Pre-procedural proton pump inhibition is associated with fewer peri-oesophageal lesions after cryoballoon pulmonary vein isolation

Abstract

Pulmonary vein isolation (PVI) using cryoenergy is safe and efficient for treatment of atrial fibrillation (AF). Pre-existing upper gastrointestinal (GI) pathologies have been shown to increase the risk for AF. Therefore, this study aimed at assessing incidental pathologies of the upper GI tract in patients scheduled for PVI and to analyse the impact of patients’ characteristics on PVI safety outcome. In 71 AF patients, who participated in the MADE-PVI trial, oesophagogastroduodenoscopy and endosonography were prospectively performed directly before and the day after PVI to assess pre-existing upper GI pathologies and post-interventional occurrence of PVI-associated lesions. Subgroup analysis of the MADE-PVI trial identified clinically relevant incidental findings in 53 patients (74.6%) with age > 50 years being a significant risk factor. Pre-existing reflux oesophagitis increased risk for PVI-associated mediastinal oedema, while patients already treated with proton pump inhibitors (PPI) had significantly fewer mediastinal oedema. Our results suggest that AF patients with pre-existing reflux oesophagitis are at higher risk for PVI-associated mediastinal lesions, which is decreased in patients with constant PPI-treatment prior to PVI. Since PVI-associated mediastinal lesions are regarded as surrogate parameter for an increased risk of the fatal complication of an oesophago-atrial fistula, our findings hint at a beneficial effect of pre-interventional prophylactic PPI-treatment to reduce risk for PVI-associated complications.German Clinical Trials Register (DRKS00016006; date of registration: 17/12/2018).

Calculated parameters of luminal esophageal temperatures predict esophageal injury following conventional and high‐power short‐duration radiofrequency pulmonary vein isolation

“…| 1173 local ischemia and necrosis of the esophageal wall 14 and potentially fistula formation. 15 The results of our study confirm the lack of predictive value of LET alone, and the suggested temperature limits are still controversial. 11,12,16,17 LET is simply a poor surrogate of tissue temperature, the distance of the closest electrode may impede detection of relevant tissue temperature increases, 12,[18][19][20] and LET maximum values ignore the impact of temporal and spatial components.…”

“…Periesophageal edema detected by EUS and gastric motility disorders (food retention) accounted for a relevant proportion of esophageal injury in this cohort, and endoscopy therefore may underestimate the true incidence of ablation‐induced injury. Although the clinical relevance is still debated, edema might be associated with occlusion of periesophageal arteries, leading to local ischemia and necrosis of the esophageal wall 14 and potentially fistula formation 15 …”

Preventing esophageal complications from atrial fibrillation ablation: A review

“…The evidence for some effect in reducing esophageal thermal lesions was suggested by a sub-study of the MADE-PVI trial. 56 This study found that pre-procedural use of proton pump inhibitors reduced esophageal/mediastinal lesions as assessed by endoscopic ultrasound as well as pre and post upper GI endoscopy.…”

Pulsed‐field ablation does not induce esophageal and periesophageal injury—A new esophageal safety paradigm in catheter ablation of atrial fibrillation

“…On the one hand, edema might be an unspecific response of the surrounding tissue due to the very limited thermal effects of PFA, 13 and mechanisms besides its thermal profile (e.g., induction of an inflammatory cascade) 28 might also play a role. On the other hand, it may be due to pre‐existing inflammation of esophageal tissue (i.e., chronic esophagitis or reflux) and not due to the ablation itself 17,18,29 …”