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Omotoye S, Singleton MJ, Zagrodzky J, Clark B, Sharma D, Metzl MD, Gallagher MM, Meininghaus DG, Leung L, Garg J, Warrier N, Panico A, Tamirisa K, Sanchez J, Mickelsen S, Sardana M, Shah D, Athill C, Hayat J, Silva R, Clark AT, Gray M, Levi B, Kulstad E, Girouard S, Zagrodzky W, Montoya MM, Bustamante TG, Berjano E, González-Suárez A, Daniels J. Mechanisms of action behind the protective effects of proactive esophageal cooling during radiofrequency catheter ablation in the left atrium. Heart Rhythm O2 2024; 5:403-416. [PMID: 38984358 PMCID: PMC11228283 DOI: 10.1016/j.hroo.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Abstract
Proactive esophageal cooling for the purpose of reducing the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures is increasingly being used and has been Food and Drug Administration cleared as a protective strategy during left atrial RF ablation for the treatment of atrial fibrillation. In this review, we examine the evidence supporting the use of proactive esophageal cooling and the potential mechanisms of action that reduce the likelihood of atrioesophageal fistula (AEF) formation. Although the pathophysiology behind AEF formation after thermal injury from RF ablation is not well studied, a robust literature on fistula formation in other conditions (eg, Crohn disease, cancer, and trauma) exists and the relationship to AEF formation is investigated in this review. Likewise, we examine the abundant data in the surgical literature on burn and thermal injury progression as well as the acute and chronic mitigating effects of cooling. We discuss the relationship of these data and maladaptive healing mechanisms to the well-recognized postablation pathophysiological effects after RF ablation. Finally, we review additional important considerations such as patient selection, clinical workflow, and implementation strategies for proactive esophageal cooling.
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Affiliation(s)
| | | | - Jason Zagrodzky
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | | | | | - Mark D. Metzl
- NorthShore University Health System, Evanston, Illinois
| | - Mark M. Gallagher
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Lisa Leung
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jalaj Garg
- Loma Linda University Medical Center, Loma Linda, California
| | - Nikhil Warrier
- MemorialCare Heart & Vascular Institute, Fountain Valley, California
| | | | - Kamala Tamirisa
- Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Dallas, Texas
| | - Javier Sanchez
- Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Dallas, Texas
| | | | | | - Dipak Shah
- Ascension Providence Hospital, Detroit, Michigan
| | | | - Jamal Hayat
- Department of Gastroenterology, St George’s University Hospital, London, United Kingdom
| | - Rogelio Silva
- Department of Medicine, Division of Gastroenterology, University of Illinois at Chicago, Chicago, Illinois
- Advocate Aurora Christ Medical Center, Chicago, Illinois
| | - Audra T. Clark
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Benjamin Levi
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | - Enrique Berjano
- Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Ana González-Suárez
- Translational Medical Device Lab, School of Medicine, University of Galway, Galway, Ireland
- Valencian International University, Valencia, Spain
| | - James Daniels
- University of Texas Southwestern Medical Center, Dallas, Texas
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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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Grosse Meininghaus D, Freund R, Koerber B, Kleemann T, Matthes H, Geller JC. Pulsed-field ablation does not induce esophageal and periesophageal injury-A new esophageal safety paradigm in catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2024; 35:86-93. [PMID: 37975544 DOI: 10.1111/jce.16132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Esophageal injury is one of the most serious complications of pulmonary vein isolation (PVI) with thermic energy sources. Better tissue selectivity of primarily non-thermic pulsed field ablation (PFA) may eliminate collateral injury, particularly the risk of atrio-esophageal fistula (AEF). OBJECTIVE To compare the incidence of any (peri)-esophageal injury following PVI using PFA to thermic energy sources. METHODS Using endoscopy, endoscopic ultrasound, and electrogastrography before and after PVI, esophageal and periesophageal injury (mucosal lesions, food retention, periesophageal edema, or vagal nerve injury) were assessed following PFA and radiofrequency (RF)- or cryoballoon (CB)-PVI. RESULTS Between December 2022 and February 2023, 20 patients (67 ± 10 years, 53% male) undergoing PFA (Farapulse, Boston Scientific) for atrial fibrillation (AF) were studied and compared with a previous cohort of 57 patients who underwent thermic PVI (CB: n = 33; RF: n = 24). Following PFA-PVI, none of the patients had mucosal lesions, food retention, or ablation-induced vagal nerve injury; four patients showed periesophageal edema. Following thermic ablation, 33/57 patients (58%) showed esophageal and/or periesophageal injury (CB: 21/33 [64%], RF: 12/24 [50%]), in detail 4/57 mucosal lesions, 18/57 food retention, 17/57 vagal nerve injury, and 20/52 edema. Midterm success rates were similar for all energy sources. CONCLUSION In contrast to thermic ablation tools, PFA is not associated with relevant esophageal and periesophageal injury, and might, therefore, reduce or eliminate the risk of potentially lethal AEF in interventional treatment of AF. The etiology of ablation-induced periesophageal edema is unknown but has not been shown to be related to lesion progression.
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Affiliation(s)
| | - Robert Freund
- Thiem Research, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Britta Koerber
- Division of Cardiology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Tobias Kleemann
- Division of Gastroenterology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Harald Matthes
- Division of Gastroenterology, Community-Hospital Havelhoehe Berlin, Berlin, Germany
| | - Johann Christoph Geller
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany
- Otto-von-Guericke University School of Medicine Magdeburg, Magdeburg, Germany
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Grosse Meininghaus D, Freund R, Kleemann T, Geller JC, Matthes H. Pulmonary vein isolation-induced vagal nerve injury and gastric motility disorders detected by electrogastrography: The side effects of pulmonary vein isolation in atrial fibrillation (SEPIA) study. J Cardiovasc Electrophysiol 2023; 34:583-592. [PMID: 36640436 DOI: 10.1111/jce.15820] [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: 09/15/2022] [Revised: 11/14/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Safety of pulmonary vein isolation (PVI) has been established in clinical studies. However, despite prevention efforts the incidence of damage to (peri)-esophageal tissue has not decreased, and the pathophysiology is incompletely understood. Damage to vagal nerve branches may be involved in lesion progression to atrio-esophageal fistula. Using electrogastrography, we assessed the incidence of periesophageal vagal nerve injury (VNI) following atrial fibrillation ablation and its association with procedural parameters and endoscopic results. METHODS Patients were studied using electrogastrography, endoscopy, and endoscopic ultrasound before and after cryoballoon (CB) or radiofrequency (RF) PVI. The incidence of ablation-induced neuropathic pattern (indicating VNI) in pre- and postprocedural electrogastrography was assessed and correlated with endoscopic results and ablation data. RESULTS Between February 2021 und January 2022, 85 patients (67 ± 10 years, 53% male) were included, 33 were treated with CB and 52 with RF (38 with moderate power moderate duration [25-30 W] and 14 with high power short duration [50 W]). Ablation-induced VNI was detected in 27/85 patients independent of the energy form. Patients with VNI more frequently had postprocedural endoscopically detected pathology (8% mucosal esophageal lesions, 36% periesophageal edema, 33% food retention) but there was incomplete overlap. Pre-existing esophagitis increased the likelihood of VNI. Ablation data and esophageal temperature data did not predict VNI. CONCLUSION PVI-induced VNI is quite common and independent of ablation energy source. VNI is part of (peri)-esophageal damage and only partially overlaps with endoscopic findings. VNI-associated acidic reflux may be involved in the complex pathophysiology of esophageal lesion progression to fistula.
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Affiliation(s)
| | - Robert Freund
- Carl-Thiem-Hospital Cottbus, Thiem Research, Cottbus, Germany
| | - Tobias Kleemann
- Department of Gastroenterology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Johann Christoph Geller
- Zentralklinik Bad Berka, Division of Cardiology, Arrhythmia Section, Bad Berka, Germany.,Otto-von-Guericke University School of Medicine Magdeburg, Magdeburg, Germany
| | - Harald Matthes
- Department of Gastroenterology, Community-Hospital Havelhoehe Berlin, Berlin, Germany
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Grosse Meininghaus D, Freund R, Kushnir A, Koerber B, Geller JC, Kleemann T. Asymptomatic esophageal perforation following high-power short-duration pulmonary vein isolation—A case of conservative cure. HeartRhythm Case Rep 2022; 8:661-665. [PMID: 36310731 PMCID: PMC9596363 DOI: 10.1016/j.hrcr.2022.07.005] [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: 12/02/2022] Open
Affiliation(s)
- Dirk Grosse Meininghaus
- Department of Cardiology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
- Address reprint requests and correspondence: Dr Dirk Grosse Meininghaus, Department of Cardiology, Carl-Thiem-Hospital, Thiemstr. 111, 03048 Cottbus, Germany.
| | - Robert Freund
- Thiem Research, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Anton Kushnir
- Department of Radiology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Britta Koerber
- Department of Cardiology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - J. Christoph Geller
- Division of Cardiology, Arrhythmia Section, Zentralklinik Bad Berka, Bad Berka, Germany
- Otto-von-Guericke University School of Medicine Magdeburg, Magdeburg, Germany
| | - Tobias Kleemann
- Department of Gastroenterology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
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