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Agarwal R, Mahajan R. To monitor, or not to monitor, that is the question. Indian Pacing Electrophysiol J 2024:S0972-6292(24)00082-2. [PMID: 38997110 DOI: 10.1016/j.ipej.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2024] Open
Affiliation(s)
- Rakesh Agarwal
- University of Adelaide, Adelaide, Australia; Lyell McEwin Hospital, Northern Adelaide Local Health Network (NALHN), Elizabeth Vale, South Australia, Australia
| | - Rajiv Mahajan
- University of Adelaide, Adelaide, Australia; Lyell McEwin Hospital, Northern Adelaide Local Health Network (NALHN), Elizabeth Vale, South Australia, Australia.
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2
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Kistler PM, Sanders P, Amarena JV, Bain CR, Chia KM, Choo WK, Eslick AT, Hall T, Hopper IK, Kotschet E, Lim HS, Ling LH, Mahajan R, Marasco SF, McGuire MA, McLellan AJ, Pathak RK, Phillips KP, Prabhu S, Stiles MK, Sy RW, Thomas SP, Toy T, Watts TW, Weerasooriya R, Wilsmore BR, Wilson L, Kalman JM. 2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation. Heart Lung Circ 2024; 33:828-881. [PMID: 38702234 DOI: 10.1016/j.hlc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 05/06/2024]
Abstract
Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.
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Affiliation(s)
- Peter M Kistler
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia.
| | - Prash Sanders
- University of Adelaide, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Chris R Bain
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Karin M Chia
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Wai-Kah Choo
- Gold Coast University Hospital, Gold Coast, Qld, Australia; Royal Darwin Hospital, Darwin, NT, Australia
| | - Adam T Eslick
- University of Sydney, Sydney, NSW, Australia; The Canberra Hospital, Canberra, ACT, Australia
| | | | - Ingrid K Hopper
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Emily Kotschet
- Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia
| | - Han S Lim
- University of Melbourne, Melbourne, Vic, Australia; Austin Health, Melbourne, Vic, Australia; Northern Health, Melbourne, Vic, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia
| | - Rajiv Mahajan
- University of Adelaide, Adelaide, SA, Australia; Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Silvana F Marasco
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | | | - Alex J McLellan
- University of Melbourne, Melbourne, Vic, Australia; Royal Melbourne Hospital, Melbourne, Vic, Australia; St Vincent's Hospital, Melbourne, Vic, Australia
| | - Rajeev K Pathak
- Australian National University and Canberra Heart Rhythm, Canberra, ACT, Australia
| | - Karen P Phillips
- Brisbane AF Clinic, Greenslopes Private Hospital, Brisbane, Qld, Australia
| | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Martin K Stiles
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Raymond W Sy
- Royal Prince Alfred Hospital, Sydney, NSW, Australia; Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Stuart P Thomas
- University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia
| | - Tracey Toy
- The Alfred Hospital, Melbourne, Vic, Australia
| | - Troy W Watts
- Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Rukshen Weerasooriya
- Hollywood Private Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia
| | | | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Vic, Australia; Royal Melbourne Hospital, Melbourne, Vic, Australia
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Khanra D, Mukherjee A, Gupta A, Rauf AM, Duggal B, Ensam B, Kalla M, DeBono J, Lencioni M, Marshall H. Clinical utility of oesophageal temperature monitoring in AF ablation: An updated meta-analysis and review of literature. Indian Pacing Electrophysiol J 2024:S0972-6292(24)00069-X. [PMID: 38782185 DOI: 10.1016/j.ipej.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 05/07/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) ablation can lead to oesophageal thermal injuries (ETI). These are thought to be the precursor of the much rarer but frequently fatal atrio-oesophageal fistulas. Many centers performing AF ablation routinely use oesophageal temperature monitoring (ETM). This meta-analysis aims to determine the utility of ETM in preventing ETI in the context of radiofrequency catheter ablation of AF. METHODS A systematic search of PubMed, Embase databases and Cochrane registry was performed comparing ETI between ETM and non-ETM strategies in AF ablation. Data on endoscopically determined ETI, AF recurrence, procedure time and ablation time were extracted. Statistical analyses including subgroup and covariate analyses were performed using random effect model in R platform. RESULTS ETI were similar in both ETM (n = 864) and non- ETM groups (n = 639) (RR 1.04, 95 % CI 0.34-3.23) across 12 studies. AF recurrence was statistically similar in both groups (IRR 0.92, 95 % CI 0.73-1.17) but showed a lower trend in non-ETM group. Ablation time was numerically lower in the ETM group and procedure time was numerically higher trend in the ETM group; but they were not statistically significant. Covariate analysis found that posterior wall ablation power setting, additional linear ablation, BMI, use of GA or prophylactic PPI after ablation had no significant correlation in the incidence of ETI. CONCLUSION ETM was not associated with a reduced incidence of ETI during AF ablation. Evidence supporting the routine use of ETM to reduce the risk of ETI or atrio-oesophageal fistulas is lacking.
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Affiliation(s)
- Dibbendhu Khanra
- Queen Elizabeth Hospital, University Hospital Birmingham, United Kingdom.
| | - Anindya Mukherjee
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, United Kingdom
| | | | - Atif Muhammad Rauf
- Queen Elizabeth Hospital, University Hospital Birmingham, United Kingdom
| | - Bhanu Duggal
- All India Institute of Medical Sciences, Rishikesh, India
| | - Bode Ensam
- Queen Elizabeth Hospital, University Hospital Birmingham, United Kingdom
| | - Manish Kalla
- Queen Elizabeth Hospital, University Hospital Birmingham, United Kingdom
| | - Joseph DeBono
- Queen Elizabeth Hospital, University Hospital Birmingham, United Kingdom
| | - Mauro Lencioni
- Queen Elizabeth Hospital, University Hospital Birmingham, United Kingdom
| | - Howard Marshall
- Queen Elizabeth Hospital, University Hospital Birmingham, United Kingdom
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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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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01771-5. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [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] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [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: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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7
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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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8
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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9
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Maccioni S, Sharma R, Lee DD, Haltner A, Khanna R, Vijgen J. Comparative Safety of Pulsed Field Ablation and Cryoballoon Ablation Technologies for Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation: A Critical Literature Review and Indirect Treatment Comparison. Adv Ther 2024; 41:932-944. [PMID: 38185778 PMCID: PMC10879347 DOI: 10.1007/s12325-023-02765-x] [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: 10/16/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Cryoballoon ablation (CBA) is a standard catheter ablation technology with demonstrated clinical effectiveness for the treatment of paroxysmal atrial fibrillation (PAF); however, it can be associated with major adverse events, including phrenic nerve paralysis. Pulsed field ablation (PFA) is a novel, minimally thermal technology with comparable effectiveness and low safety risk. This study aimed to compare the safety profiles of PFA and CBA through critical analyses of the literature and indirect treatment comparisons. METHODS Studies were identified by searching the MEDLINE database and the Clinicaltrials.gov registry. Registered clinical trials and/or Food and Drug Administration Investigation Device Exemption (FDA IDE) studies evaluating PFA or CBA in adult patients with drug-refractory PAF between January 2008 and March 2023 were selected. Comparative safety between PFA and CBA was assessed for major and prespecified adverse events. Indirect comparisons were conducted using the proportion of patients experiencing adverse events and confirmed with single-arm meta-analyses and sensitivity analyses. RESULTS Data were extracted from three PFA publications including a total of 497 patients and six CBA studies including a total of 1113 patients. The analysis revealed that PFA was associated with significantly lower risk of major adverse events {risk difference - 4.3% [95% confidence interval (CI) - 5.8, - 2.8]; risk ratio 0.16 [95% CI 0.07, 0.45]} and prespecified adverse events [risk difference - 2.5% (95% CI - 4.4, - 0.5); risk ratio 0.53 (95% CI 0.31, 0.96)]. Meta-analyses confirmed the lower rate of major adverse events for PFA [0.4% (95% CI 0.0, 1.3)] vs. CBA [5.6% (95% CI 2.6, 8.6)] and prespecified adverse events for PFA [2.7% (95% CI 1.2, 4.1)] vs. CBA [5.8% (95% CI 2.7, 9.0)]. Sensitivity analyses exploring heterogeneity across studies confirmed robustness of the main analyses. CONCLUSION The findings of this study show that PFA has a more favorable safety profile than CBA, with significantly lower risks of major and prespecified adverse events. These indirect comparisons help contextualize the safety of PFA compared to CBA for the treatment of drug-refractory PAF in the absence of head-to-head studies.
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Affiliation(s)
- Sonia Maccioni
- Johnson and Johnson Medical Devices, Franchise Health Economics and Market Access, Irvine, CA, 92618, USA.
| | - Reecha Sharma
- Johnson and Johnson Medical Devices, Clinical Research, Irvine, CA, 92618, USA
| | | | | | - Rahul Khanna
- Medical Device Epidemiology and Real-World Data Sciences, Johnson and Johnson, New Brunswick, NJ, USA
| | - Johan Vijgen
- Cardiology Department, Jessa Hospitals, Hasselt, Belgium
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10
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Wang YH, Tang XM, Jiang RH, Sun YX, Liu Q, Zhang P, Yu L, Lin JW, Cheng H, Chen SQ, Zhang ZW, Sheng X, Lin N, Chen XL, Fu GS, Jiang CY. Fecal calprotectin: A novel predictor of ulcerated esophageal injury after atrial fibrillation catheter ablation. Pacing Clin Electrophysiol 2024; 47:167-171. [PMID: 38041413 DOI: 10.1111/pace.14896] [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: 09/25/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Atrial esophageal fistula (AEF) is a lethal complication that can occur post atrial fibrillation (AF) ablation. Esophageal injury (EI) is likely to be the initial lesion leading to AEF. Endoscopic examination is the gold standard for a diagnosis of EI but extensive endoscopic screening is invasive and costly. This study was conducted to determine whether fecal calprotectin (Fcal), a marker of inflammation throughout the intestinal tract, may be associated with the existence of esophageal injury. METHODS This diagnostic study was conducted in a cohort of 166 patients with symptomatic AF undergoing radiofrequency catheter ablation from May 2020 to June 2021. Fcal tests were performed 1-7 days after ablation. All patients underwent endoscopic ultrasonography 1 or 2 days after ablation. RESULTS The levels of Fcal were significantly different between the EI and non-EI groups (404.9 µg/g (IQR 129.6-723.6) vs. 40.4 µg/g (IQR 15.0-246.2), p < .001). Analysis of ROC curves revealed that a Fcal level of 125 µg/g might be the optimal cut-off value for a diagnosis of EI, giving a 78.8% sensitivity and a 65.4% specificity. The negative predictive value of Fcal was 100% for ulcerated EI. CONCLUSIONS The level of Fcal is associated with EI post AF catheter ablation. 125 µg/g might be the optimal cut-off value for a diagnosis of EI. Negative Fcal could predict the absence of ulcerated EI, which could be considered a precursor to AEF.
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Affiliation(s)
- Yun-He Wang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao-Mei Tang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ru-Hong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ya-Xun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Wei Lin
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Cheng
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shi-Quan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zu-Wen Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ne Lin
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao-Li Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guo-Sheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
- Comprehensive Unit of National regional medical center, Hangzhou, Zhejiang Province, China
| | - Chen-Yang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
- Comprehensive Unit of National regional medical center, Hangzhou, Zhejiang Province, China
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11
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Chen WT, Chung FP, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Lin CY, Chang TY, Kuo L, Wu CI, Liu CM, Liu SH, Hsieh YC, Li CH, Chen SA. Lower contact force predicts right pulmonary vein carina breakthrough after ablation index-guided pulmonary vein isolation using high-power short-duration. J Cardiovasc Electrophysiol 2024; 35:60-68. [PMID: 37888200 DOI: 10.1111/jce.16119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/30/2023] [Accepted: 10/24/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Carina breakthrough (CB) at the right pulmonary vein (RPV) can occur after circumferential pulmonary vein isolation (PVI) due to epicardial bridging or transient tissue edema. High-power short-duration (HPSD) ablation may increase the incidence of RPV CB. Currently, the surrogate of ablation parameters to predict RPV CB is not well established. This study investigated predictors of RPV CB in patients undergoing ablation index (AI)-guided PVI with HPSD. METHODS The study included 62 patients with symptomatic atrial fibrillation (AF) who underwent AI-guided PVI using HPSD. Patients were categorized into two groups based on the presence or absence of RPV CB. Lesions adjacent to the RPV carina were assessed, and CB was confirmed through residual voltage, low voltage along the ablation lesions, and activation wavefront propagation. RESULTS Out of the 62 patients, 21 (33.87%) experienced RPV CB (Group 1), while 41 (66.13%) achieved first-pass RPV isolation (Group 2). Despite similar AI and HPSD, patients with RPV CB had lower contact force (CF) at lesions adjacent to the RPV carina. Receiver operating characteristic (ROC) curve analysis identified CF < 10.5 g as a predictor of RPV CB, with 75.7% sensitivity and 56.2% specificity (area under the curve: 0.714). CONCLUSION In patients undergoing AI-guided PVI with HPSD, lower CF adjacent to the carina was associated with a higher risk of RPV CB. These findings suggest that maintaining higher CF during ablation in this region may reduce the occurrence of RPV CB.
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Affiliation(s)
- Wei-Tso Chen
- Department of Medicine, Division of Cardiology, Hualien Tzu Chi, Hospital, Hualien, Taiwan
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Po Chung
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Shih-Lin Chang
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Li-Wei Lo
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Yu-Feng Hu
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Tze-Fan Chao
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Jo-Nan Liao
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Chin-Yu Lin
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Ting-Yung Chang
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Ling Kuo
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Cheng-I Wu
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Chih-Min Liu
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Shin-Huei Liu
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Yu-Cheng Hsieh
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Taichung Veterans General Hospital, Cardiovascular Center, Taichung, Taiwan
| | - Cheng-Hung Li
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Taichung Veterans General Hospital, Cardiovascular Center, Taichung, Taiwan
| | - Shih-Ann Chen
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Taichung Veterans General Hospital, Cardiovascular Center, Taichung, Taiwan
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12
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Pereira R, Pisani C, Aiello V, Cestari I, Oyama H, Santos O, Otubo J, Moura D, Scanavacca M. Safety of an esophageal deviator for atrial fibrillation catheter ablation. Heart Rhythm O2 2023; 4:565-573. [PMID: 37744938 PMCID: PMC10513920 DOI: 10.1016/j.hroo.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Esophageal thermal injury is a complication of atrial fibrillation (AF) ablation, and it can be avoided by esophageal deviation during left atrial posterior wall radiofrequency catheter ablation. Objective This study aimed to evaluate the safety of a nitinol-based mechanical esophageal displacement device (MEDD) and its performance. Methods This preclinical safety study was conducted on 20 pigs, with 10 undergoing radiofrequency AF ablation using the MEDD and 10 serving as a control group under anticoagulation but without radiofrequency application. Esophageal traumatic injuries were classified from 0 to 4 and were grouped as absent (grade 0), minor (grade 1 or 2), moderate (grade 3), or major risk lesions (grade 4) by anatomopathological study. Grades 1 and 2 were considered acceptable. Fluoroscopy was used to measure displacement. Results Five (25%) pigs developed traumatic lesions, 4 with grade 1 and 1 with grade 2 (2-mm superficial ulcer). There was no difference in lesion occurrence between the radiofrequency and control groups (30% and 20%, respectively; P = .43). Under rightward displacement, the right edge moved 23.9 (interquartile range [IQR] 21.3-26.3) mm and the left edge moved 16.3 (IQR 13.8-18.4) mm (P < .001) from baseline. Under leftward displacement, the right edge moved 13.5 (IQR 10.9-15.3) mm and the left edge moved 16.5 (IQR 12.3-18.5) mm (P = .07). A perforation to the pharyngeal diverticulum occurred in 1 pig, related to an accidental extubation. Conclusion In pigs, the MEDD demonstrated safety in relation to esophageal tissue, and successful deviation. Esophageal traumatic injuries were acceptable, but improper manipulation led to pharyngeal lesion.
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Affiliation(s)
- Renner Pereira
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Cristiano Pisani
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Vera Aiello
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Idágene Cestari
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Helena Oyama
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Osmar Santos
- Department of Materials and Processes, Aeronautics Institute of Technology, São José dos Campos, Brazil
| | - Jorge Otubo
- Department of Materials and Processes, Aeronautics Institute of Technology, São José dos Campos, Brazil
| | - Daniel Moura
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Mauricio Scanavacca
- Arrhythmia Unit, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
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13
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Hamed M, Elseidy SA, Abdelazeem M, Morcos R, Abdallah A, Sammour Y, Barakat AF, Khalife W, Ramu V, Mamas MA, Elbadawi A. Role of oesophageal cooling in the prevention of oesophageal injury in atrial fibrillation catheter ablation: a systematic review and meta-analysis of randomized controlled trials. Europace 2023; 25:euad080. [PMID: 37021812 PMCID: PMC10227763 DOI: 10.1093/europace/euad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/28/2023] [Indexed: 04/07/2023] Open
Abstract
AIMS To evaluate the efficacy of oesophageal cooling in the prevention of oesophageal injury in patients undergoing atrial fibrillation (AF) catheter ablation. METHODS AND RESULTS Comprehensive search of MEDLINE, EMBASE, and Cochrane databases through April 2022 for randomized controlled trials (RCTs) evaluating the role of oesophageal cooling compared with control in the prevention of oesophageal injury during AF catheter ablation. The study primary outcome was the incidence of any oesophageal injury. The meta-analysis included 4 RCTs with a total of 294 patients. There was no difference in the incidence of any oesophageal injury between oesophageal cooling and control [15% vs. 19%; relative risk (RR) 0.86; 95% confidence interval (CI) 0.31-2.41]. Compared with control, oesophageal cooling showed lower risk of severe oesophageal injury (1.5% vs. 9%; RR 0.21; 95% CI 0.05-0.80). There were no significant differences among the two groups in mild to moderate oesophageal injury (13.6% vs. 12.1%; RR 1.09; 95% CI 0.28-4.23), procedure duration [standardized mean difference (SMD) -0.03; 95% CI -0.36-0.30], posterior wall radiofrequency (RF) time (SMD 0.27; 95% CI -0.04-0.58), total RF time (SMD -0.50; 95% CI -1.15-0.16), acute reconnection incidence (RR 0.93; 95% CI 0.02-36.34), and ablation index (SMD 0.16; 95% CI -0.33-0.66). CONCLUSION Among patients undergoing AF catheter ablation, oesophageal cooling did not reduce the overall risk of any oesophageal injury compared with control. Oesophageal cooling might shift the severity of oesophageal injuries to less severe injuries. Further studies should evaluate the long-term effects after oesophageal cooling during AF catheter ablation.
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Affiliation(s)
- Mohamed Hamed
- Department of Internal Medicine, Florida Atlantic University, 777 Glades Road BC-71, Boca Raton, FL 33431, USA
| | - Sheref A Elseidy
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621, USA
| | - Mohamed Abdelazeem
- Department of Internal Medicine, St. Elizabeth’s Medical Center, 736 Cambridge St, Brighton, MA 02135, USA
| | - Ramez Morcos
- Division of Cardiology, Florida Atlantic University, 777 Glades Road BC-71, Boca Raton, FL 33431, USA
| | - Ahmed Abdallah
- Division of Cardiology, East Tennessee State University, 1276 Gilbreath Dr, Johnson City, TN 37614, USA
| | - Yasser Sammour
- Division of Cardiology, Houston Methodist Hospital, 6565 Fannin St, Houston, TX 77030, USA
| | - Amr F Barakat
- UPMC Heart and Vascular Institute, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA 15213, USA
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, 1302 Mechanic St, Galveston, TX 77550, USA
| | - Vijay Ramu
- Division of Cardiology, East Tennessee State University, 1276 Gilbreath Dr, Johnson City, TN 37614, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, Newcastle ST5 5BG, UK
| | - Ayman Elbadawi
- Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
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14
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Hartl S, Reinsch N, Füting A, Neven K. Pearls and Pitfalls of Pulsed Field Ablation. Korean Circ J 2023; 53:273-293. [PMID: 37161743 PMCID: PMC10172271 DOI: 10.4070/kcj.2023.0023] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 05/11/2023] Open
Abstract
Pulsed field ablation (PFA) was recently rediscovered as an emerging treatment modality for the ablation of cardiac arrhythmias. Ultra-short high voltage pulses are leading to irreversible electroporation of cardiac cells subsequently resulting in cell death. Current literature of PFA for pulmonary vein isolation (PVI) consistently reported excellent acute and long-term efficacy along with a very low adverse event rate. The undeniable benefit of the novel ablation technique is that cardiac cells are more susceptible to electrical fields whereas surrounding structures such as the pulmonary veins, the phrenic nerve or the esophagus are not, or if at all, minimally affected, which results in a favorable safety profile that is expected to be superior to the current standard of care without compromising efficacy. Nevertheless, the exact mechanisms of electroporation are not yet entirely understood on a cellular basis and pulsed electrical field protocols of different manufactures are not comparable among one another and require their own validation for each indication. Importantly, randomized controlled trials and comparative data to current standard of care modalities, such as radiofrequency- or cryoballoon ablation, are still missing. This review focuses on the "pearls" and "pitfalls" of PFA, a technology that has the potential to become the future leading energy source for PVI and beyond.
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Affiliation(s)
- Stefan Hartl
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Department of Medicine, Witten/Herdecke University, Witten, Germany.
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15
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Floria M, Iov DE, Tanase DM, Barboi OB, Baroi GL, Burlacu A, Grecu M, Sascau RA, Statescu C, Mihai C, Drug VL. Gastro-Esophageal Reflux Disease and Paroxysmal Atrial Fibrillation Ablation. Life (Basel) 2023; 13:life13051107. [PMID: 37240752 DOI: 10.3390/life13051107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/15/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
Patients undergoing ablation for atrial fibrillation may be at increased risk of developing gastroesophageal reflux disease. We prospectively studied the presence of symptomatic gastroesophageal reflux disease in naïve patients who underwent atrial fibrillation ablation. METHODS The presence of typical symptoms suggestive of gastroesophageal reflux disease was clinically assessed by the gastroenterologist at baseline and at 3 months after ablation. In addition to that, all patients underwent upper gastrointestinal endoscopy. RESULTS Seventy-five patients were included in two groups: 46 patients who underwent atrial fibrillation ablation (study group) and 29 patients without ablation (control group). Patients with atrial fibrillation ablation were younger (57.76 ± 7.66 years versus 67.81 ± 8.52 years; p = 0.001), predominantly male (62.2% versus 33.3%; p = 0.030) and with higher body mass index (28.96 ± 3.12 kg/m2 versus 26.81 ± 5.19 kg/m2; p = 0.046). At three months after the ablation, in the study and control groups, there were 88.9% and 57.1% patients in sinus rhythm, respectively, (p = 0.009). Symptomatic gastroesophageal reflux disease was not more frequent in the study group (42.2% versus 61.9%; p = 0.220). There was no difference in terms of sinus rhythm prevalence in patients with versus without symptomatic gastroesophageal reflux disease (89.5% versus 88.5%; p = 0.709). CONCLUSION In this small prospective study, typical symptoms suggestive of gastroesophageal reflux disease were not more frequent three months following atrial fibrillation ablation.
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Affiliation(s)
- Mariana Floria
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Internal Medicine Clinic, Saint Spiridon Emergency Hospital, 700115 Iași, Romania
| | - Diana-Elena Iov
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Institute of Gastroenterology and Hepatology, 700115 Iasi, Romania
| | - Daniela Maria Tanase
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Internal Medicine Clinic, Saint Spiridon Emergency Hospital, 700115 Iași, Romania
| | - Oana Bogdana Barboi
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Internal Medicine Clinic, Saint Spiridon Emergency Hospital, 700115 Iași, Romania
| | - Genoveva Livia Baroi
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Vascular Surgery, Saint Spiridon Emergency Hospital, 700115 Iași, Romania
| | - Alexandru Burlacu
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Department, Cardiovascular Disease Institute, 700503 Iași, Romania
| | - Mihaela Grecu
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Department, Cardiovascular Disease Institute, 700503 Iași, Romania
| | - Radu Andy Sascau
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Department, Cardiovascular Disease Institute, 700503 Iași, Romania
| | - Cristian Statescu
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Department, Cardiovascular Disease Institute, 700503 Iași, Romania
| | - Catalina Mihai
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Institute of Gastroenterology and Hepatology, 700115 Iasi, Romania
| | - Vasile Liviu Drug
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
- Institute of Gastroenterology and Hepatology, 700115 Iasi, Romania
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16
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List S, Meinhardt C, Mueller J, Deneke T, Barth S, Waechter C, Luesebrink U, Elsaesser A, Arlt A, Halbfass P. Incidence of ablation-induced esophageal lesions and gastroparesis in patients undergoing ablation index guided high power short duration atrial fibrillation ablation. J Cardiovasc Electrophysiol 2023; 34:82-89. [PMID: 36321661 DOI: 10.1111/jce.15731] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Aim of this study was to evaluate the incidence of ablation-induced endoscopically detected esophageal lesions (EDEL) and gastroparesis in patients undergoing high-power short-duration (HPSD) atrial fibrillation (AF) ablation using different target ablation index (AI) values. METHODS AND RESULTS Consecutive patients undergoing AF ablation were included. Radiofrequency (RF) ablation was performed using HPSD ablation (50 W, target AI of 320 and 350 (group 1) and 380 (group 2) at posterior wall). Postablation endoscopy was performed in all patients. In total, 233 patients (66.8 ± 10 years; 52% male) were included consecutively (n = 137 patients in group 1 and n = 96 patients in group 2). Mean AI values und RF time at posterior wall was significantly higher and longer in group 2 compared to group 1 patients (413 ± 9 vs. 392 ± 19 AI, p < 0.01; 9.0 ± 0.8 s vs. 7.8 ± 0.7 s, p < 0.01). Esophageal endoscopy revealed esophageal lesions or gastroparesis in 43 of 233 patients (18.5%) in the total cohort (13.1% in group 1 and 26.0% in group 2; p = 0.02). Incidence of EDEL was 8.0% and 13.5% in group 1 and group 2, respectively. According to logistic analysis incidence of EDEL and/or gastroparesis was significantly lower in patients with a higher body mass index and higher in group 2 patients compared to group 1 patients. CONCLUSION The incidence of EDEL or gastroparesis in patients undergoing HPSD AF ablation was 18.5% in the total cohort. The risk of EDEL and gastroparesis was associated with a higher AI target value of 380 compared to 320 and 350 at posterior wall and was reversely associated with body mass index.
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Affiliation(s)
- Stephan List
- Clinic for Internal Medicine and Invasive Cardiology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Christian Meinhardt
- Clinic for Gastroenterology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Julian Mueller
- Clinic for Invasive Electrophysiology, Cardiovascular Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany.,Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Thomas Deneke
- Clinic for Invasive Electrophysiology, Cardiovascular Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Sebastian Barth
- Clinic for Invasive Electrophysiology, Cardiovascular Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany.,Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Christian Waechter
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Ulrich Luesebrink
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Albrecht Elsaesser
- Clinic for Internal Medicine and Invasive Cardiology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Alexander Arlt
- Clinic for Gastroenterology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Philipp Halbfass
- Clinic for Internal Medicine and Invasive Cardiology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.,Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
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17
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Schade A, Costello-Boerrigter L, Deneke T, Steinborn F, Chapran M, Vathie K, Milisavljevic N, Franz M, Surber R, Assani M, Hamo H, Khshfeh M, Lauten A, Mattea V. Oesophageal safety in voltage-guided atrial fibrillation ablation using ablation index or contact force only: a prospective comparison. Europace 2022; 24:1909-1916. [PMID: 35851917 DOI: 10.1093/europace/euac103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Left atrial ablation using radiofrequency (RF) is associated with endoscopically detected thermal oesophageal lesions (EDELs). The aim of this study was to compare EDEL occurrence after conventional contact force-guided (CFG) RF ablation vs. an ablation index-guided (AIG) approach in clinical routine of voltage-guided ablation (VGA). Predictors of EDEL were also assessed. METHODS AND RESULTS This study compared CFG (n = 100) with AIG (n = 100) in consecutive atrial fibrillation ablation procedures, in which both pulmonary vein isolation and VGA were performed. In the AIG group, AI targets were ≥500 anteriorly and ≥350-400 posteriorly. Upper endoscopy was performed after ablation.The CFG and AIG groups had comparable baseline characteristics. The EDEL occurred in 6 and 5% (P = 0.86) in the CFG and AIG groups, respectively. Category 2 lesions occurred in 4 and 2% (P = 0.68), respectively. All EDEL healed under proton pump inhibitor therapy. The AI > 520 was the only predictor of EDEL [odds ratio (OR) 3.84; P = 0.039]. The more extensive Category 2 lesions were predicted by: AI max > 520 during posterior ablation (OR 7.05; P = 0.042), application of posterior or roof lines (OR 5.19; P = 0.039), existence of cardiomyopathy (OR 4.93; P = 0.047), and CHA2DS2-VASc score (OR 1.71; P = 0.044). The only Category 2 lesion with AI max < 520 (467) occurred in a patient with low body mass index. CONCLUSIONS Both methods were comparable with respect to clinical complications and EDEL. In consideration of previous reconnection data and our study results regarding oesophageal safety, optimal AI target range might be between 400 and 450.
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Affiliation(s)
- Anja Schade
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Lisa Costello-Boerrigter
- Department of Cardiology and Center for Clinical Studies, Central Clinic Bad Berka, Robert-Koch-Alle 9, 99438 Bad Berka, Germany
| | - Thomas Deneke
- Department of Cardiology II/Interventional Electrophysiology, Rhoen-Klinikum Campus Bad Neustadt, Von-Guttenberg Str. 11, 97616 Bad Neustadt, Germany
| | - Frank Steinborn
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Mykhaylo Chapran
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Koroush Vathie
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Nemanja Milisavljevic
- Department of Internal Medicine 2, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Marcus Franz
- Department of Internal Medicine I/Cardiology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Ralf Surber
- Department of Internal Medicine I/Cardiology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Mohamad Assani
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Hussam Hamo
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Muhammed Khshfeh
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Alexander Lauten
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Violeta Mattea
- Department of Cardiology/Interventional Electrophysiology, Helios Hospital Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
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18
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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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19
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Wilson ZT, Khan A, Morris MF, Amabile O, Bahu M, Uppalapu S. Lessons Learned from a Delayed Diagnosis of Atrioesophageal Fistula: A Multidisciplinary Approach. Pacing Clin Electrophysiol 2022; 45:1092-1096. [PMID: 35363909 DOI: 10.1111/pace.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/28/2022] [Accepted: 02/20/2022] [Indexed: 11/28/2022]
Abstract
Atrioesophageal fistulas are a rare complication of radiofrequency ablation that requires rapid identification and emergent surgical repair to prevent morbidity and mortality. We report a case of a 32-year-old man with atrial fibrillation presenting with chest pain followed by rapidly progressive sepsis and embolic cerebrovascular accident 23 days after radiofrequency ablation. Subtle initially overlooked findings on multiple computed tomography caused a delay in diagnosis. Atrioesophageal fistulas remain diagnostically challenging. A high index of suspicion coupled with serial computed tomography of the chest with intravenous and oral contrast reviewed by a multimodal team is essential to make a timely diagnosis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Ahad Khan
- Banner University Medical Center Phoenix Phoenix, AZ, USA
| | | | - Orazio Amabile
- Banner University Medical Center Phoenix Phoenix, AZ, USA
| | - Marwan Bahu
- Banner University Medical Center Phoenix Phoenix, AZ, USA
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20
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Mueller J, Halbfass P, Sonne K, Nentwich K, Ene E, Berkovitz A, Lehmkuhl L, Barth S, Simu GR, Wächter C, Behnes M, Deneke T. Safety aspects of very high power very short duration atrial fibrillation ablation using a modified Radiofrequency RF-Generator: Single center experience. J Cardiovasc Electrophysiol 2022; 33:920-927. [PMID: 35233883 DOI: 10.1111/jce.15433] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/26/2022] [Accepted: 02/13/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION High power short duration ablation proved to be an effective and safe ablation technique for atrial fibrillation (AF). In former case series a significant amount of post-ablation coagulation at the catheter tip as well as silent cerebral lesions in post-procedural cerebral MRI have been identified in patients undergoing de-novo AF ablations with very high power 90 W short duration (vHPvSD) ablations using the QDot ablation catheter in combination with a novel RF-generator (nGEN, BiosenseWebster). Therefore, the RF generator software has been recently modified. METHODS AND RESULTS Consecutive patients undergoing a first AF ablation including pulmonary vein isolation (PVI) with vHPvSD (90 W, with a predefined ablation time of 3 seconds at posterior LA wall sites and 4 seconds at other ablation sites) using the QDOT Micro ablation catheter (Biosense Webster) in conjunction with the technically modified nGEN RF generator (software V1c; Biosense Webster) were included. Procedural characteristics including first-pass isolation per pulmonary vein (PV) pair and early reconnection location within the 30-minute waiting period were recorded. In all patients post-ablation endoscopy to document any thermal esophageal injury (EDEL) and in eligible patients a cerebral magnetic resonance imaging (cMRI) to detect silent cerebral events (SCE)/lesions (SCL) were performed. All acute procedure related complications were recorded during the time until hospital discharge. Furthermore, short-term and mid-term success after 3 and 6 to 12 months of follow-up was investigated. In total, 34 consecutive patients (67±9 years; 62% male; 68% paroxysmal AF) were included. First-pass isolation of all PVs was achieved in 6/34 (18%) patients. First-pass isolation was seen in 37/68 (54%) of PV pairs. Early reconnection occurred in 11 (32%) patients (including reconnections at posterior LA wall sites n=6 and at non-posterior sites n=5). No patient had an EDEL (0%). In 6/23 (26%) patients undergoing post-ablation cerebral MRI SCE were identified. In 6 patients coagulation on the catheter tip was detected at the end of the procedure. No further peri- or post-procedural complications were detected. Early AF recurrence before discharge was seen in 1/34 (3%) of the patients included in this study. Within 3 months 10/34 (29%) revealed AF recurrence during blanking period. After a mean follow-up of 7 months 31/34 (88%) patients revealed sinus rhythm. CONCLUSION AF ablation using 90W vHPvSD with a specialized ablation catheter in conjunction with a recently modified RF-generator was associated with no EDEL in the whole study cohort and 26% SCE in a subgroup of patients undergoing acute post-ablation cerebral MRI. Accordingly to our previously published results, a relevant number of catheter tip coagulations was identified in this patient cohort even after modifications of the RF-generator. The vHPvSD ablation technique using the present and the previous generator seems to be associated with a very low rate of esophageal injury. However, the recently revised generator software also produced a relevant number of catheter tip coagulum formation and SCE. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Julian Mueller
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany.,Department of Cardiology and Angiology, Philipps-University Marburg, Germany.,First Department of Medicine, University Medical Centre Mannheim, Germany
| | - Philipp Halbfass
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany.,Department of Cardiology and Angiology, Philipps-University Marburg, Germany
| | - Kai Sonne
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Karin Nentwich
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Elena Ene
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Artur Berkovitz
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Lukas Lehmkuhl
- Clinic for Radiology, Heart Center Bad Neustadt a.d. Saale, Germany
| | - Sebastian Barth
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Gelu Radu Simu
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Christian Wächter
- Department of Cardiology and Angiology, Philipps-University Marburg, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim, Germany
| | - Thomas Deneke
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
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21
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Müller J, Berkovitz A, Halbfass P, Nentwich K, Ene E, Sonne K, Simu G, Chakarov I, Barth S, Waechter C, Behnes M, Akin I, Deneke T. Acute oesophageal safety of high-power short duration with 50 W for atrial fibrillation ablation. Europace 2022; 24:928-937. [DOI: 10.1093/europace/euab329] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/23/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
Pulmonary vein isolation (PVI) using radiofrequency (RF) ablation is an effective treatment option for patients with atrial fibrillation (AF). This study aims to investigate the safety of high-power short duration (HPSD) with emphasis on oesophageal lesions after PVI.
Methods and results
Consecutive patients undergoing AF ablation with HPSD (50 W; ablation index (AI)-guided; target AI 350 for posterior wall ablation, AI 450 for anterior wall ablation) using the ThermoCool SmartTouch SF catheter were included. Patients underwent post-ablation oesophageal endoscopy to detect and categorize thermal oesophageal injury (EDEL). Occurrence and risk factors of oesophageal lesions and perforating complications were analysed. A total of 1033 patients underwent AF ablation with HPSD. Of them, 953 patients (67.6 ± 9.6 years; 58% male; 43% paroxysmal AF; 68% first PVI) underwent post-procedural oesophageal endoscopy and were included in further analyses. Median procedure time was 82.8 ± 24.4 min with ablation times of 16.1 ± 9.2 min. Thermal oesophageal injury was detected in 58 patients (6%) (n = 29 Category 1 erosion, n = 29 Category 2 ulcerous). One patient developed oesophageal perforation (redo, 4th AF ablation). No patient died. Using multivariable regression models, increased total ablation time [odds ratio (OR) 1.029, P = 0.010] and history of stroke (OR 2.619, P = 0.033) were associated with increased incidence of EDEL after AF ablation, whereas increased body mass index was protective (OR 0.980, P = 0.022).
Conclusion
Thermal oesophageal lesions occur in 6% of HPSD AF ablations. The risk for development of perforating complications seems to be low. Incidence of atrio-oesophageal fistula (0.1%) is comparable to other reported series about RF ablation approaches.
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Affiliation(s)
- Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
- First Department of Medicine, University Medical Centre Mannheim (UMM), Mannheim, Germany
| | - Artur Berkovitz
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
| | - Philipp Halbfass
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Karin Nentwich
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Elena Ene
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
| | - Kai Sonne
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
| | - Gelu Simu
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
| | - Ivalyo Chakarov
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
| | - Sebastian Barth
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Christian Waechter
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Mannheim, Germany
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
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22
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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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Deneke T, Nentwich K, Halbfaß P, Sommer P. There is glory in prevention!-Atrio-esophageal fistula and atrial fibrillation ablation. Europace 2021; 23:491-493. [PMID: 33439994 DOI: 10.1093/europace/euaa417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas Deneke
- Clinic for Electrophysiology, Heart Center Bad Neustadt, Rhön-Klinikum Campus Bad Neustadt, Von-Guttenberg-Str 11, D-97616Bad Neustadt an der Saale, Germany
| | - Karin Nentwich
- Clinic for Electrophysiology, Heart Center Bad Neustadt, Rhön-Klinikum Campus Bad Neustadt, Von-Guttenberg-Str 11, D-97616Bad Neustadt an der Saale, Germany
| | - Philipp Halbfaß
- Clinic for Electrophysiology, Heart Center Bad Neustadt, Rhön-Klinikum Campus Bad Neustadt, Von-Guttenberg-Str 11, D-97616Bad Neustadt an der Saale, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
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24
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Gandjbakhch E, Mandel F, Dagher Y, Hidden-Lucet F, Rollin A, Maury P. Incidence, epidemiology, diagnosis and prognosis of atrio-oesophageal fistula following percutaneous catheter ablation: a French nationwide survey. Europace 2021; 23:557-564. [PMID: 33221901 DOI: 10.1093/europace/euaa278] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/22/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Rate, incidence, risk factors, and optimal management of atrio-oesophageal fistula (AOF) after catheter ablation for atrial fibrillation (AF) remain obscure. METHODS AND RESULTS All French centres performing AF ablation were identified and surveys were sent concerning the number of procedures, eventual cases of AOF, and characteristics of such cases. Eighty-two of the 103 centres (80%) performing AF ablation in France were included, with a total of 129 286 AF ablations since 2006 (93% of the whole procedures in France). Thirty-three AOF were reported (reported rate 0.026% per procedure) with a stable reported annual incidence despite the increasing number of procedures. Sensitivity of computed tomography (CT) scan for AOF was 81%. Mortality was 60%, significantly lower in case of surgical corrective therapy (31 vs. 93%, P = 0.001). CONCLUSION The reported rate of AOF after AF ablation in this nationwide survey was 0.026%, with a stable reported annual incidence over time. A normal CT scan does not rule out the diagnosis and should be repeated in case of suspicion. Prognosis remains poor with a mortality of 60% and crucially dependant of immediate surgical correction. No clear protective strategy has been proven effective.
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Affiliation(s)
- Estelle Gandjbakhch
- Sorbonne Universités, AP-HP, Heart Institute, La Pitié-Salpêtrière University Hospital, 75013 Paris, France
| | - Franck Mandel
- Department of Cardiology, University Hospital Rangueil, 31059 Toulouse, France
| | - Yann Dagher
- Sorbonne Universités, AP-HP, Heart Institute, La Pitié-Salpêtrière University Hospital, 75013 Paris, France
| | - Francoise Hidden-Lucet
- Sorbonne Universités, AP-HP, Heart Institute, La Pitié-Salpêtrière University Hospital, 75013 Paris, France
| | - Anne Rollin
- Department of Cardiology, University Hospital Rangueil, 31059 Toulouse, France
| | - Philippe Maury
- Department of Cardiology, University Hospital Rangueil, 31059 Toulouse, France.,Unité INSERM U 1048, Toulouse, France
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25
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Moiroux-Sahraoui A, Manceau G, Schoell T, Combes A, Bouglé A, Leprince P, Vaillant JC, Lebreton G. Atrio-oesophageal fistula following atrial fibrillation ablation: how to manage this dreaded complication? Interact Cardiovasc Thorac Surg 2021; 33:935-940. [PMID: 34313300 DOI: 10.1093/icvts/ivab202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/17/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Atrio-oesophageal fistula is a rare but serious complication of radiofrequency catheter ablation of atrial fibrillation. Therapeutic options are surgery, oesophageal stenting and conservative treatment (antibiotics and anticoagulation). However, there are no guidelines available. Since no article dwells on the technical considerations of this surgery, we aim to present here our experience and share our surgical approach. METHODS Between January 2012 and March 2020, all consecutive patients treated for atrio-oesophageal fistula following radiofrequency catheter ablation of atrial fibrillation at our institution were analysed retrospectively. The diagnosis was made on a set of clinical and radiological signs. All patients benefitted from a combined approach involving both digestive and cardiac surgeons. Femoro-femoral peripheral cardiopulmonary by-pass was used. The surgical approach was a right posterolateral thoracotomy. Atrial repair was done on fibrillating heart without cross-clamping, using a left atriotomy. Digestive management consisted of a total oesophagectomy. RESULTS We identified 6 patients with this complication. The median age was 53 [34-72] years. Symptoms were neurological symptoms, fever and chest pain. Diagnostic modalities were cerebral imaging, chest CT and transthoracic echocardiogram. Atrial repair consisted in a suture of the atrium or by using a pericardial patch. With a median follow-up of 3.1 [0.1-7.7] years, only one patient died during the follow-up. CONCLUSIONS Our experience shows that an aggressive surgery with a large resection of the oesophagus and left atrial repair by right thoracotomy in the same time provides good results. The ability to involve simultaneously both experienced digestive and cardiac surgical teams is the key for this strategy.
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Affiliation(s)
- Alexander Moiroux-Sahraoui
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital,Department of Cardiac Surgery, Paris, France
| | - Gilles Manceau
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital,Department of Digestive and Hepato-Pancreato-Biliary Surgery, Paris, France
| | - Thibaut Schoell
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital,Department of Cardiac Surgery, Paris, France
| | - Alain Combes
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical-Surgical Intensive Care Unit, Paris, France
| | - Adrien Bouglé
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Anesthesiology and Critical Care, Paris, France
| | - Pascal Leprince
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital,Department of Cardiac Surgery, Paris, France
| | - Jean Christophe Vaillant
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital,Department of Digestive and Hepato-Pancreato-Biliary Surgery, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital,Department of Cardiac Surgery, Paris, France
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26
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Ugata Y, Michihata N, Matsui H, Fushimi K, Yasunaga H. Impact of proton pump inhibitors on mortality and severe esophageal injury after catheter ablation for atrial fibrillation: a nationwide retrospective study using propensity score matching. Heart Vessels 2021; 36:1730-1738. [PMID: 33929573 DOI: 10.1007/s00380-021-01860-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/23/2021] [Indexed: 11/26/2022]
Abstract
Studies on the protective effects of proton pump inhibitors (PPIs) on mortality and severe esophageal injury after catheter ablation for atrial fibrillation are lacking. However, some reports have recommended use of PPIs for prophylaxis against esophageal injury. We investigated the effects of PPIs on mortality and severe esophageal injury after ablation. We retrospectively extracted data for adult in-patients who received catheter ablation with a diagnosis of atrial fibrillation from July 2010 to March 2018. The patients were divided into two groups: with PPI (PPI group) and without PPI (non-PPI group) administration before or on the day of ablation. The primary composite outcome was all-cause 30-day mortality and incidence of severe esophageal injury with complication (cardiac tamponade, ischemic stroke, or sepsis) within 30 days of ablation. Secondary outcomes included incidence of cardiac tamponade, ischemic stroke, and sepsis within 30 days of ablation. Propensity score matching was performed to compare the primary and secondary outcomes between the two groups. We identified 141,649 eligible patients, comprising 62,558 in the PPI group and 79,091 in the non-PPI group. Propensity score-matching analysis showed that PPI use was not associated with reduced proportion of the primary outcome (adjusted odds ratio 1.02; 95% confidence interval 0.71-1.47). PPI use may not be beneficial for reducing mortality or severe complications.
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Affiliation(s)
- Yusuke Ugata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
- Department of Cardiology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Saitama, 330-8503, Japan.
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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27
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Groenveld HF, Mulder BA, Blaauw Y. Routine measurement of oesophageal temperature during cryoballoon pulmonary vein isolation. Neth Heart J 2021; 29:237-238. [PMID: 33599969 PMCID: PMC7991066 DOI: 10.1007/s12471-021-01551-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- H F Groenveld
- Department of Cardiology, Heart Centre, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
| | - B A Mulder
- Department of Cardiology, Heart Centre, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Y Blaauw
- Department of Cardiology, Heart Centre, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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28
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van Opstal JM, Stevenhagen YJ, van Dessel PFHM, Scholten MF. Reply to the letter of Groenveld et al.: 'Routine measurement of oesophageal temperature during cryoballoon pulmonary vein isolation'. Neth Heart J 2021; 29:239-240. [PMID: 33709211 PMCID: PMC7990989 DOI: 10.1007/s12471-021-01558-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- J M van Opstal
- Department of Cardiology, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Y J Stevenhagen
- Department of Cardiology, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - P F H M van Dessel
- Department of Cardiology, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - M F Scholten
- Department of Cardiology, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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29
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Ahn JH, Park J, Jo JS, Lee SH, On YK, Park KM, Oh EJ, Ko JS, Jeong JS. The frequency of gastroesophageal reflux when radiofrequency catheter ablation procedures for atrial fibrillation under general anesthesia with a supraglottic device: Observational pilot study. Medicine (Baltimore) 2021; 100:e24595. [PMID: 33578560 PMCID: PMC7886399 DOI: 10.1097/md.0000000000024595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023] Open
Abstract
Gastroesophageal reflux (GER) in radiofrequency catheter ablation (RFCA) occurs due to vagal plexus damage during pulmonary vein isolation. We hypothesized that the frequency of GER in the oropharynx will be less compared to other areas (low-esophagus, mid-esophagus). We confirmed the frequency of GER before and after RFCA in 3 areas.We studied 30 patients who were scheduled for RFCA under general anesthesia. Anesthesia was performed using supraglottic devices (SGD) with a suction port. Two esophageal temperature probes capable of suction and measuring temperature were inserted through the suction port. The pH of the 3 areas was measured before and after the RFCA at 3 areas (mid-esophagus, low-esophagus, and oropharynx).GER was observed in 13 of 30 patients (43%). In one patient, it was observed in the oropharynx, in 4 patients it was observed in the mid-esophagus, and in 13 patients, it was observed in the low-esophagus. For patients with GER at the oropharynx and mid-esophagus, it was also observed at the low-esophagus. The difference in the pH before and after the RFCA was not significant at the oropharynx and mid-esophagus (P = .726 and P = .424, respectively), but it was significantly different at the low-esophagus (P < .001). The total ablation time was longer in the GER group compared to the non-GER group (P = .021).GER after RFCA occurred in 43% of patients, only 1 patient in the oropharynx. And aspiration pneumonia after SGD extubation did not occur. Therefore, the use of SGDs in RFCA does not completely eliminate the possibility of aspiration, so care should be taken.
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Affiliation(s)
- Jin Hee Ahn
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul
| | - Jiyeon Park
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon
| | - Jae Seong Jo
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul
| | - Young Keun On
- Department of Cardiology, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyoung-Min Park
- Department of Cardiology, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun Jeong Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine
| | - Justin Sangwook Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine
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30
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Piringer R, Deneke T, Foldyna B, Sonne K, Nentwich K, Ene E, Barth S, Lüsebrink U, Berkovitz A, Halbfass P. Incidence of ablation-induced esophageal injury associated with high-power short duration temperature-controlled pulmonary vein isolation using a specialized open-irrigated ablation catheter: A retrospective single-center study. J Cardiovasc Electrophysiol 2021; 32:695-703. [PMID: 33442930 DOI: 10.1111/jce.14883] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION To evaluate short-term efficacy and incidence of ablation-induced endoscopically detected esophageal injury in patients undergoing high-power, short-duration (HPSD) pulmonary vein isolation using a novel irrigated radiofrequency ablation catheter and ablation generator setup. METHODS AND RESULTS Atrial fibrillation (AF) patients, who underwent AF ablation using an irrigated radiofrequency ablation catheter specifically designed for a HPSD ablation approach (50 W, with a target Ablation Index of 350 at posterior wall), received postablation esophageal endoscopy after ablation. In total 45 consecutive patients (67 ± 10 years; 58% male; 42% paroxysmal AF) undergoing AF ablation using a specialized ablation catheter (QDOT) were included in the study. Thirty-one of 45 patients (69%) underwent a first-time pulmonary vein isolation (Group 1, 67 ± 11 years; 55% male; 48% paroxysmal AF). Fourteen patients (31%) underwent a redo AF procedure (Group 2, 66 ± 8 years; 64% male; 29% paroxysmal AF). Patients undergoing first-time pulmonary vein isolation were included in the final analysis. In these patients an endoscopically detected esophageal lesion (EDEL) was detected in 5 of 31 (16%) patients (erosion n = 2, ulcer n = 3). Mean contact force at posterior wall ablation sites was significantly lower in patients with postprocedural EDEL compared with patients without EDEL (11.9 ± 0.8 g vs. 15.6 ± 4.7 g). CONCLUSION PVI using a specialized high-power ablation catheter in conjunction with a HPSD ablation approach results in a 16% incidence of EDEL in first AF ablation candidates. Future studies evaluating high-power short duration ablation strategies should include esophageal endoscopy to estimate the risk of clinically relevant esophageal complications.
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Affiliation(s)
| | - Thomas Deneke
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Borek Foldyna
- Clinic for Diagnostic and Interventional Radiology, Heart Center Bad Neustadt a.d. Saale, Bad Neustadt a.d. Saale, Germany.,Cardiovascular Imaging Research Center, Massachusetts General Hospital - Harvard Medical School, Boston, Massachusetts, USA
| | - Kai Sonne
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Karin Nentwich
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Elena Ene
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Sebastian Barth
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Ulrich Lüsebrink
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Artur Berkovitz
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Philipp Halbfass
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany.,Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
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31
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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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32
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Ariyaratnam JP, Sanders P. Protecting the oesophagus during left atrial ablation: A surplus of options but an absence of evidence. Indian Pacing Electrophysiol J 2020; 20:219-220. [PMID: 32979484 PMCID: PMC7691772 DOI: 10.1016/j.ipej.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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33
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Bhardwaj R, Koruth JS, Reddy VY. Current Status of Esophageal Protection. Card Electrophysiol Clin 2020; 12:247-257. [PMID: 32451108 DOI: 10.1016/j.ccep.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Catheter ablation of atrial fibrillation necessitates ablation on the posterior left atrium. The anterior esophagus touches the posterior left atrium, although its course is highly variable. The proximity of the left atrium to the esophagus confers risk of injury with radiofrequency and cryoablation owing to the heat transfer that occurs with thermal ablation. Early detection of esophageal temperature changes with probes may decrease the extent of damage to the esophagus, but evidence is mixed. Avoiding ablation on the esophagus with esophageal deviation and modifying ablation approaches may decrease the risk of injury.
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Affiliation(s)
- Rahul Bhardwaj
- Loma Linda University, 11234 Anderson Street, Room 4404, Loma Linda, CA 92354, USA
| | - Jacob S Koruth
- Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Suite 1030, New York, NY 10029, USA
| | - Vivek Y Reddy
- Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Suite 1030, New York, NY 10029, USA.
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34
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Zhang ZW, Zhang P, Jiang RH, Liu Q, Sun YX, Yu L, Lin JW, Chen SQ, Sheng X, Fu GS, Jiang CY. Risk of esophageal thermal injury during catheter ablation for atrial fibrillation guided by different ablation index. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:633-639. [PMID: 32419141 DOI: 10.1111/pace.13941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/24/2020] [Accepted: 05/10/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND During ablation for atrial fibrillation (AF), energy delivery toward the left atrial posterior wall may cause esophageal injury (EI). Ablation index (AI) was introduced to estimate ablation lesion size, however, the impact of AI technology on the risk of EI has not been explored. METHOD From March 2019 to December 2019, 60 patients with paroxysmal AF undergoing first-time ablation were prospectively enrolled. The first 30 consecutive patients were ablated with the AI target value of 400 (AI-400 group), and the later 30 consecutive patients were ablated with the AI target value of 350 at the posterior wall (AI-350 group). Endoscopic ultrasonography was used to evaluate EI postablation. EI was classified as a category 1 (erythema or erosion) or a category 2 (hematoma or ulceration). RESULTS Compared with the AI-400 group (59.9 ± 8.4 years; male, 60%), the AI-350 group (59.1 ± 9.9 years; male, 50%) had a lower incidence of EI (3.3% vs 26.7%, P = .03). There was no significant difference in the percentage of first-pass PVI between the AI-400 group and the AI-350 group (left PVI: 80% vs 73.4%, P = .54; right PVI: 80% vs 60%, P = .1). Neither ablation time nor fluoroscopy time was significantly different between the AI-400 group and the AI-350 group. CONCLUSIONS AF ablation guide by AI target value of 350 may reduce esophageal thermal injury and has a similar efficiency on the acute success rate of first-pass PVI compared with an AI target value of 400 at the posterior wall.
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Affiliation(s)
- Zu-Wen Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ru-Hong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ya-Xun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Wei Lin
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shi-Quan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guo-Sheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chen-Yang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and, Regenerative Medicine of Zhejiang Province, Hangzhou, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
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35
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Kim YG, Shim J, Lee KN, Lim JY, Chung JH, Jung JS, Choi JI, Lee SH, Son HS, Kim YH. Management of Atrio-esophageal Fistula Induced by Radiofrequency Catheter Ablation in Atrial Fibrillation Patients: a Case Series. Sci Rep 2020; 10:8202. [PMID: 32424298 PMCID: PMC7235255 DOI: 10.1038/s41598-020-65185-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 04/28/2020] [Indexed: 11/23/2022] Open
Abstract
Atrio-esophageal fistula (AEF) is one of the most devastating complication of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) and surgical repair is strongly recommended. However, optimal surgical approach remains to be elucidated. We retrospectively reviewed AEF cases that occurred after RFCA in a single center and evaluated the clinical results of different surgical approach. Surgical or endoscopic repair was attempted in five AF patients who underwent RFCA. Atrio-esophageal fistula and mediastinal infection was not controlled in the patient who underwent endoscopic repair eventually died. Lethal cerebral air embolism occurred two days after surgery in a patient who underwent esophageal repair only. Primary surgical repair of both the left atrium (LA) and esophagus was performed in the remaining three patients. Among these three patients, two underwent external LA repair and the remaining had internal LA repair via open-heart surgery. External repair of the LA was unsuccessful and one patient dies and another had to undergo second operation with internal repair of the LA. The patient who underwent internal LA repair during the first operation survived without additional surgery. Furthermore, we applied veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with artificial induction of ventricular fibrillation in this patient to prevent air and septic embolism and she had no neurologic sequelae. In summary, surgical correction can be considered preferentially to correct AEF. Open-heart surgical repair of LA from the internal side seems to be an acceptable surgical method. Application of VA-ECMO with artificial induction of ventricular fibrillation might be effective to prevent air and septic embolism.
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Affiliation(s)
- Yun Gi Kim
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Jaemin Shim
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea.
| | - Kwang-No Lee
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Ju Yong Lim
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Jae Ho Chung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Jong-Il Choi
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Sung Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Ho Sung Son
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea.
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36
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Zhang P, Zhang YY, Ye Q, Jiang RH, Liu Q, Ye Y, Wu JG, Sheng X, Fu GS, Cha YM, Jiang CY. Characteristics of Atrial Fibrillation Patients Suffering Esophageal Injury Caused by Ablation for Atrial Fibrillation. Sci Rep 2020; 10:2751. [PMID: 32066780 PMCID: PMC7026048 DOI: 10.1038/s41598-020-59539-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue-Yue Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qian Ye
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ru-Hong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yang Ye
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jia-Guo Wu
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guo-Sheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chen-Yang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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37
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Hysi I, Fabre O. Atrio-oesophageal fistula after the cryomaze procedure: the devil is in the details. Eur J Cardiothorac Surg 2020; 57:410-411. [PMID: 31168587 DOI: 10.1093/ejcts/ezz169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/09/2019] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ilir Hysi
- Department of Cardiac Surgery, Lens Hospital and Bois Bernard Private Hospital, Ramsay Générale de Santé, Lens, France
| | - Olivier Fabre
- Department of Cardiac Surgery, Lens Hospital and Bois Bernard Private Hospital, Ramsay Générale de Santé, Lens, France
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38
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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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Stauber A, Kornej J, Bollmann A, Hindricks G, Sommer P. Relevance of esophageal position and temperature on thermal injuries and rhythm outcome in atrial fibrillation ablations. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 43:194-200. [PMID: 31853994 DOI: 10.1111/pace.13865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/05/2019] [Accepted: 12/11/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Thermolesions are a dangerous complication of atrial fibrillation (AF) ablation. We aimed to assess the reasons for thermolesions and the effect of esophageal position on recurrences. METHODS The study included consecutive patients undergoing AF catheter ablation at Heart Center Leipzig between January and September 2014. We collected data of esophagus localization, temperature, endoscopy, and follow-up. RESULTS The study included 645 patients into analyses. A total of 626 (97.2%) received a temperature probe. Esophageal position was categorized: (A) behind left pulmonary veins, (B) left ostial, (C) in the middle of left atrium, (D) right ostial, and (E) behind right pulmonary veins. The most frequent esophageal position was B-C (n = 201, 32.1%), followed by B (n = 161, 25.7%), and C (n = 147, 23.5%). The temperature was highest in A-B positions (42.04°C) and in D-E positions (41.70°C). There was a significant correlation between the endoscopically detected esophageal lesions (EDEL) and the esophageal position (r² = -.115, P = .004) and the esophageal temperature (r² = .162, P = .000), but not with body mass index (BMI) (r² = -.016, P = .688). Additional substrate modification in the left atrium resulted in significantly higher esophageal temperatures (P < .001) and more frequent EDEL (P = .049). An EDEL was found in 15 patients (2.3% of all patients, 5.6% of patients receiving endoscopy). Of those, the median esophageal temperature was 41.8°C (interquartile range [IQR]: 41.2-42.4). Neither esophageal position nor temperature during ablation was associated with arrhythmia recurrences (both P > .400). CONCLUSIONS EDEL depended on the esophageal position and temperature, but not on BMI. Esophageal position and intraluminal temperature during ablation had no effect on recurrences.
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Affiliation(s)
- Annina Stauber
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Jelena Kornej
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | - Philipp Sommer
- Clinic of Electrophysiology, Heart and Diabetes Center NRW, University Hospital of Ruhr-University Bochum, Bad Oeynhausen, Germany
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40
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Pürerfellner H, Deneke T. Esophageal Temperature Monitoring: The Faster the World Turns the Less Latency Will Be Acceptable. JACC Clin Electrophysiol 2019; 5:1289-1291. [PMID: 31753434 DOI: 10.1016/j.jacep.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/06/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Helmut Pürerfellner
- Department for Cardiology/Invasive Electrophysiology, Ordensklinikum Linz Elisabethinen, Linz, Austria.
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center Bad Neustadt, Rhoen Clinic Campus Bad Neustadt, Bad Neustadt, Germany
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41
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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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Halbfass P, Berkovitz A, Pavlov B, Sonne K, Nentwich K, Ene E, Hoerning F, Barth S, Zacher M, Deneke T. Incidence of acute thermal esophageal injury after atrial fibrillation ablation guided by prespecified ablation index. J Cardiovasc Electrophysiol 2019; 30:2256-2261. [PMID: 31559655 DOI: 10.1111/jce.14193] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/07/2019] [Accepted: 09/16/2019] [Indexed: 01/22/2023]
Abstract
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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Affiliation(s)
- Philipp Halbfass
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany.,Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Artur Berkovitz
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Borche Pavlov
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Kai Sonne
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Karin Nentwich
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Elena Ene
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Frank Hoerning
- Department of Internal Medicine, Rhön-Klinikum Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Sebastian Barth
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Michael Zacher
- Department of Clinical Documentation and Statistics, Rhön-Klinikum Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Thomas Deneke
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
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43
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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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