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Menya D, Bouaoun L, Chepkomoi T, Simba H, Anabwani AA, Anabwani E, Dzamalala CP, Dzamalala C, Kamdolozi M, Gama CB, Apuleni O, Schüz J, Middleton DRS, McCormack V. Hot beverage consumption in the African Esophageal Cancer Corridor: A community-based thermal exposure measurement study across the lifespan. Cancer Epidemiol 2024; 92:102614. [PMID: 38986356 DOI: 10.1016/j.canep.2024.102614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 07/12/2024]
Abstract
"Very hot beverage" (>65°C) consumption is an IARC probable carcinogen and may contribute to the African esophageal cancer burden. We conducted community cross-sectional exposure studies of hot beverage consumption in Kenya and Malawi during 2018-2019, aiming to: (i) implement a detailed measurement protocol incorporating three measurements of sip temperature and volume so as to predict each sip's intra-esophageal liquid temperature (IELT); (ii) examine variations by seasonality, drinking venue and age, including children. 246 participants were included, of whom 236 had drink measurements (52 children and 183 adults). Among adults, mean (SD) temperatures at first sip were 67 (9) and 68 (7) °C in Kenya and Malawi respectively, i.e. 58 and almost 70 % of first sips were > 65 °C. In both countries, adults exhibited a protective habit of smaller sips at higher temperatures (mean 11 mL at first sip), whereas the larger middle sip (20 mL) had the highest IELT (45 °C). The highest temperatures were observed in men and for drinks taken in social settings, whereas we did not detect seasonality or associations with other esophageal cancer risk factors. Measurements were difficult to make for 20 % (8/43) of Kenyan children whose drink was cooled by pouring between cups ('poesha'). Where poesha was not practiced, IELTs were lower in children (especially < 10 years) than in adults, owing to a mean of 8 °C cooler first sip temperature, however 20 % of first sips were > 65 °C. If very hot beverage consumption is an esophageal carcinogen, lowering sip temperatures and volumes in East Africa would form important prevention avenues.
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Affiliation(s)
- Diana Menya
- School of Public Heath, Moi University, Eldoret, Kenya.
| | - Liacine Bouaoun
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | - Tabitha Chepkomoi
- School of Medicine and Health Sciences, Kabarak University, Nakuru, Kenya
| | - Hannah Simba
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | | | | | | | - Chimwemwe Dzamalala
- School of Public Heath, Moi University, Eldoret, Kenya; Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer (IARC), Lyon, France; School of Medicine and Health Sciences, Kabarak University, Nakuru, Kenya; Kamuzu University of Health Sciences, Blantyre, Malawi; Blantyre Cancer Registry, Malawi; Centre for Public Health, Queen's University, Belfast, UK
| | | | | | | | - Joachim Schüz
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | | | - Valerie McCormack
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer (IARC), Lyon, France.
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Omotoye S, Singleton MJ, Zagrodzky J, Clark B, Sharma D, Metzl MD, Gallagher MM, Meininghaus DG, Leung L, Garg J, Warrier N, Panico A, Tamirisa K, Sanchez J, Mickelsen S, Sardana M, Shah D, Athill C, Hayat J, Silva R, Clark AT, Gray M, Levi B, Kulstad E, Girouard S, Zagrodzky W, Montoya MM, Bustamante TG, Berjano E, González-Suárez A, Daniels J. Mechanisms of action behind the protective effects of proactive esophageal cooling during radiofrequency catheter ablation in the left atrium. Heart Rhythm O2 2024; 5:403-416. [PMID: 38984358 PMCID: PMC11228283 DOI: 10.1016/j.hroo.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Abstract
Proactive esophageal cooling for the purpose of reducing the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures is increasingly being used and has been Food and Drug Administration cleared as a protective strategy during left atrial RF ablation for the treatment of atrial fibrillation. In this review, we examine the evidence supporting the use of proactive esophageal cooling and the potential mechanisms of action that reduce the likelihood of atrioesophageal fistula (AEF) formation. Although the pathophysiology behind AEF formation after thermal injury from RF ablation is not well studied, a robust literature on fistula formation in other conditions (eg, Crohn disease, cancer, and trauma) exists and the relationship to AEF formation is investigated in this review. Likewise, we examine the abundant data in the surgical literature on burn and thermal injury progression as well as the acute and chronic mitigating effects of cooling. We discuss the relationship of these data and maladaptive healing mechanisms to the well-recognized postablation pathophysiological effects after RF ablation. Finally, we review additional important considerations such as patient selection, clinical workflow, and implementation strategies for proactive esophageal cooling.
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Affiliation(s)
| | | | - Jason Zagrodzky
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | | | | | - Mark D. Metzl
- NorthShore University Health System, Evanston, Illinois
| | - Mark M. Gallagher
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Lisa Leung
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jalaj Garg
- Loma Linda University Medical Center, Loma Linda, California
| | - Nikhil Warrier
- MemorialCare Heart & Vascular Institute, Fountain Valley, California
| | | | - Kamala Tamirisa
- Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Dallas, Texas
| | - Javier Sanchez
- Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Dallas, Texas
| | | | | | - Dipak Shah
- Ascension Providence Hospital, Detroit, Michigan
| | | | - Jamal Hayat
- Department of Gastroenterology, St George’s University Hospital, London, United Kingdom
| | - Rogelio Silva
- Department of Medicine, Division of Gastroenterology, University of Illinois at Chicago, Chicago, Illinois
- Advocate Aurora Christ Medical Center, Chicago, Illinois
| | - Audra T. Clark
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Benjamin Levi
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | - Enrique Berjano
- Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Ana González-Suárez
- Translational Medical Device Lab, School of Medicine, University of Galway, Galway, Ireland
- Valencian International University, Valencia, Spain
| | - James Daniels
- University of Texas Southwestern Medical Center, Dallas, Texas
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Salihu A, Lu H, Maurizi N, Tzimas G, Herrera Siklody C, Le Bloa M, Domenichini G, Teres C, Hugelshofer S, Monney P, Pruvot E, Muller O, Antiochos P, Pascale P. Prevention of esophageal lesions during atrial fibrillation catheter ablation using esophageal temperature monitoring: A systematic review and meta-analysis. Pacing Clin Electrophysiol 2024; 47:614-625. [PMID: 38558218 DOI: 10.1111/pace.14972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 03/04/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION The use of esophageal temperature monitoring (ETM) for the prevention of esophageal injury during atrial fibrillation (AF) ablation is often advocated. However, evidence supporting its use is scarce and controversial. We therefore aimed to review the evidence assessing the efficacy of ETM for the prevention of esophageal injury. METHODS We performed a meta-analysis and systematic review of the available literature from inception to December 31, 2022. All studies comparing the use of ETM, versus no ETM, during radiofrequency (RF) AF ablation and which reported the incidence of endoscopically detected esophageal lesions (EDELs) were included. RESULTS Eleven studies with a total of 1112 patients undergoing RF AF ablation were identified. Of those patients, 627 were assigned to ETM (56%). The overall incidence of EDELs was 9.8%. The use of ETM during AF ablation was associated with a non significant increase in the incidence of EDELs (12.3% with ETM, vs. 6.6 % without ETM, odds ratio, 1.44, 95%CI, 0.49, 4.22, p = .51, I2 = 72%). The use of ETM was associated with a significant increase in the energy delivered specifically on the posterior wall compared to patients without ETM (mean power difference: 5.13 Watts, 95% CI, 1.52, 8.74, p = .005). CONCLUSIONS The use of ETM does not reduce the incidence of EDELs during RF AF ablation. The higher energy delivered on the posterior wall is likely attributable to a false sense of safety that may explain the lack of benefit of ETM. Further randomized controlled trials are needed to provide conclusive results.
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Affiliation(s)
- Adil Salihu
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Henri Lu
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Niccolo Maurizi
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Georgios Tzimas
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claudia Herrera Siklody
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathieu Le Bloa
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giulia Domenichini
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Cheryl Teres
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah Hugelshofer
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre Monney
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Etienne Pruvot
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Olivier Muller
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Panagiotis Antiochos
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrizio Pascale
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Chahine Y, Afroze T, Bifulco SF, Tekmenzhi DV, Jafarvand M, Boyle PM, Akoum N. Machine learning identifies esophageal luminal temperature patterns associated with thermal injury in catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2024; 35:737-746. [PMID: 38355929 DOI: 10.1111/jce.16213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Luminal esophageal temperature (LET) monitoring during atrial fibrillation (AF) ablation is widely used to reduce the incidence of endoscopically detected esophageal lesion (EDEL). We sought to assess whether specific patterns of LET variation are associated with EDEL. METHODS A high-fidelity multisensor probe was used to record LET in AF patients undergoing radiofrequency ablation (RFA) or cryoballoon ablation (CBA). Explainable machine learning and SHapley Additive exPlanations (SHAP) analysis were used to predict EDEL and assess feature importance. RESULTS A total of 94 patients (38.3% persistent AF, 71.3% male, 72 RFA, and 22 CBA) were included. EDEL was detected in 11 patients (10 RFA and one CBA). In the RFA group, the highest LET recorded was similar between patients with and without EDEL (40.6 [40.1-41]°C vs. 40.2 [39.1-40.9]°C; p = .313), however, the rate of LET rise for the highest recorded peak was higher (0.08 [0.03-0.12]°C/s vs. 0.02 [0.01-0.05]°C/s; p = .033), and the area under the curve (AUC) for the highest peak was smaller (412.5 [206.8-634.1] vs. 588.6 [380.4-861.1]; p = .047) in patients who had EDEL. In case of CBA, the patient with EDEL had a faster LET decline (0.12 vs. 0.07 [0.02-0.14]°C/s), and a smaller AUC for the lowest trough (2491.3 vs. 2629.3 [1712.6-5283.2]). SHAP analysis revealed that a rate of LET change higher than 0.05°C/s and an AUC less than 600 were more predictive of EDEL in RFA. CONCLUSION The rate of LET change and AUC for the recorded temperature predicted EDEL, whereas absolute peak temperatures did not.
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Affiliation(s)
- Yaacoub Chahine
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Tanzina Afroze
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Savannah F Bifulco
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
| | - Demyan V Tekmenzhi
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Mahbod Jafarvand
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Patrick M Boyle
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
- Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, Washington, USA
- Center for Cardiovascular Biology, University of Washington, Seattle, Washington, USA
| | - Nazem Akoum
- Division of Cardiology, University of Washington, Seattle, Washington, USA
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
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Sanchez J, Woods C, Zagrodzky J, Nazari J, Singleton MJ, Schricker A, Ruppert A, Brumback B, Jenny B, Athill C, Joseph C, Shah D, Upadhyay G, Kulstad E, Cogan J, Leyton-Mange J, Cooper J, Tamirisa K, Omotoye S, Timilsina S, Perez-Verdia A, Kaplan A, Patel A, Ro A, Corsello A, Kolli A, Greet B, Willms D, Burkland D, Castillo D, Zahwe F, Nayak H, Daniels J, MacGregor J, Sackett M, Kutayli WM, Barakat M, Percell R, Akrivakis S, Hao SC, Liu T, Panico A, Ramireddy A, Dewland T, Gerstenfeld EP, Lanes DB, Sze E, Francisco G, Silva J, McHugh J, Sung K, Feldman L, Serafini N, Kawasaki R, Hongo R, Kuk R, Hayward R, Park S, Vu A, Henry C, Bailey S, Mickelsen S, Taneja T, Fisher W, Metzl M. Atrioesophageal Fistula Rates Before and After Adoption of Active Esophageal Cooling During Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2023; 9:2558-2570. [PMID: 37737773 DOI: 10.1016/j.jacep.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Active esophageal cooling reduces the incidence of endoscopically identified severe esophageal lesions during radiofrequency (RF) catheter ablation of the left atrium for the treatment of atrial fibrillation. A formal analysis of the atrioesophageal fistula (AEF) rate with active esophageal cooling has not previously been performed. OBJECTIVES The authors aimed to compare AEF rates before and after the adoption of active esophageal cooling. METHODS This institutional review board (IRB)-approved study was a prospective analysis of retrospective data, designed before collecting and analyzing the real-world data. The number of AEFs occurring in equivalent time frames before and after adoption of cooling using a dedicated esophageal cooling device (ensoETM, Attune Medical) were quantified across 25 prespecified hospital systems. AEF rates were then compared using generalized estimating equations robust to cluster correlation. RESULTS A total of 14,224 patients received active esophageal cooling during RF ablation across the 25 hospital systems, which included a total of 30 separate hospitals. In the time frames before adoption of active cooling, a total of 10,962 patients received primarily luminal esophageal temperature (LET) monitoring during their RF ablations. In the preadoption cohort, a total of 16 AEFs occurred, for an AEF rate of 0.146%, in line with other published estimates for procedures using LET monitoring. In the postadoption cohort, no AEFs were found in the prespecified sites, yielding an AEF rate of 0% (P < 0.0001). CONCLUSIONS Adoption of active esophageal cooling during RF ablation of the left atrium for the treatment of atrial fibrillation was associated with a significant reduction in AEF rate.
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Affiliation(s)
| | | | | | - Jose Nazari
- NorthShore University Health System, Evanston, Illinois, USA
| | | | - Amir Schricker
- Mills-Peninsula Medical Center, Burlingame, California, USA
| | | | | | | | | | | | - Dipak Shah
- Ascension Michigan, Detroit, Michigan, USA
| | | | - Erik Kulstad
- The University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - John Cogan
- Memorial Healthcare System, Hollywood, Florida, USA
| | | | - Julie Cooper
- The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | | | | | | | - Apoor Patel
- Houston Methodist Hospital, Houston, Texas, USA
| | - Alex Ro
- NorthShore University Health System, Evanston, Illinois, USA
| | | | | | - Brian Greet
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Danya Willms
- Sharp Memorial Hospital, San Diego, California, USA
| | | | | | | | - Hemal Nayak
- University of Texas, San Antonio, Texas, USA
| | - James Daniels
- The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Matthew Sackett
- Centra Heart and Vascular Institute, Lynchburg, Virginia, USA
| | | | | | | | | | - Steven C Hao
- Sutter Pacific Medical Foundation, San Francisco, California, USA
| | - Taylor Liu
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | | | | | - Thomas Dewland
- University of California-San Fransisco, San Fransico, California, USA
| | | | | | - Edward Sze
- MaineHealth Cardiology, Portland, Maine, USA
| | | | - Jose Silva
- Centra Heart and Vascular Institute, Lynchburg, Virginia, USA
| | - Julia McHugh
- Centra Heart and Vascular Institute, Lynchburg, Virginia, USA
| | - Kai Sung
- Tri-City Cardiology, Mesa, Arizona, USA
| | - Leon Feldman
- Eisenhower Medical Center, Rancho Mirage, California, USA
| | | | - Raymond Kawasaki
- Northwest Community Healthcare, Arlington Heights, Illinois, USA
| | - Richard Hongo
- California Pacific Medical Center, San Francisco, California, USA
| | - Richard Kuk
- Centra Heart and Vascular Institute, Lynchburg, Virginia, USA
| | - Robert Hayward
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | - Shirley Park
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | - Andrew Vu
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | | | - Shane Bailey
- LoneStar Heart and Vascular, New Braunfels, Texas, USA
| | | | - Taresh Taneja
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | - Westby Fisher
- NorthShore University Health System, Evanston, Illinois, USA
| | - Mark Metzl
- NorthShore University Health System, Evanston, Illinois, USA
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Teres C, Soto-Iglesias D, Penela D, Falasconi G, Viveros D, Meca-Santamaria J, Bellido A, Alderete J, Chauca A, Ordoñez A, Martí-Almor J, Scherer C, Panaro A, Carballo J, Cámara Ó, Ortiz-Pérez JT, Berruezo A. Relationship between the posterior atrial wall and the esophagus: esophageal position and temperature measurement during atrial fibrillation ablation (AWESOME-AF). A randomized controlled trial. J Interv Card Electrophysiol 2022; 65:651-661. [PMID: 35861901 DOI: 10.1007/s10840-022-01302-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) implies unavoidable ablation lesions to the left atrial posterior wall, which is closely related to the esophagus, leading to several potential complications. This study evaluates the usefulness of the esophageal fingerprint in avoiding temperature rises during paroxysmal atrial fibrillation (PAF) ablation. METHODS Isodistance maps of the atrio-esophageal relationship (esophageal fingerprint) were derived from the preprocedural computerized tomography. Patients were randomized (1:1) into two groups: (1) PRINT group, the PVI line was modified according to the esophageal fingerprint; (2) CONTROL group, standard PVI with operator blinded to the fingerprint. The primary endpoint was temperature rise detected by intraluminal esophageal temperature probe monitoring. Ablation settings were as specified on the Ablate BY-LAW study protocol. RESULTS Sixty consecutive patients referred for paroxysmal AF ablation were randomized (42 (70%) men, mean age 60 ± 11 years). Temperature rise (> 39.1 °C) occurred in 5 (16%) patients in the PRINT group vs. 17 (56%) in the CONTROL group (p < 0.01). Three AF recurrences were documented at a mean follow-up of 12 ± 3 months (one (3%) in the PRINT group and 2 (6.6%) in the CONTROL group, p = 0.4). CONCLUSION The esophageal fingerprint allows for a reliable identification of the esophageal position and its use for PVI line deployment results in less frequent esophageal temperature rises when compared to the standard approach. Further studies are needed to evaluate the impact of PVI line modification to avoid esophageal heating on long-term outcomes. The development of new imaging-derived tools could ultimately improve patient safety (NCT04394923).
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Affiliation(s)
- Cheryl Teres
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain.,Lausanne University Hospital, Lausanne, Switzerland
| | - David Soto-Iglesias
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Diego Penela
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Giulio Falasconi
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Daniel Viveros
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | | | - Aldo Bellido
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Jose Alderete
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Alfredo Chauca
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Augusto Ordoñez
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Julio Martí-Almor
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Claudia Scherer
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Alejandro Panaro
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Julio Carballo
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Óscar Cámara
- Department of Information and Communication Technologies, BCN-MedTech, Universitat Pompeu Fabra, PhySense group, Barcelona, Spain
| | | | - Antonio Berruezo
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain.
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Radiofrequency Pulmonary Vein Isolation without Esophageal Temperature Monitoring: Contact-Force Characteristics and Incidence of Esophageal Thermal Damage. J Clin Med 2022; 11:jcm11236917. [PMID: 36498492 PMCID: PMC9741279 DOI: 10.3390/jcm11236917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Esophageal thermal lesions following pulmonary vein isolation (PVI) for atrial fibrillation (AF) potentially harbor lethal complications. Radiofrequency (RF)-PVI using contact force-technology can reduce collateral damage. We evaluated the incidence of endoscopically detected esophageal lesions (EDEL) and the contribution of contact force to esophageal lesion formation without esophageal temperature monitoring. One hundred and thirty-one AF patients underwent contact force-guided RF-PVI. Contact force, energy, force-time-integral, and force-power-time-integral were adopted. During PVI at the posterior segment of the wide antral circumferential line, limits were set for energy (30 W), duration (30 s) and contact force (40 g). Ablations were analyzed postero-superior and -inferior around PVs. Endoscopy within 120 h identified EDEL in six patients (4.6%). In EDEL(+), obesity was less frequent (17% vs. 68%, p = 0.018), creatinine was higher (1.55 ± 1.18 vs. 1.07 ± 0.42 mg/dL, p = 0.016), and exclusively at the left postero-inferior site, force-time-integral and force-power-time-integral were greater (2973 ± 3267 vs. 1757 ± 1262 g·s, p = 0.042 and 83,547 ± 105,940 vs. 43,556 ± 35,255 g·J, p = 0.022, respectively) as compared to EDEL(-) patients. No major complications occurred. At 12 months, arrhythmia-free survival was 74%. The incidence of EDEL was low after contact force-guided RF-PVI. Implementing combined contact force-indices on the postero-inferior site of left-sided PVs may reduce EDEL.
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Grosse Meininghaus D, Freund R, Heimbaecher L, Kleemann T, Kushnir A, Geller JC. Incidence and clinical relevance of upper gastrointestinal pathology during preprocedural endoscopy in patients undergoing pulmonary vein isolation. Clin Res Cardiol 2022; 111:1069-1076. [PMID: 35716196 DOI: 10.1007/s00392-022-02050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/31/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Reflux-induced esophagitis might facilitate ablation-induced esophageal lesions (ELs) following pulmonary vein isolation (PVI), and these may progress to atrio-esophageal fistula (AEF). In contrast, preexisting ELs are not prone to progression but may affect procedure planning. OBJECTIVE To study the incidence of preexisting esophageal and upper gastrointestinal (UGI) pathology in patients undergoing PVI, and the relation to ablation-induced ELs. METHODS From 08/2018 to 09/2021, consecutive patients undergoing (radiofrequency [RF] or cryoballoon [CB]) PVI were examined by esophagogastroscopy (EGD) before and following ablation. Postprocedural endoscopic ultrasound (EUS) was added in 2021. RESULTS 412 patients (median age 67.5 [IQR 61.3-75.0] years, 56.1% male) were studied. Preprocedural EGD showed abnormalities in 226/399 patients, 15% in the lower third of the esophagus. Half (99/226) were relevant for PVI, 13 procedures were postponed, 6 due to pathological EGD results. A third of the patients with new esophageal injury following ablation had preexisting esophagitis which was associated with a trend for a higher incidence of ELs after RF ablation (12.5 vs. 6.9%, p = 0.232), and a six- and two-fold higher rate of food retention after CB-PVI (28.6 vs. 4.5%, p = 0.008) and RF ablation (8.3 vs. 4.4%, p = 0.279), respectively. CONCLUSION (1) EGD before PVI showed UGI abnormalities in > 50% of patients, one-fourth of these relevant for PVI. (2) Esophageal inflammation was associated with a higher incidence of post-ablation (peri)-esophageal injury. Whether having this information before ablation is able to reduce ELs or AEF remains to be shown.
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Affiliation(s)
- Dirk Grosse Meininghaus
- Department of Cardiology, Carl-Thiem-Hospital Cottbus, Thiemstr. 111, 03048, Cottbus, Germany.
| | - Robert Freund
- Thiem Research, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Lukas Heimbaecher
- Department of Cardiology, Carl-Thiem-Hospital Cottbus, Thiemstr. 111, 03048, Cottbus, Germany
| | - Tobias Kleemann
- Department of Gastroenterology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Anton Kushnir
- Department of Radiology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - J Christoph Geller
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany.,Otto-Von-Guericke University School of Medicine, Magdeburg, Germany
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9
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Esophageal temperature during atrial fibrillation ablation poorly predicts esophageal injury: An observational study. Heart Rhythm O2 2022; 2:570-577. [PMID: 34988501 PMCID: PMC8703177 DOI: 10.1016/j.hroo.2021.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Esophageal injury (EI) remains a concern when performing pulmonary vein isolation (PVI) using the high-power short-duration (HPSD) technique. Objective We aim to indicate that high esophageal temperature during HPSD PVI does not correlate with positive esophageal endoscopy (EGD) findings. Methods A retrospective observational study was performed on 43 patients undergoing PVI using HPSD (50 W for 6–7 seconds per lesion) at Tulane Medical Center from July 2020 to January 2021. Esophageal temperature was monitored throughout the procedure using a temperature probe and patients underwent EGD the following day. Small ulcers, nonbleeding erosions, erythema, and/or esophagitis were considered positive EGD findings. Results Mean age was 64.9 years; 46.5% of the patients were female. Eleven patients had positive EGD findings (group 1) and 32 patients had normal EGD (group 2). There was no statistical difference in mean esophageal peak temperature between group 1 and group 2 (43.9°C ± 2.9°C and 42.5°C ± 2.3°C, respectively, P = .17). There was no association between positive EGD results and esophageal temperature during PVI. Mean baseline esophageal temperature was similar in both groups (36.1°C, P = .78). Average contact force (P = .53), ablation time (P = .67), age (P = .3096), sex (P = .4), body mass index (P = .14), and other comorbidities did not correlate with positive endoscopy results. We found positive correlation between the distance of the left atrium (LA) to esophagus and positive EGD (P = .0001). Conclusion EI during HPSD PVI does not correlate to esophageal temperature changes during ablation. However, esophageal injury does correlate to a shorter proximity of the esophagus to the LA.
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10
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Interdisciplinary management of the emergency treatment in an atrioesophageal fistula. Ann Thorac Surg 2021; 114:e149-e151. [PMID: 34890569 DOI: 10.1016/j.athoracsur.2021.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/29/2021] [Accepted: 10/14/2021] [Indexed: 11/21/2022]
Abstract
The atrioesophageal fistula is a fulminant complication of radiofrequency ablation in atrial fibrillation, with a mortality of up to 80%. Surgical approaches have been insufficiently dealt with in literature. Treating a 42-year-old male patient, we developed an interdisciplinary two-step concept: 1. the resection of the affected third of the esophagus and the closing of the atrial defect using cardiopulmonary bypass and cardioplegic cardiac arrest; 2. a second surgery to restore gastrointestinal continuity after an adequate term. Our patient has fully recovered.
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11
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Zagrodzky J, Bailey S, Shah S, Kulstad E. Impact of Active Esophageal Cooling on Fluoroscopy Usage During Left Atrial Ablation. J Innov Card Rhythm Manag 2021; 12:4749-4755. [PMID: 34676132 PMCID: PMC8519316 DOI: 10.19102/icrm.2021.121101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Abstract
Risks to collateral structures exist with radiofrequency (RF) ablation of the left atrium to obtain pulmonary vein isolation (PVI) for the treatment of atrial fibrillation. Passive luminal esophageal temperature (LET) monitoring is commonly utilized, but increasing data suggest limited benefits with LET monitoring. In contrast, active cooling of the esophagus has been shown to significantly reduce esophageal injury. Active cooling of the esophagus also avoids the need for stopping and repositioning an LET probe during use, which may reduce the need for fluoroscopy use. This study aimed to measure the impact on fluoroscopy use during RF ablation with esophageal cooling using a dedicated cooling device in a low-fluoroscopy practice. All patients who underwent PVI over a one-year timeframe by a single provider were analyzed. Patients undergoing PVI prior to the incorporation of an esophageal cooling protocol into standard ablation practice were treated with traditional LET monitoring. Patients treated after this point received active esophageal cooling, in which no LET monitoring is utilized. A total of 280 patients were treated; 91 patients were treated using LET monitoring, and 189 patients were treated with esophageal cooling. The mean total fluoroscopy time before the implementation of the esophageal cooling protocol in 91 patients was 194 seconds [standard deviation (SD): 182 seconds] per case, with a median of 144 seconds. The mean total fluoroscopy time after implementation in 189 patients was 126 seconds (SD: 120 seconds) per case with a median of 96 seconds, representing a reduction of 35% per case (p < 0.0001, Mann-Whitney U test). In this largest study to date of active esophageal cooling during PVI, a 35% reduction in fluoroscopy time compared with patients who received LET monitoring was found. This reduction was seen despite an already low fluoroscopy usage rate in place.
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Affiliation(s)
- Jason Zagrodzky
- Department of Electrophysiology, St. David’s South Austin Medical Center, Austin, TX, USA
| | - Shane Bailey
- Department of Electrophysiology, St. David’s South Austin Medical Center, Austin, TX, USA
| | | | - Erik Kulstad
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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12
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Theoretical Evaluation of Microwave Ablation Applied on Muscle, Fat and Bone: A Numerical Study. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11178271] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
(1) Background: Microwave ablation (MWA) is a common tumor ablation surgery. Because of the high temperature of the ablation antenna, it is strongly destructive to surrounding vital tissues, resulting in high professional requirements for clinicians. The method used to carry out temperature observation and damage prediction in MWA is significant; (2) Methods: This work employs numerical study to explore temperature distribution of typical tissues in MWA. Firstly, clinical MWA based on isolated biological tissue is implemented. Then, the Pennes models and microwave radiation physics are established based on experimental parameters and existing related research. Initial values and boundary conditions are adjusted to better meet the real clinical materials and experimental conditions. Finally, clinical MWA data test this model. On the premise that the model is matched with clinical MWA, fat and bone are deduced for further heat transfer analysis. (3) Results: Numerical study obtains the temperature distribution of biological tissue in MWA. It observes the heat transfer law of ablation antenna in biological tissue. Additionally, combined with temperature threshold, it generates thermal damage of biological tissues and predicts the possible risks in MWA; (4) Conclusions: This work proposes a numerical study of typical biological tissues. It provides a new theoretical basis for clinically thermal ablation surgery.
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13
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Grosse Meininghaus D, Blembel K, Waniek C, Kruells-Muench J, Ernst H, Kleemann T, Geller JC. Temperature monitoring and temperature-driven irrigated radiofrequency energy titration do not prevent thermally induced esophageal lesions in pulmonary vein isolation: A randomized study controlled by esophagoscopy before and after catheter ablation. Heart Rhythm 2021; 18:926-934. [PMID: 33561587 DOI: 10.1016/j.hrthm.2021.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoscopically detected esophageal lesions (EDELs) are common following pulmonary vein isolation (PVI) and may progress to atrioesophageal fistula (AEF). OBJECTIVE The purpose of this study was to study (1) the benefit of luminal esophageal temperature (LET) monitoring and (2) the impact of esophagogastroduodenoscopy (EGD) in detecting EDEL and defining pre-existing lesions. The primary endpoint was the number of ablation-induced lesions. METHODS Patients with atrial fibrillation were randomized to PVI with LET monitoring (LET[+]) or without LET monitoring (LET[-]). All patients underwent EGD before and after PVI. Ablation power at the left atrial (LA) posterior wall was limited to 25 W in all patients and was titrated to a minimum of 10 W guided by esophageal temperature in the LET[+] group. RESULTS Eighty-six patients (age 67 ± 10 years; 57% male) were included (44 LET[+], 42 LET[-]). PVI was achieved in all, and additional linear LA lesions were done in 50%. Eight patients developed EDEL (6 LET[+], 2 LET[-]; P = NS). Whereas LET <41°C did not differentiate with regard to EDEL formation, temperature overshooting ≥42°C was associated with a higher risk for new EDEL. Two-thirds of patients showed incidental findings (esophagitis, gastric ulcer) on preprocedural EGD; 8 esophageal lesions were pre-existing. Four patients in the LET[+] group developed epistaxis following insertion of the probe. CONCLUSION Monitoring of LET does not prevent ablation-induced esophageal lesions. Patients without temperature surveillance were not at higher risk, but temperatures ≥42°C were associated with increased likelihood of mucosal lesions.
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Affiliation(s)
| | - Kai Blembel
- Department of Cardiology, Carl-Thiem-Hospital Cottbus, Germany
| | - Claudia Waniek
- Department of Cardiology, Carl-Thiem-Hospital Cottbus, Germany; Thiem Research, Carl-Thiem-Hospital Cottbus, Germany
| | | | - Helmut Ernst
- Department of Gastroenterology, Carl-Thiem-Hospital Cottbus, Germany
| | - Tobias Kleemann
- Department of Gastroenterology, Carl-Thiem-Hospital Cottbus, Germany
| | - J Christoph Geller
- Division of Cardiology, Arrhythmia Section, Zentralklinik Bad Berka, Germany; Otto-von-Guericke University School of Medicine, Magdeburg, Germany
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14
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Kar R, Post A, John M, Rook A, Razavi M. An initial ex vivo evaluation of temperature profile and thermal injury formation on the epiesophageal surface during radiofrequency ablation. J Cardiovasc Electrophysiol 2021; 32:704-712. [PMID: 33476464 DOI: 10.1111/jce.14911] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Few studies have examined heat transfer and thermal injury on the epiesophageal surface during radiofrequency application, or compared the risk of esophageal thermal injury between standard and high-power, short-duration (HPSD) ablation. We studied the thermodynamics of HPSD and standard ablation at different tissue interfaces between the left atrium and esophagus, focusing on epiesophageal temperature changes and thermal injury. METHODS AND RESULTS Fresh porcine heart and esophageal sections were secured to a custom holder and submerged in a temperature-controlled, circulating water bath. During ablation, thermistors recorded temperatures at the catheter tip-atrial interface, epiesophageal-atrial interface, and esophageal lumen. Samples were ablated in triplicate with the following parameters: contact force (15/25g), power (10/20/30 W standard; 40/45/50 W HPSD), and duration (10/20/30 s standard; 5/10/15 s HPSD). Epiesophageal and endoluminal temperature rises were greater in HPSD than in standard ablation (epiesophageal: 5.9 ± 5.6 vs. 2.2 ± 2.0°C, p < .01; endoluminal: 0.7 ± 0.5 vs. 0.4 ± 0.2°C, p < .01). Six of 30 HPSD ablations and 1 of 26 standard ablations caused esophageal injury. The delay between the peak epiesophageal and endoluminal temperatures was greater in HPSD than in standard ablation (24.2 ± 22.1 vs. 13.0 ± 11.0 s, p = .023). Likewise, the peak epiesophageal surface temperature differed more from the concurrent endoluminal temperature in HPSD ablation (5.1 ± 5.3 vs. 1.7 ± 2.0°C, p < .01). CONCLUSION Endoluminal temperature underestimates epiesophageal surface temperature substantially during HPSD ablation. Visible epiesophageal injury was associated with a 2.2 ± 2.1°C rise in endoluminal temperature, corresponding to a 10.2 ± 6.5°C rise in epiesophageal temperature.
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Affiliation(s)
- Ronit Kar
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, Texas, USA.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA
| | - Allison Post
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA
| | - Mathews John
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA
| | - Ashley Rook
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA
| | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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15
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Borges AP, Gazzoni GF, Yanez JPG, Andrade KD, Boff CDO, Ferreira FVC, Bartholomay E, Rösler ÁM, Lucchese FA, Kalil CA. Incidence of Esophageal Thermal Injury Using a Safety Protocol During Atrial Fibrillation Ablation. JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i4.3413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective: Catheter ablation has been a common procedure used for the management of atrial fibrillation (AF). Atrioesophagel fistula (AEF) is one of the most feared complications of AF ablation. Although it is a rare complication, severe esophageal thermal injury must be avoided. It is important to describe a safe method of preventing esophageal injuries without increasing AF recurrence. Methods: A retrospective cohort study of consecutive patients who underwent radiofrequency AF catheter ablation during 1 year-period wa conducted. One hundred and four patients were enrolled divided in two groups: one with a maximum recorded esophageal temperature (ET) < 38 °C and other with a maximum recorded ET ≥ 38 °C. The primary endpoint was detection of endoscopic esophageal lesions after AF ablation and the secondary endpoint was AF recurrence according to the maximum ET reached during the procedure. Results: The maximum ET was on average 37.3 ± 1.0 °C. Only 4 (3.8%) patients had esophageal lesion diagnosed by upper gastrointestinal endoscopy. There were no cases of esophageal perforation. The AF recurrence rate was 9.6% during the follow-up (10 patients, 3 from the ET max < 38 °C group and 7 from the ET max ≥ 38 °C group; p = 0.181). The maximum ET was not associated with AF recurrence after catheter ablation (OR = 1.65, 95% CI = 0.84-3.24, p = 0.14). Conclusions: A low incidence of esophageal injury after AF ablation with the use of a specific esophageal protection protocol was found. There was no esophageal perforation. The AF recurrence rate was similar to that described in the literature.
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Affiliation(s)
- Anibal Pires Borges
- Hospital São Francisco – Santa Casa de Misericórdia – Porto Alegre/RS – Brazil
| | | | | | - Karina de Andrade
- Hospital São Francisco – Santa Casa de Misericórdia – Porto Alegre/RS – Brazil
| | | | | | - Eduardo Bartholomay
- Hospital São Francisco – Santa Casa de Misericórdia – Porto Alegre/RS – Brazil
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16
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Fukaya H, Niwano S, Tanabe S, Kishihara J, Shirakawa Y, Kobayashi S, Arakawa Y, Nishinarita R, Horiguchi A, Ishizue N, Wada T, Oikawa J, Ako J. Severe hypoperistalsis caused by a 3-min single shot cryoballoon ablation for paroxysmal atrial fibrillation: A case report. J Cardiol Cases 2020; 22:26-28. [PMID: 32636965 DOI: 10.1016/j.jccase.2020.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/22/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022] Open
Abstract
A 61-year-old male was referred to our hospital to receive catheter ablation of paroxysmal atrial fibrillation. Since no anatomical abnormalities were detected by preoperative computed tomography of left atrium and pulmonary veins (PVs), he underwent a cryoballoon ablation for a PV isolation. We performed single, 3-min freeze applications to all four PVs while monitoring the esophageal temperature. Immediately after the procedure, he complained of nausea, followed by a body weight loss of 9 kg over 2 months. Since no structural abnormalities were detected even through careful evaluation, he was diagnosed with hypoperistalsis caused by the cryoballoon ablation. Although his symptoms partially improved, they persisted over a year. The cryoballoon procedure is believed to be relatively safe, but even just a simple 3-min freeze application caused severe hypoperistalsis in the present case. Operators should recognize the risk of such complications. <Learning objective: Cryoballoon ablation is thought to be a safe procedure, however, there are important complications. Asymptomatic or mild-symptomatic hypoperistalsis after cryoballoon ablation is not uncommon. In this case, even just a single 3-min freeze for each pulmonary vein caused severe hypoperistalsis. Repetitive or longer freezes are reported as a risk for this complication, therefore, the operator should recognize the risk of this complication, and a shorter freeze time may be considered instead of a fixed 3-min freeze.>.
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Affiliation(s)
- Hidehira Fukaya
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Satoshi Tanabe
- Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yuki Shirakawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shuhei Kobayashi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yuki Arakawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Ryo Nishinarita
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Ai Horiguchi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Naruya Ishizue
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takuya Wada
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Jun Oikawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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17
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Jiang R, Zei PC, Jiang C. Prevention of left atrium esophagus fistula: Appraisal of existing technologies and strategies. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:646-654. [PMID: 32391576 DOI: 10.1111/pace.13939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/27/2020] [Accepted: 05/08/2020] [Indexed: 12/17/2022]
Abstract
Catheter ablation has emerged as an effective treatment for atrial fibrillation (AF). Atrial esophageal fistula (AEF) is a rare, but feared complication. With increasing utilization of ablation therapy for AF, the understanding of the relationship between AEF and ablation has been improved in recent years. Efforts to reduce the risk of AEF have focused on decreasing the risk of severe esophageal injury (EI) and the presumed subsequent progression from EI to AEF, including esophageal temperature monitoring, esophageal cooling systems, esophageal deviation devices, and decreasing and/or curtailing ablation energy delivery. Periprocedural assessment may help identify higher risk patients and detect early esophageal lesions. This review systematically summarizes and evaluates the current strategies and techniques utilized to reduce the risk of AEF in the clinical workflow for AF ablation. We expect that this review will help clinicians to better understand the principles, advantages, and disadvantages of these methods, and to find suitable strategies using current available tools.
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Affiliation(s)
- Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, Hangzhou, Zhejiang, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
| | - Paul C Zei
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, Hangzhou, Zhejiang, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
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18
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Barbhaiya CR, Kogan EV, Jankelson L, Knotts RJ, Spinelli M, Bernstein S, Park D, Aizer A, Chinitz LA, Holmes D. Esophageal temperature dynamics during high-power short-duration posterior wall ablation. Heart Rhythm 2020; 17:721-727. [DOI: 10.1016/j.hrthm.2020.01.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
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19
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Marashly Q, Chelu MG. Ablation Approaches and Imaging Modalities to Lower Risk of Atrioesophageal Injury During Catheter Ablation for Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2020. [DOI: 10.1007/s12170-019-0635-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Leung LWM, Gallagher MM, Santangeli P, Tschabrunn C, Guerra JM, Campos B, Hayat J, Atem F, Mickelsen S, Kulstad E. Esophageal cooling for protection during left atrial ablation: a systematic review and meta-analysis. J Interv Card Electrophysiol 2019; 59:347-355. [PMID: 31758504 PMCID: PMC7591442 DOI: 10.1007/s10840-019-00661-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/31/2019] [Indexed: 12/18/2022]
Abstract
Purpose Thermal damage to the esophagus is a risk from radiofrequency (RF) ablation of the left atrium for the treatment of atrial fibrillation (AF). The most extreme type of thermal injury results in atrio-esophageal fistula (AEF) and a correspondingly high mortality rate. Various strategies for reducing esophageal injury have been developed, including power reduction, esophageal deviation, and esophageal cooling. One method of esophageal cooling involves the direct instillation of cold water or saline into the esophagus during RF ablation. Although this method provides limited heat-extraction capacity, studies of it have suggested potential benefit. We sought to perform a meta-analysis of published studies evaluating the use of esophageal cooling via direct liquid instillation for the reduction of thermal injury during RF ablation. Methods We searched PubMed for studies that used esophageal cooling to protect the esophagus from thermal injury during RF ablation. We then performed a meta-analysis using a random effects model to calculate estimated effect size with 95% confidence intervals, with an 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 preclinical 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 with a low-capacity thermal extraction technique, reduces the severity of lesions resulting from RF ablation. Conclusions Esophageal cooling reduces the severity of the lesions that may result from RF ablation, even when relatively low heat extraction methods are used, such as the direct instillation of small volumes of cold liquid. Further investigation of this approach is warranted, particularly with higher heat extraction capacity techniques.
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Affiliation(s)
- Lisa WM Leung
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, St. George’s, University of London, Cranmer Terrace, Tooting, London, SW17 0RE UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, St. George’s, University of London, Cranmer Terrace, Tooting, London, SW17 0RE UK
| | - Pasquale Santangeli
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, PA 19104 Philadelphia, United States
| | - Cory Tschabrunn
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, PA 19104 Philadelphia, United States
| | - Jose M Guerra
- Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, CIBERCV, Carrer de Sant Quintí, 89, 08041 Barcelona, Spain
| | - Bieito Campos
- Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, CIBERCV, Carrer de Sant Quintí, 89, 08041 Barcelona, Spain
| | - Jamal Hayat
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, St. George’s, University of London, Cranmer Terrace, Tooting, London, SW17 0RE UK
| | - Folefac Atem
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, 75390 Dallas, TX United States
| | - Steven Mickelsen
- Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 52242 Iowa City, United States
| | - Erik Kulstad
- Department of Emergency Medicine, UT Southwestern Medical Center, 5323 Harry Hines Blvd, 75390 Dallas, TX United States
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21
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Lupercio F, Lin AY, Aldaas OM, Romero J, Briceno D, Hoffmayer KS, Han FT, Di Biase L, Feld GK, Hsu JC. Role of adjunctive posterior wall isolation in patients undergoing atrial fibrillation ablation: a systematic review and meta-analysis. J Interv Card Electrophysiol 2019; 58:77-86. [DOI: 10.1007/s10840-019-00634-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
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22
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Fischer G, Handler M, Johnston PR, Baumgarten D. Impedance and conductivity of bovine myocardium during freezing and thawing at slow rates - implications for cardiac cryo-ablation. Med Eng Phys 2019; 74:89-98. [PMID: 31570217 DOI: 10.1016/j.medengphy.2019.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 09/12/2019] [Accepted: 09/16/2019] [Indexed: 01/19/2023]
Abstract
Increasing impedance during freezing might be a valuable marker for guiding cardiac cryo-ablation. We provide model based insights on how decreasing temperature below the freezing point of tissue relates to the percentage of frozen water. Furthermore, we provide experimental data for comparing this percentage with the increase in impedance. Measurements were performed on a bovine tissue sample at frequencies between 5 and 80 kHz. Slow cooling and heating rates were applied to minimize temperature gradients in the myocardial sample and to allow accurate assessment of the freezing point. Computer simulation was applied to link impedance with temperature dependent conductivities. The osmotic virial equation was used to estimate the percentage of frozen water. Measurements identified the freezing point at -0.6 ∘C. At -5 ∘C, impedance rose by more than a factor of ten compared to that at the freezing point and the percentage of frozen water was estimated as being 89%. At -49 ∘C impedance had increased by up to three orders of magnitude and ice formation was most pronounced in the extracellular space. Progressive ice formation in tissue is reflected by a large increase in impedance, and impedance increases monotonically with the percentage of frozen water. Its analysis allows for experimental assessment of factors relevant to cell death. Solid ice contributes to the rupture of the micro-vasculature, while phase shifts reflect concentration differences between extra- and intracellular space driving osmotic water transfer across cell membranes.
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Affiliation(s)
- G Fischer
- Institute of Electrical and Biomedical Engineering, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnoefer-Zentrum 1, Hall in Tyrol 6060, Austria; AFreeze GmbH, Innsbruck, Austria.
| | - M Handler
- Institute of Electrical and Biomedical Engineering, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnoefer-Zentrum 1, Hall in Tyrol 6060, Austria; School of Environment and Science, Queensland Micro- and Nanotechnology Centre, Griffith University, Nathan, Queensland, Australia
| | - P R Johnston
- School of Environment and Science, Queensland Micro- and Nanotechnology Centre, Griffith University, Nathan, Queensland, Australia
| | - D Baumgarten
- Institute of Electrical and Biomedical Engineering, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnoefer-Zentrum 1, Hall in Tyrol 6060, Austria; Institute of Electrical and Biomedical Engineering, Technische Universität Ilmenau, Ilmenau, Germany
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23
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Wu TC, Pisani C, Scanavacca MI. Approaches to the Diagnosis and Management of Atrial-Esophageal Fistula After Catheter Ablation for Atrial Arrhythmias. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0602-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Cronin B, Dalia A, Nguyen QS, Slotto J, Elhassan A, Maus T, Essandoh MK. The Year in Electrophysiology: Selected Highlights From 2018. J Cardiothorac Vasc Anesth 2019; 33:1771-1777. [PMID: 30765206 DOI: 10.1053/j.jvca.2019.01.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Indexed: 01/20/2023]
Abstract
This article is the first in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, the associate editor-in-chief, Dr. Augoustides, and the editorial board for the opportunity to start this series, namely the research highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This first article focuses on esophageal thermal injury during radiofrequency ablation, perioperative management of patients presenting for ablation procedures, left atrial appendage occlusion devices, and, finally, heart failure diagnostic devices.
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Affiliation(s)
- Brett Cronin
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center, San Diego, CA.
| | - Adam Dalia
- Division of Cardiac Anesthesiology, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | | | - James Slotto
- University of California, San Diego, San Diego, CA
| | | | - Timothy Maus
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center, San Diego, CA
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
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