD and EUS were repeated 1 week after the PVI. In all patients, a regular contact area between the LA and the esophagus could be demonstrated before PVI. The mean vertical contact length was 4.4Ϯ1.5 cm (range, 2-10 cm); and the mean distance between the anterior wall of the esophagus and the endocardium was 2.6Ϯ0.8 mm (range, 1.4 -4.0 mm). After PVI, morphological changes of the periesophageal connective tissue and the posterior wall of the LA were diagnosed by endosonography in 8 patients (27%; 95% confidence interval, 12.73-47.24). No mucosal changes of the esophagus in terms of erythema or ulcers were found. In all but one patient (who refused the control), all periesophageal and atrial changes had resolved within 1 week. No atrioesophageal fistula occurred during follow-up (mean follow-up, 294Ϯ110 days [range, 36 -431 days]). Conclusions-Mucosal changes of the esophagus after PVI-like ulcers or erythema could not be demonstrated, yet structural changes of the mediastinum, which were only visible by endosonography, occurred in 27% of patients in the present study. This may indicate a higher than expected periesophageal injury because of PV ablation. Endosonography might prove to be a sensitive and reliable tool in the follow-up after PVI. (Circ Arrhythm Electrophysiol. 2010;3:155-159.)

Effect of Atrial Fibrillation Ablation on Gastric Motility

“…Some of the well-identified UGI system complications, including atrioesophageal fistulae, esophageal ulcerations, gastroesophageal reflux, acute pyloric spasm, and gastric hypomotility, are at least partially a consequence of VN injury. [3][4][5][6][7][8][9][10][11] Because the consequences of UGI injury can be catastrophic, the importance of understanding the effect of AF ablation on VN injury cannot be overstated.…”

“…25,26 It can also be a result of plexi compression from edema resulting from an RFA-induced inflammatory response of the neighboring mediastinal structures (indirect consequence of RFA). 8 Microhematomas from vascular injury during RFA may also cause the same effect on these plexi. 27 It should also be noted that some of UGI dysfunction can be because of direct injury to the intrinsic (myentric) plexi of the esophagus without affecting the VN, through the similar pathological mechanisms.…”

“…Some of the reported UGI complications resulting from AF ablation include atrioesophageal fistulae, esophageal mucosal ulcerations with or without bleeding, gastroesophageal reflux, pyloric spasm, and gastric hypomotility. [3][4][5][6][7][8][9][10][11] The exact mechanism of these injuries is not known; however, injury to the vagus nerve (VN) and its components are proposed to be one of the major players in many of these complications. 5,10 The VN because of its close proximity to the posterior wall of the LA is susceptible to the thermal injury from RFA.…”

Cerebral Air Emboli With Atrial-Esophageal Fistula Following Atrial Fibrillation Ablation

“…12 Due to the high incidence of esophageal injury and potential severity of complications, 1 study suggested follow-up with EGD and endosonography for reevaluation of esophageal injury postablation. 13 However, if AEF is already suspected, it has also been suggested that esophageal procedures be completely avoided due to air embolization as a direct cause from endoscopy. 8 Further safeguards include a reduction Figure 3.…”

Esophageal and Mediastinal Lesions Following Multielectrode Duty-Cycled Radiofrequency Pulmonary Vein Isolation: Simple Equals Safe?

“…9 In brief, EGD and EUS were performed after receiving written consent from the patient regarding the endoscopic procedure in a fasting state of at least 6 hours before the examination. Sedation was performed by intravenous administration of propofol in a dosage as required for adequate sedation.…”