Luminal Esophageal Temperature Monitoring With a Deflectable Esophageal Temperature Probe and Intracardiac Echocardiography May Reduce Esophageal Injury During Atrial Fibrillation Ablation Procedures

Abstract

Background-Luminal esophageal temperature (LET) monitoring is one strategy to minimize esophageal injury during atrial fibrillation ablation procedures. However, esophageal ulceration and fistulas have been reported despite adequate LET monitoring. The objective of this study was to assess a novel approach to LET monitoring with a deflectable LET probe on the rate of esophageal injury in patients undergoing atrial fibrillation ablation. Methods and Results-Forty-five consecutive patients undergoing an atrial fibrillation ablation procedure followed by esophageal endoscopy were included in this prospective observational pilot study. LET monitoring was performed with a 7F deflectable ablation catheter that was positioned as close as possible to the site of left atrial ablation using the deflectable component of the catheter guided by visualization of its position on intracardiac echocardiography. Ablation in the posterior left atrial was limited to 25 W and terminated when the LET increased 2°C from baseline. Endoscopy was performed 1 to 2 days after the procedure. All patients had at least 1 LET elevation Ͼ2°C necessitating cessation of ablation. Deflection of the LET probe was needed to accurately measure LET in 5% of patients when ablating near the left pulmonary veins, whereas deflection of the LET probe was necessary in 88% of patients when ablating near the right pulmonary veins. The average maximum increase in LET was 2.5Ϯ1.5°C. No patients had esophageal thermal injury on follow-up endoscopy. Conclusions-A strategy of optimal LET probe placement using a deflectable LET probe and intracardiac echocardiography guidance, combined with cessation of radiofrequency ablation with a 2°C rise in LET, may reduce esophageal thermal injury during left atrial ablation procedures. (Circ Arrhythm Electrophysiol. 2011;4:149-156.)

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

“…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.…”

Incidence of esophageal injury after pulmonary vein isolation in patients with a low body mass index and esophageal temperature monitoring at a 39 °C setting

“…The incidence of esophageal injury after RF ablation of AF has been reported to range from 5% to 50% depending on the RF power settings and ablation strategies [6][7][8]. To avoid this complication, esophageal temperature probes, inserted nasally and advanced to the level of the left atrium (LA) under fluoroscopic guidance, are used to mark the location of the esophageal lumen and permit real-time intraluminal esophageal temperature monitoring (ETM) during ablation [9][10][11]. Furthermore, body mass index (BMI) has been reported to be a predictor of esophageal injury, indicating that patients with a lower BMI (o24.9) are at a higher risk [12].…”

“…The first goal of the current study was to investigate the incidence of esophageal injury after a single procedure using ETM in patients with a BMI o24. 9. A secondary goal was to assess the rhythm outcome after a single Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/joa procedure using ETM as compared to the conventional procedure without the use of ETM.…”