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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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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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Guckel D, Bergau L, Braun M, El Hamriti M, Mörsdorf M, Fink T, Sciacca V, Khalaph M, Imnadze G, Sommer P, Sohns C. Direct comparison of two 50 W high power short duration approaches-Temperature- versus ablation index-guided radiofrequency ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2022; 33:2517-2527. [PMID: 36104929 DOI: 10.1111/jce.15674] [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: 06/02/2022] [Revised: 08/31/2022] [Accepted: 09/11/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Approaches applying higher energy levels for shorter periods (high power short duration, HPSD) to improve lesion formation for atrial fibrillation (AF) ablation have been introduced. This single-center study aimed to compare the efficacy, safety, and lesion formation using the novel DiamondTemp (DT) catheter or an ablation index (AI)-guided HPSD ablation protocol using a force-sensing catheter with surround-flow irrigation. METHODS One hundred thirteen consecutive patients undergoing radiofrequency-guided catheter ablation (RFCA) for AF were included. Forty-five patients treated with the DT catheter (50 W, 9 s), were compared to 68 consecutive patients undergoing AI-guided ablation (AI anterior 550; AI posterior 400) adherent to a 50 W HPSD protocol. Procedural data and AF recurrence were evaluated. RESULTS Acute procedural success was achieved in all patients (n = 113, 100%). DT-guided AF ablation was associated with a longer mean procedure duration (99.10 ± 28.30 min vs. 78.24 ± 25.55, p < .001) and more RF applications (75.24 ± 30.76 min vs. 61.27 ± 14.06, p = .019). RF duration (792.13 ± 311.23 s vs. 1035.54 ± 287.24 s, p < .001) and fluoroscopy dose (183.81 ± 178.13 vs. 295.80 ± 247.54 yGym2 , p = .013) were lower in the DT group. AI-guided HPSD was associated with a higher AF-free survival rate without reaching statistical significance (p = .088). Especially patients with PERS AF (p = .009) as well as patients with additional atrial arrhythmia substrate (p = .002) benefited from an AI-guided ablation strategy. CONCLUSION Temperature- and AI- controlled HPSD RFCA using 50 W was safe and effective. AI-guided HPSD ablation seems to be associated with shorter procedure durations and fewer RF applications. Particularly in advanced AF, freedom from AF-recurrence may be improved using an AI-guided HPSD approach.
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Affiliation(s)
- Denise Guckel
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Leonard Bergau
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Martin Braun
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Mustapha El Hamriti
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Maximilian Mörsdorf
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Thomas Fink
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Moneeb Khalaph
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Guram Imnadze
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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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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Miwa Y, Mohri T, Katsume Y, Tashiro M, Momose Y, Nonoguchi N, Hoshida K, Togashi I, Hagiwara Y, Maeda A, Ueda A, Sato T, Soejima K. Left Atrial Reverse Remodeling Following the Modified Box Isolation with Centerline in Patients with Persistent Atrial Fibrillation. Int Heart J 2021; 62:1005-1011. [PMID: 34544979 DOI: 10.1536/ihj.21-108] [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: 11/18/2022]
Abstract
Esophageal injury is a rare but serious complication of atrial fibrillation (AF) ablation. To minimize esophageal injury, our persistent AF (PerAF) protocol involves complete left atrial posterior wall (LAPW) and pulmonary vein (PV) isolation (box isolation), with a centerline away from the esophagus. However, there has been a concern that extensive LA isolation might deteriorate LA function. There has been a paucity of data on LA remodeling after box isolation. Therefore, we compared LA size pre- and post-box isolation with an LAPW centerline in patients with PerAF.Patients who underwent catheter ablation (CA) for PerAF between November 2016 and December 2018 were retrospectively evaluated.The LAPW, including all PVs, was completely isolated in 105 consecutive patients (75 men; mean age: 68 ± 10 years) with PerAF, including 58 patients with long-standing PerAF. During a follow-up of 660 ± 332 days, 76 patients (72%) were arrhythmia-free. The LA dimension (38 ± 6 mm versus 42 ± 7 mm; P < 0.0001) and volume index (38 ± 13 mL/m2 versus 47 ± 14 mL/m2; P < 0.0001) at 6 months post-ablation were significantly decreased in patients who maintained sinus rhythm compared to pre-ablation. In patients with recurrent AF/atrial tachycardia (AT), these parameters were also significantly decreased (P < 0.001, respectively).Box isolation with a posterior centerline has no esophageal complications and a high clinical success rate in patients with PerAF. Reverse remodeling could be achieved even when using extensive isolation of the PV and LAPW in patients with PerAF.
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Affiliation(s)
- Yosuke Miwa
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Takato Mohri
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Yumi Katsume
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Mika Tashiro
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Yuichi Momose
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Noriko Nonoguchi
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Kyoko Hoshida
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Ikuko Togashi
- Division of Advanced Arrhythmia Management, Kyorin University Hospital
| | - Yo Hagiwara
- Division of Engineering, Kyorin University Hospital
| | - Akiko Maeda
- Division of Advanced Arrhythmia Management, Kyorin University Hospital
| | - Akiko Ueda
- Division of Advanced Arrhythmia Management, Kyorin University Hospital
| | - Toshiaki Sato
- Division of Advanced Arrhythmia Management, Kyorin University Hospital
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital
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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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Jiang R, Zei PC, Jiang C. Prevention of left atrium esophagus fistula: Appraisal of existing technologies and strategies. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:646-654. [PMID: 32391576 DOI: 10.1111/pace.13939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/27/2020] [Accepted: 05/08/2020] [Indexed: 12/17/2022]
Abstract
Catheter ablation has emerged as an effective treatment for atrial fibrillation (AF). Atrial esophageal fistula (AEF) is a rare, but feared complication. With increasing utilization of ablation therapy for AF, the understanding of the relationship between AEF and ablation has been improved in recent years. Efforts to reduce the risk of AEF have focused on decreasing the risk of severe esophageal injury (EI) and the presumed subsequent progression from EI to AEF, including esophageal temperature monitoring, esophageal cooling systems, esophageal deviation devices, and decreasing and/or curtailing ablation energy delivery. Periprocedural assessment may help identify higher risk patients and detect early esophageal lesions. This review systematically summarizes and evaluates the current strategies and techniques utilized to reduce the risk of AEF in the clinical workflow for AF ablation. We expect that this review will help clinicians to better understand the principles, advantages, and disadvantages of these methods, and to find suitable strategies using current available tools.
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Affiliation(s)
- Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, Hangzhou, Zhejiang, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
| | - Paul C Zei
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, Hangzhou, Zhejiang, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
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