Esophageal Injury and Temperature Monitoring During Atrial Fibrillation Ablation

Abstract

Background-It is common practice to empirically limit the radiofrequency (RF) power when ablating the posterior left atrium during atrial fibrillation ablation to avoid thermal injury to the esophagus. The objective of this study was to determine whether RF energy delivery limited by luminal esophageal temperature (LET) monitoring is associated with a reduction in esophageal injury compared with a strategy of RF power limitation alone. Methods and Results-Eighty-one consecutive patients who underwent atrial fibrillation ablation followed by esophageal endoscopy were included in this observational study. All patients underwent extraostial electric pulmonary vein isolation by using an electroanatomic mapping system and irrigated RF ablation. All RF applications on the posterior left atrium were limited to 35 W. A commercially available, single-thermocouple esophageal probe was used to monitor LET in a subset of patients (nϭ67). In these cases, applications were promptly interrupted when LET was Ն38.5°C; further applications were performed at reduced power to obtain a LET Ͻ38.5°C. Esophageal endoscopy was performed 1 to 3 days after the procedure. Ablation-related esophageal ulcerations were identified in 9 of 81 (11%) patients. All patients were asymptomatic. Of these 81 patients, LET monitoring during ablation occurred in 67 (83%) of patients. Esophageal injury was observed more frequently (36% versus 6%, PϽ0.006) in the group without LET monitoring. Conclusions-These data suggest that LET monitoring may be associated with a reduction in esophageal injury compared with power limitation alone. (Circ Arrhythmia Electrophysiol. 2008;1:162-168.)

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…1174 Esophageal tissue injury has been reported in up to 50% of patients. 637,882,1175 Observed asymptomatic esophageal ulcers were usually healed on repeat endoscopy at 2–3 weeks. 1176 One study reported endoscopy performed on 267 patients who underwent RF ablation.…”

“…882,883,884,885 Unfortunately, because the esophagus is broad, the lateral position of the temperature probe or mapping electrode might not align with the ablation electrode, and the operator could receive a false impression of safety. 1398 There is general agreement among those operators who employ temperature probes that an increase in esophageal temperature should trigger interruption of RF energy delivery.…”

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

“…The location of the esophagus can be "visualized" using a variety of approaches, including multidetector CT [423], topographic tagging of the esophageal position with an electroanatomical mapping system [424,425], barium paste [426,427], and ICE [428,429]. A third strategy involves the use of luminal esophageal temperature monitoring to identify potentially dangerous heating of the esophagus [430][431][432]. Importantly, since the esophagus is broad, the lateral position of the temperature probe or mapping electrode may not align with the ablation electrode and the operator may have a false impression of safety.…”

“…Although left atrial-esophageal fistulae are rare (occurring after <0.1-0.25% of AF ablation procedures) [386,420,506,549], injury to the esophagus is common following AF ablation. In several clinical studies, endoscopy performed 1-3 days after AF ablation using RF energy, HIFU, laser balloon, or cryothermia identified an asymptomatic esophageal ulcer (directly behind the LA) in 4-60% (generally 15-20%) of patients [282,428,432,[580][581][582][583][584][585][586][587][588]. The asymptomatic esophageal ulcers were usually healed on repeat endoscopy at 2-3 weeks following treatment with a proton pump inhibitor and a cytoprotective agent such as sucralfate [583,586].…”

Atrial fibrillation ablation using remote magnetic navigation and the risk of atrial-esophageal fistula: international multicenter experience

“…AEF is associated with very high mortality rate (~80 %), and survivors are often neurologically impaired [2]. Attempts to limit this complication were done by monitoring of esophageal temperature, limiting energy delivery [6,7], divert or cool esophagus [8,9], and administrating proton-pump inhibitors (PPI) [10,11]. The clinical efficacy of these maneuvers is largely unknown, and despite their introduction, the AEF rates remain steady in most recent AF ablation reports [12,13].…”