Temporal relationships between esophageal injury type and progression in patients undergoing atrial fibrillation catheter ablation

Yarlagadda, Bharath; Deneke, Thomas; Turagam, Mohit K.; Dar, Tawseef; Paleti, Swathi; Parikh, Valay; DiBiase, Luigi; Halfbass, Philipp; Santangeli, Pasquale; Mahapatra, Srijoy; Cheng, Jie; Russo, Andrea M.; Edgerton, James R.; Mansour, Moussa; Ruskin, Jeremy N.; Dukkipati, Srinivas; Wilber, David J.; Reddy, Vivek Y.; Packer, Douglas L.; Natale, Andrea; Lakkireddy, Dhanunjaya

doi:10.1016/j.hrthm.2018.09.027

Cited by 64 publications

(67 citation statements)

References 18 publications

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“…The use of a standardized classification of esophageal lesions (Kansas City Classification [KCC]) was recently proposed to identify patients with low‐risk esophageal lesions who might benefit from conservative management. In this study, all patients with erythema (KCC type 1) and superficial ulcers (KCC type 2a) responded to conservative therapy and recovered within 2 and 4 weeks, respectively 24 …”

Section: Esophageal Injury: Clinical Evaluation and Managementmentioning

confidence: 72%

“… 22 The type and severity of esophageal injury vary according to the extension of thermal damage to the esophageal wall (transmural involvement), as it happens from the outside in. Mild, superficial lesions with erythematous changes are more frequent and usually associated with a better prognosis, while deep ulcerations and hemorrhagic signs are more prone to evolve to esophageal perforation and, ultimately, AEF 23,24 …”

Section: Esophageal Injury: Pathogenesis and Risk Factorsmentioning

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 Injury: Clinical Evaluation and Managementmentioning

confidence: 72%

Section: Esophageal Injury: Pathogenesis and Risk Factorsmentioning

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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“…EUS was performed by experienced operators to assess the magnitude of EI. EI was defined as any esophageal lesion adjacent to the contact area between the esophagus and the LA, and was defined according to Kansas City classification: type 1: erythema; type 2: ulcers (2a: superficial ulcers; 2b: deep ulcers); type 3: perforation (3a: perforation without communication with the atria; 3b: perforation with atrioesophageal fistula) 18 . All gastroscopies (GIFQ 260, GIFQ 165, GIFQ 145; Olympus, Japan) were performed by endoscopists in an endoscopy laboratory.…”

Section: Overlap Between the Ablation Lesion And Esophagus Course Bementioning

confidence: 99%

Characteristics of Atrial Fibrillation Patients Suffering Esophageal Injury Caused by Ablation for Atrial Fibrillation

Zhang

et al. 2020

Sci Rep

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The close proximity of esophagus to the left atrial posterior wall predisposes esophagus to thermal injury during catheter ablation for atrial fibrillation (AF). In this retrospective study, we aimed to investigate risk factors of esophageal injury (EI) caused by catheter ablation for AF. Patients who underwent first-time AF ablation from July 2013 to June 2018 were included. The esophagus was visualized by oral soluble contrast during ablation for all patients and a subset of patients were selected to undergo endoscopic ultrasonography (EUS) to estimate EI post ablation. Degree of EI was categorized as Kansas City classification: type 1: erythema; type 2: ulcers (2a: superficial ulcers; 2b: deep ulcers); type 3: perforation (3a: perforation without communication with the atria; 3b: atrioesophageal fistula [AEF]). Of 3,852 patients, 236 patients (61.5 ± 9.7 years; male, 69%) received EUS (EUS group) and 3616 (63.2 ± 10.9 years; male, 61.1%) without EUS (No-EUS group). In EUS group, EI occurred in 63 patients (type 1 EI in 35 and type 2 EI in 28), and no type 3 EI was observed during follow up. In a multivariable logistic regression analysis, an overlap between the ablation lesion and esophagus was an independent predictor of EI (odds ratio, 21.2; 95% CI: 6.23-72.0; P < 0.001). In No-EUS group, esophagopericardial fistula (EPF; n = 3,0.08%) or AEF (n = 2,0.06%) was diagnosed 4-37 days after ablation. In 3 EPF patients, 2 completely recovered with conservative management and 1 died. Two AEF patients died. Ablation at the vicinity of the esophagus predicts risk of EI. EUS post ablation may prevent the progression of EI and should be considered in management of EI. It remains challenging to identify patients with high risk of EI. Pulmonary vein isolation (PVI) has emerged as a cornerstone therapy for atrial fibrillation (AF) ablation. The close proximity of esophagus to the left atrial posterior wall predisposes esophagus to thermal injury during catheter ablation for AF and Esophageal perforation to the left atrium is a fatal complication 1-5. Introduction of contact force-sensing catheters and cryo-balloon catheters appears to make no change in procedural complication rates for patients undergoing AF ablation 6 , and the utility of contact force-sensing (CF-sensing) catheter may be associated with increased rates of atrioesophageal fistula (AEF) formation 7. A recent study appreciably suggested that postprocedural gastroesophageal endoscopy (GSE) could identify EI, and higher intraesophageal temperature measured by a luminal esophageal temperature probe (LET) was associated with the occurrence of EI 5. However, the protective effect of LET remains controversial since LET itself may also cause EI 8,9 , and routine GSE post AF ablation was not available. Until now, there is no widely accepted approach to minimize esophageal injury (EI) caused by catheter ablation for AF. We sought to identify risk factors of EI caused by ablation for AF, and explore the potential management of EI in this study.

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“…Ablation‐induced EDELs have been documented in up to 56% of AF ablation patients and may be precursors of perforating severe esophageal complications like atrioesophageal fistula . The incidence of perforating esophageal complications reported may be lower than the true incidence because of underdetection and underreporting.…”

Section: Introductionmentioning

confidence: 97%

“…esophageal complications like atrioesophageal fistula. 2,3 The incidence of perforating esophageal complications reported may be lower than the true incidence because of underdetection and underreporting. According to a worldwide survey and a registry study, the incidence of atrioesophageal fistula after AF ablation was below 0.2%, whereas a recently published study with rigid postablation endoscopy found an incidence of atrioesophageal fistula and esophageal perforation of up to 0.6% in patients.…”

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confidence: 99%

Incidence of acute thermal esophageal injury after atrial fibrillation ablation guided by prespecified ablation index

Halbfaß

Berkovitz

Павлов

et al. 2019

Cardiovasc electrophysiol

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Introduction Ablation index (AI), a novel parameter defining energy application at single ablation lesions, calculated by integration of ablation time, energy, catheter stability, and contact force, has been documented to be associated with effective lesions and higher ablation efficacy. Using a prespecified target AI in addition to acute lesion efficacy may affect local collateral damage like esophageal thermal injury when used for guiding radiofrequency (RF) ablation at the posterior left atrial (LA) wall. Methods and Results Consecutive patients undergoing first AF ablations using AI were included. Ablation energy was reduced to 25 W when ablating at posterior LA wall. Two different individually defined AI target values were used (300 and 350 for posterior wall ablation). Esophageal endoscopy (EE) was performed 1 to 3 days after ablation procedure to document and categorize endoscopically detected esophageal thermal lesion (EDEL). Two‐hundred and eleven consecutive patients with postprocedural EE were included. Incidence of EDEL was 14% (29 of 211 patients; mild category 1 lesions in 22 of 29 patients (76%) and severe category 2 lesions (ulcers > 5 mm) in 7 of 29 patients (24% of EDEL group, 3% of total group). Ablation time at posterior LA wall (9.5 vs 9.0 minutes [P = .67]) was comparable in patients with and without EDEL. Conclusion LA posterior wall RF ablation adopting AI ≤350 was associated with 14% esophageal thermal injury including 3% of severe esophageal thermal ulcers. This incidence is comparable to historic control groups with non AI–guided AF ablation.

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Temporal relationships between esophageal injury type and progression in patients undergoing atrial fibrillation catheter ablation

Cited by 64 publications

References 18 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

Characteristics of Atrial Fibrillation Patients Suffering Esophageal Injury Caused by Ablation for Atrial Fibrillation

Incidence of acute thermal esophageal injury after atrial fibrillation ablation guided by prespecified ablation index

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