Esophageal Findings in the Setting of a Novel Preventive Strategy to Avoid Thermal Lesions during Hybrid Thoracoscopic Radiofrequency Ablation for Atrial Fibrillation

Abstract

Purpose The development of an atrio-esophageal fistula, a rare yet potentially lethal complication of ablation for atrial fibrillation, could be related to direct tissue heat transfer during and immediately after the ablation. We therefore studied the postoperative esophageal findings by esophagogastroduodenoscopy in patients that underwent a hybrid ablation procedure using a novel preventive strategy to avoid thermal lesions. Methods Thirty-four patients (28 males; 65 years ± 9 years) were retrospectively included. All underwent a hybrid ablation in our center between April 2015 and November 2019 and agreed to an esophagogastroduodenoscopy within 0–14 days (mean: 5 days) following the ablation. To reduce the incidence of thermal lesions three procedural preventive strategies were introduced: (i) videoscopic intrathoracic transesophageal echocardiographic probe visualization to understand the relationship between posterior left atrial wall and esophagus, with probe retraction before ablation; (ii) lifting the cardiac tissue away from the esophagus during energy application; and (iii) a 30-s cool-off period after energy delivery with irrigation of the device, the ablated tissue, and the surrounding tissues. Results No esophageal thermal lesions were observed. One third of patients were diagnosed with incidental esophageal findings unrelated to the ablation procedure (11; 32.4%). Conclusion Novel preventive strategies by visualization and by avoiding contact between the ablation catheter or ablated tissue and the pericardium, seems to eliminate the potential risk of esophageal thermal lesions in the setting of hybrid ablation. Since one third of patients had preexisting esophageal disease, a more comprehensive pre-operative screening could be important to reduce the risk.

Esophageal Protection and Temperature Monitoring Using the Circa S-Cath™ Temperature Probe during Epicardial Radiofrequency Ablation of the Pulmonary Veins and Posterior Left Atrium

“…When these ablation catheters are removed immediately after the energy delivery, the high atrial tissue temperature has the capacity to transmit heat through the convection to the adjacent structures for approximately 30 s. Thus, if the heated atrial tissue touches the pericardium overlying the esophagus, it acts as a heat sink, potentially causing a thermal injury. To avoid this, Kronenberger et al proposed three mitigation strategies to minimize this risk [ 7 ]. A direct videoscopic inspection and pericardial access allows for the confirmation of the position of the esophagus (bulging of the TEE probe through the posterior pericardium) with regard to the left atrial posterior wall by advancing and retracting the TEE probe prior to an ablation.…”

“…Before their discharge, patients were educated extensively on the signs and symptoms of an esophageal injury, as published by our group to ensure a postoperative clinical vigilance [ 7 ]. After their discharge, the patients were seen in the outpatient arrhythmia clinic at 1, 3, 6, 12 and 24 months for a clinical evaluation and to assess any possible procedure-related complications.…”

“…Further on, no systematic postoperative esophagoscopy was performed. However, in a previous paper by our research group [ 7 ], the postoperative esophageal findings were studied after using the same perioperative mitigation strategies. No esophageal thermal lesions were observed.…”