Lethal atrioesophageal fistula after pulmonary vein isolation using high-intensity focused ultrasound (HIFU)

Borchert, Bianca; Lawrenz, Thorsten; Hansky, Bert; Stellbrink, Christoph

doi:10.1016/j.hrthm.2007.08.023

Cited by 77 publications

(41 citation statements)

References 16 publications

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“…Esophageal perforation and LA-esophageal fistula have occurred in 1 patient each at 2 weeks following HIFU ablation of AF. 7 The present study suggests that, when sonicating in the LA (outside the PV), maintaining a distance of at least 3 to 4 mm between the sonication ring and the esophagus may prevent esophageal injury. The reason this relatively short distance appears safe is because of the high absorption of 9 MHz ultrasound energy by the atrial myocardium, reducing the amount of energy absorbed by the esophagus.…”

Section: Discussionmentioning

confidence: 64%

Canine Model of Esophageal Injury and Atrial-Esophageal Fistula After Applications of Forward-Firing High-Intensity Focused Ultrasound and Side-Firing Unfocused Ultrasound in the Left Atrium and Inside the Pulmonary Vein

Yokoyama

Nakagawa

Seres

et al. 2009

Circ: Arrhythmia and Electrophysiology

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Background-Left atrial-esophageal fistula is a serious and poorly understood complication of catheter ablation of atrial fibrillation. The purpose of this study was to (1) develop a canine model of esophageal injury and left atrial-esophageal fistula after applications of forward-firing high-intensity focused ultrasound (HIFU) and side-firing unfocused ultrasound (SFU); (2) examine the relationship to esophageal temperature (Eso-temp); and (3) study the evolution of injury/healing. Methods and Results-Twenty dogs were studied. After transeptal puncture, HIFU catheter (ProRhythm Inc; 13 dogs) was positioned close to the esophagus, either outside (nϭ6) or inside (nϭ7) the inferior pulmonary vein (PV). In 7 other dogs, an SFU catheter was placed deep inside the PV, close to the esophagus. A balloon (20-to 25-mm diameter) with 7 thermocouples (2-mm separation) was positioned in the esophagus (Eso-balloon). Variable air filling of the Eso-balloon controlled the distance from the esophagus to the sonication source, pressing the esophagus against left atrium/PV. One to 9 (median, 5) HIFU (35 W) and 5 to 7 (median, 5) SFU (40 W) sonications were delivered for 40 seconds. Maximum luminal Eso-temp was closely related to HIFU Eso-balloon distance. For HIFU outside PV, Eso-temp Ն50°C occurred only for HIFU Eso-balloon distance Յ2 mm. For HIFU/SFU inside the PV, Eso-temp was Ն50°C, with HIFU Eso-balloon distance up to 6.8 mm. Endoscopy identified esophageal ulcer immediately after ablation in 11 of 13 HIFU dogs and 7 of 7 SFU dogs, all with Eso-temp Ն50°C. Endoscopy at 2 weeks showed ulcer healing in 5 of 11 chronic dogs and ulcer size progression with relaxation of the lower esophageal sphincter and esophagitis in 6 dogs. Two dogs developed left atrial-esophageal fistula and died at 2 weeks. Conclusions-This model produces esophageal ulcer when Eso-temp is Ն50°C. Eso-temp is higher with HIFU/SFU applications closer to the esophagus and with HIFU/SFU applications inside the PV. Ulcer progression and left atrial-esophageal fistula were associated with reflux esophagitis. (Circ Arrhythmia Electrophysiol. 2009;2:41-49.)

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Section: Discussionmentioning

confidence: 64%

Canine Model of Esophageal Injury and Atrial-Esophageal Fistula After Applications of Forward-Firing High-Intensity Focused Ultrasound and Side-Firing Unfocused Ultrasound in the Left Atrium and Inside the Pulmonary Vein

Yokoyama

Nakagawa

Seres

et al. 2009

Circ: Arrhythmia and Electrophysiology

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“…AEFs have also been reported following ablation with a focal ultrasound balloon ablation system that is no longer clinically available. 705,1167 Esophageal erosion has also been reported with a circular multielectrode irrigated RF ablation system. 1171 It is notable that 51% of the writing group members report having had a patient at their center develop an AEF following AF ablation.…”

Section: Section 10: Complicationsmentioning

confidence: 99%

“…806,866,920,1162,1163,1164,1165,1166,1167,1168,1169 It is a possible complication after catheter ablation using any energy modality that produces transmural atrial lesions. Although early reports showed AEF resulting from RF ablation, more recently, AEFs have also been reported after CBA.…”

Section: Section 10: Complicationsmentioning

confidence: 99%

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

Calkins,

Kuck,

Cappato

et al. 2012

Heart Rhythm

1,754

1,468

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“…10,11 Later series using a technically improved third generation HIFU balloon demonstrated acute pulmonary vein isolation in 80 % of all PV. Moreover, 60 % of veins were isolated after a single shot.…”

Section: Single-shot Devicesmentioning

confidence: 99%

The Future of Pulmonary Vein Isolation – Single-shot Devices, Remote Navigation or Improving Conventional Radiofrequency Delivery by Contact Monitoring and Lesion Characterisation?

Filgueiras-Rama¹,

Merino

2013

Arrhythmia &Amp; Electrophysiology Review

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59Atrial fibrillation (AF) is the most common sustained arrhythmia in the clinical practice. 1 The prevalence of the arrhythmia is progressively increasing in developed countries and moreover, it is expected to affect up to 12 million people only in the US by 2050.2 Antiarrhythmic drugs continue to represent the first-line of treatment in AF patients, either to restore sinus rhythm or to prevent recurrences.3 However, current antiarrhythmic drugs usually do not achieve complete elimination of the arrhythmia burden and do not have a wide safety profile.4,5 Surgical elimination of certain arrhythmogenic substrates such as AF may represent a therapeutic option. 6 However, nowadays catheter-based ablation is the most common alternative to treat symptomatic patients when antiarrhythmic drugs fail. 3 The cornerstone radiofrequency (RF) catheter-based procedure pioneered by Haïssaguerre and colleagues, of ablating ectopic triggers that arise from the pulmonary veins (PV) in paroxysmal AF, 7 has progressively evolved to new technical developments aiming to simplify pulmonary vein isolation and increase safety. 8 To reach such objectives it is essential to increase catheter stability, achieve predictable lesion formation, reduce procedure and X-ray exposure time, and make simple and automatic either different steps or the whole procedure by using an anatomically-based ablation approach.The so-called single-shot devices for PV isolation, robotic catheter navigation and ablation, contact force-controlled catheter ablation and new realtime imaging of endocardial ablation are the main available technological breakthroughs intending to overcome some of the conventional manual-guided RF delivery shortcomings. The present review is focused on compiling current clinical data, potential advantages and shortcomings of these new ablation strategies for PV isolation. Single-shot DevicesSeveral single-shot devices have been developed in recent years to facilitate PV isolation, based on the encouraging aim of achieving complete isolation of the vein after one single application (single-shot) using circular catheters or balloon-like ablation devices. Among these devices, high-intensity focused ultrasound (HIFU) applied via a balloon catheter (BC) integrates a 9 megahertz (MHz) ultrasound crystal, which generates a ring of ultrasound energy at the base of the balloon. The third generation of HIFU-BC (12 French of outer diameter) is steerable through a pull wire mechanism integrated in the handle of the catheter and is available in balloon sizes (sonication ring diameter) of 24 millimetres (mm) (20 mm), 27 mm (25 mm) and 32 mm (30 mm), respectively (ProRhythm Inc, Ronkonkoma, New York, US). The catheter also has a lumen for insertion of a hexapolar spiral mapping catheter to record PV potentials.Beyond the circumferential lesion design instead of point-by-point ablation, the technology has the potential benefit of not being critically dependent on balloon-to-tissue contact. Initial reports using first and second generation HIFU balloon c...

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Lethal atrioesophageal fistula after pulmonary vein isolation using high-intensity focused ultrasound (HIFU)

Cited by 77 publications

References 16 publications

Canine Model of Esophageal Injury and Atrial-Esophageal Fistula After Applications of Forward-Firing High-Intensity Focused Ultrasound and Side-Firing Unfocused Ultrasound in the Left Atrium and Inside the Pulmonary Vein

Canine Model of Esophageal Injury and Atrial-Esophageal Fistula After Applications of Forward-Firing High-Intensity Focused Ultrasound and Side-Firing Unfocused Ultrasound in the Left Atrium and Inside the Pulmonary Vein

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 Future of Pulmonary Vein Isolation – Single-shot Devices, Remote Navigation or Improving Conventional Radiofrequency Delivery by Contact Monitoring and Lesion Characterisation?

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