Oesophageal cooling with ice water does not reduce the incidence of oesophageal lesions complicating catheter ablation of atrial fibrillation: randomized controlled study

Kuwahara, Taishi; Takahashi, Atsushi; Okubo, Kenji; Takagi, Katsumasa; Yamao, Kazuya; Nakashima, Emi; Kawaguchi, Naohiko; Takigawa, Masateru; Watari, Yuji; Sugiyama, Tomoko; Handa, Keita; Kimura, Shigeru; Hikita, Hiroyuki; Sato, Akira; Aonuma, Kazutaka

doi:10.1093/europace/eut368

Cited by 55 publications

(45 citation statements)

References 23 publications

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“…The protective role of temperature‐triggered instillation of free cold liquid inside the esophagus during CA has been evaluated in different clinical trials with inconsistent results. Kuwahara et al 122 in a randomized controlled study including 100 patients, infused ice water when LET reached 42°C during CA; although the lesions were slightly milder in the cooling group, no significant difference in the incidence of esophageal lesions was found between groups. Despite the risk of aspiration (free liquid inside the esophagus), conscious sedation and periodic esophageal aspiration were performed in all patients, and no bronchoaspiration was reported 122 .…”

Section: Esophageal Protection Strategiesmentioning

confidence: 99%

“…Kuwahara et al 122 in a randomized controlled study including 100 patients, infused ice water when LET reached 42°C during CA; although the lesions were slightly milder in the cooling group, no significant difference in the incidence of esophageal lesions was found between groups. Despite the risk of aspiration (free liquid inside the esophagus), conscious sedation and periodic esophageal aspiration were performed in all patients, and no bronchoaspiration was reported 122 . In a clinical trial including 318 patients undergoing CA using a RF hot balloon‐based isolation, the instillation of a cold mixture containing contrast (Iopamidol) and saline reduced not only the occurrence but the severity of the esophageal injury, especially when a 39°C LET cutoff was used.…”

Section: Esophageal Protection Strategiesmentioning

confidence: 99%

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Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies

Assis

Shah

Narasimhan

et al. 2020

Cardiovasc electrophysiol

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Catheter ablation has become an important element in the management of atrial fibrillation. Several technical advances allowed for better safety profiles and lower recurrence rates, leading to an increasing number of ablations worldwide. Despite that, major complications are still reported, and esophageal thermal injury remains a significant concern as atrioesophageal fistula (AEF) is often fatal. Recognition of the mechanisms involved in the process of esophageal lesion formation and the identification of the main determinants of risk have set the grounds for the development and improvement of different esophageal protective strategies. More sensitive esophageal temperature monitoring, safer ablation parameters and catheters, and different energy sources appear to collectively reduce the risk of esophageal thermal injury. Adjunctive measures such as the prophylactic use of proton-pump inhibitors, as well as esophageal cooling or deviation devices, have emerged as complementary methods with variable but promising results. Nevertheless, as a multifactorial problem, no single esophageal protective measure has proven to be sufficiently effective to eliminate the risk, and further investigation is still warranted.Early screening in the patients at risk and prompt intervention in the cases of AEF are important risk modifiers and yield better outcomes. K E Y W O R D S atrial fibrillation, atrioesophageal fistula, catheter ablation, esophageal cooling, esophageal lesion, esophageal protection, esophageal thermal damage 1366 | ASSIS ET AL. SUPPORTING INFORMATIONAdditional supporting information may be found online in the Supporting Information section.How to cite this article: Assis FR, Shah R, Narasimhan B, et al.Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies.

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Section: Esophageal Protection Strategiesmentioning

confidence: 99%

Section: Esophageal Protection Strategiesmentioning

confidence: 99%

Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies

Assis

Shah

Narasimhan

et al. 2020

Cardiovasc electrophysiol

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“…al performed a study of 100 patients using very small volumes (5 mL) of ice water as the which was injected prior to RF energy delivery, and subsequently when esophageal temperatures reached 42°C. [18] The severity of the esophageal lesions was qualitatively graded as mild, moderate, or severe, according to their extent and color, with the severe category corresponding to those categorized as grade III or IV by John et al The authors found that this approach reduced the severity of esophageal lesions, but did not reduce their incidence: lesions occurred in 20% of the experimental group, and 22% of the controls, with 3 moderate and 7 mild in the cooled group and 3 severe, 1 moderate, and 7 mild in the control (Fig 2). The percentage of patients free from any ulceration or erosion in each group was found to be 63.6%, 87.5%, and 95.2%, respectively (Fig 3).…”

Section: Resultsmentioning

confidence: 99%

“…[9][10][11] Esophageal cooling has also been investigated in multiple studies for the purpose of protecting the esophagus during RF ablation. [12][13][14][15][16][17][18][19][20] Various approaches to cooling have been utilized, including expandable balloon devices, a cooling sac circulating water, and direct instillation of ice-cold water or saline into the esophagus, with investigations utilizing animal models, mathematical models, and human clinical studies. The majority of human clinical studies have utilized direct instillation of ice cold water or saline.…”

Section: Introductionmentioning

confidence: 99%

Esophageal Cooling For Protection During Left Atrial Ablation: A Systematic Review And Meta- Analysis

Leung

Gallagher

Tschabrunn

et al. 2019

Preprint

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Objective: We sought to perform a meta-analysis of existing studies evaluating esophageal cooling via direct liquid instillation for the reduction of thermal injury. Methods: We reviewed Medline for existing studies involving esophageal cooling for protection of thermal injury during RF ablation. A meta-analysis was then performed using random effects model to calculate estimated effect size with 95% confidence intervals, with outcome of esophageal lesions, stratified by severity, as determined by post-procedure endoscopy. Results: A total of 9 studies were identified and reviewed. After excluding pre-clinical and mathematical model studies, 3 were included in the meta-analysis, totaling 494 patients. Esophageal cooling showed a tendency to shift lesion severity downward, such that total lesions did not show a statistically significant change (OR 0.6, 95% CI 0.15 to 2.38). For high grade lesions, a significant OR of 0.39 (95% CI 0.17 to 0.89) in favor of esophageal cooling was found, suggesting that esophageal cooling, even utilizing a low-capacity thermal extraction technique, reduces lesion severity from RF ablation. Conclusions: Esophageal cooling reduces lesion severity encountered during RF ablation, even when using relatively low heat extraction methods such as direct instillation of cold liquid. Further investigation of this approach is warranted.

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“…Kuwahara et al reported that AF ablation can result in esophageal injury due to tissue heating at the posterior wall of the left atrium. This heating causes mild ulceration but in rare cases to atrio-esophageal fistulae, a life-threatening complication [66]. In addition, catheter and sheath manipulation can result to tear of the left atrium and mitral valve trauma and avulsion [67].…”

Section: Complications Of Atrial Fibrillation Ablationmentioning

confidence: 99%

Invasive management of atrial fibrillation

Vlachos

Letsas

Efremidis

2016

Continuing Cardiol Educ

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Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, affects 1% of the general population with increased incidence in the elderly population and is an important contributor to population morbidity and mortality. This article reviews the current invasive management of AF. Pulmonary vein isolation (PVI) is the cornerstone of current ablation techniques for the treatment of paroxysmal atrial fibrillation (AF). Despite proven PVI, a subset of patients still experience recurrent arrhythmia, mostly due to a higher prevalence of non‐PV triggers. PVI is associated with worse arrhythmia‐free survival in patients with persistent AF than those with paroxysmal AF. Accumulating data have shown that elimination of atrial fibrillation 9 (AF) sources (rotors or rotational activity, drivers, electrograms with continuous activity) should be the goal in persistent AF ablation. Pulmonary vein isolation, linear lesions, and complex fractionated atrial electrograms (CFAEs) ablation have shown limited efficacy in patients with persistent AF. A combined approach using voltage, CFAEs, and dominant frequency (DF) mapping may be helpful for the identification of AF sources and subsequent focal substrate modification. The fibrillatory activity is maintained by intramural reentry centered on fibrotic patches. Voltage mapping may assist in the identification of fibrotic areas. Stable rotors display the higher DF and possibly drive AF. Furthermore, the single rotor is usually consistent with organized AF electrograms without fractionation. It is therefore quite possible that rotors are located at relatively “healthy islands” within the patchy fibrosis. This is supported by the fact that high DF sites have been negatively correlated with the amount of fibrosis. CFAEs are located in areas adjacent to high DF. In conclusion, patchy fibrotic areas displaying the maximum DF along with high organization index and the lower fractionation index are potential targets of ablation. Prospective studies are required to validate the efficacy of substrate modification in left atrial ablation outcomes. Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/4469458/Activity.aspx

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Oesophageal cooling with ice water does not reduce the incidence of oesophageal lesions complicating catheter ablation of atrial fibrillation: randomized controlled study

Abstract: Oesophageal cooling may alleviate the severity of oesophageal lesions but does not reduce the incidence of this complication under the specific protocol evaluated here.

Cited by 55 publications

References 23 publications

Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies

Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies

Esophageal Cooling For Protection During Left Atrial Ablation: A Systematic Review And Meta- Analysis

Invasive management of atrial fibrillation

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