Radiofrequency Catheter Ablation for Atrial Fibrillation Elicited “Jackhammer Esophagus”: A New Complication Due to Vagal Nerve Stimulation?

Abstract

Radiofrequency catheter ablation (RFCA) is a potentially curative method for treatment of highly symptomatic and drug-refractory atrial fibrillation (AF). However, this technique can provoke esophageal and nerve lesion, due to thermal injury. To our knowledge, there have been no reported cases of a newly described motor disorder, the Jackhammer esophagus (JE) after RFCA, independently of GERD. We report a case of JE diagnosed by high-resolution manometry (HRM), in whom esophageal symptoms developed 2 weeks after RFCA, in absence of objective evidence of GERD. A 65-year-old male with highly symptomatic, drug-refractory paroxysmal AF was candidate to complete electrical pulmonary vein isolation with RFCA. Prior the procedure, the patient underwent HRM and impedance-pH to rule out GERD or hiatal hernia presence. All HRM parameters, according to Chicago classification, were within normal limits. No significant gastroesophageal reflux was documented at impedance pH monitoring. Patient underwent RFCA with electrical disconnection of pulmonary vein. After two weeks, patient started to complain of dysphagia for solids, with acute chest-pain. The patient repeated HRM and impedance-pH monitoring 8 weeks after RFCA. HRM showed in all liquid swallows the typical spastic hypercontractile contractions consistent with the diagnosis of JE, whereas impedance-pH monitoring resulted again negative for GERD. Esophageal dysmotility can represent a possible complication of RFCA for AF, probably due to a vagal nerve injury, and dysphagia appearance after this procedure must be timely investigated by HRM.

Jackhammer esophagus with and without esophagogastric junction outflow obstruction demonstrates altered neural control resembling type 3 achalasia

“…However, the jackhammer phenotype is heterogenous, and exaggerated contraction has also been demonstrated in the context of distal obstruction, in esophageal submucosal infiltration with eosinophils, in opioid‐induced esophageal dysfunction, and in esophageal hypersensitivity with or without gastroesophageal reflux as a noxious trigger . Hypercontractile esophagus has also been reported after ablation therapy for atrial fibrillation, and after lung transplant, hypothesized to be related to irritation, stimulation or ablation of the vagus nerve. These associations lend credence to the notion that there might be an inherent predisposition toward esophageal hypercontractility in some individuals, and various mechanical, inflammatory, and luminal factors can trigger the manometric manifestations.…”

When the Heart Triggers the Esophagus: Esophageal Spasm after Electrical Cardioversion

“…According to our review of the literature, this represents the first report of esophageal spasm after electrical cardioversion. Tolone et al described a case of jackhammer esophagus two weeks after catheter ablation for atrial fibrillation, assuming a radiofrequency-induced vagal nerve thermal injury as the provoking factor [4] . Khan and colleagues reported an episode of transient esophageal hypercontractility 4 weeks after lung transplantation, hypothesizing a vagotomy-related gastro-esophageal reflux disease as the causative mechanism [5] .…”

Jackhammer oesophagus in a case of linitis plastica

“…A case report has described jackhammer oesophagus noted in a postlung transplant patient, which later resolved 5. Similarly, Tolone et al 6 reported jackhammer oesophagus triggered by radiofrequency catheter ablation in a patient with atrial fibrillation. Eosinophilic oesophagitis with muscularis propria infiltration was recently reported in association of hypercontractile oesophagus in Japan,7 and was successfully treated with a peroral endoscopic myomectomy (POEM) procedure.…”