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Velasco A, Buch C, Hui D, Joseph C, Onsager D, Zagrodzky W, Kulstad E, Nayak HM. Hybrid convergent procedure with proactive oesophageal cooling for the treatment of long-standing persistent atrial fibrillation: a case series. Eur Heart J Case Rep 2024; 8:ytae301. [PMID: 38966596 PMCID: PMC11223606 DOI: 10.1093/ehjcr/ytae301] [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: 02/20/2024] [Revised: 03/19/2024] [Accepted: 06/07/2024] [Indexed: 07/06/2024]
Abstract
Background The hybrid convergent procedure is approved to treat symptomatic patients with long-standing persistent atrial fibrillation (AF). Despite direct visualization during surgical ablation as well as the use of luminal oesophageal temperature (LET) monitoring, oesophageal injury is still possible. A dedicated device for proactive oesophageal cooling has recently been cleared by the Food and Drug Administration to reduce the likelihood of ablation-related oesophageal injury resulting from radiofrequency cardiac ablation procedures. This report describes the first uses of proactive oesophageal cooling for oesophageal protection during the epicardial ablation portion of hybrid convergent procedures. Case summary Five patients with long-standing persistent AF underwent hybrid convergent ablations with the use of proactive oesophageal cooling as means of oesophageal protection. All cases were completed successfully with no adverse effects. Most notably, cases were shorter when compared to cases using LET monitoring, likely due to lack of pauses for overheating of the oesophagus that would otherwise be required to prevent damage to the oesophagus. Discussion This report describes the first uses of proactive oesophageal cooling for oesophageal protection during the epicardial ablation portion of five hybrid convergent procedures. Use of cooling enabled uninhibited deployment of lesions without the need to pause energy delivery due to elevated temperatures in the oesophagus, providing a feasible alternative to LET monitoring.
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Affiliation(s)
- Alejandro Velasco
- Division of Cardiology, University of Texas Health, San Antonio, TX, USA
| | - Chirag Buch
- Division of Cardiology, University of Texas Health, San Antonio, TX, USA
| | - Dawn Hui
- Division of Cardiothoracic Surgery, University of Texas Health, San Antonio, TX, USA
| | - Christopher Joseph
- Department of Emergency Medicine, University of Texas Southwestern Medical Centre, Dallas, TX, USA
| | - David Onsager
- Division of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - William Zagrodzky
- Department of Biochemistry, Colorado College, 14 E Cache La Poudre St, Colorado Springs, CO 80903, USA
| | - Erik Kulstad
- Department of Emergency Medicine, University of Texas Southwestern Medical Centre, Dallas, TX, USA
| | - Hemal M Nayak
- Division of Cardiology, University of Texas Health, San Antonio, TX, USA
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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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Zagrodzky W, Cooper J, Joseph C, Sackett M, Silva J, Kuk R, McHugh J, Brumback B, Park S, Hayward R, Taneja T, Vu A, Liu T, Kulstad E, Kaplan A, Ramireddy A, Omotoye S. Association between proactive esophageal cooling and increased lab throughput. J Cardiovasc Electrophysiol 2024; 35:1150-1155. [PMID: 38566579 DOI: 10.1111/jce.16263] [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: 01/24/2024] [Revised: 02/29/2024] [Accepted: 03/16/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Proactive esophageal cooling has been FDA cleared to reduce the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures. Data suggest that procedure times for RF pulmonary vein isolation (PVI) also decrease when proactive esophageal cooling is employed instead of luminal esophageal temperature (LET) monitoring. Reduced procedure times may allow increased electrophysiology (EP) lab throughput. We aimed to quantify the change in EP lab throughput of PVI cases after the introduction of proactive esophageal cooling. METHODS EP lab throughput data were obtained from three EP groups. We then compared EP lab throughput over equal time frames at each site before (pre-adoption) and after (post-adoption) the adoption of proactive esophageal cooling. RESULTS Over the time frame of the study, a total of 2498 PVIs were performed over a combined 74 months, with cooling adopted in September 2021, November 2021, and March 2022 at each respective site. In the pre-adoption time frame, 1026 PVIs were performed using a combination of LET monitoring with the addition of esophageal deviation when deemed necessary by the operator. In the post-adoption time frame, 1472 PVIs were performed using exclusively proactive esophageal cooling, representing a mean 43% increase in throughput (p < .0001), despite the loss of two operators during the post-adoption time frame. CONCLUSION Adoption of proactive esophageal cooling during PVI ablation procedures is associated with a significant increase in EP lab throughput, even after a reduction in total number of operating physicians in the post-adoption group.
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Affiliation(s)
| | - Julie Cooper
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Matthew Sackett
- Centra Health, Centra Lynchburg General Hospital and Centra Specialty Hospital, Lynchburg, Virginia, USA
| | - Jose Silva
- Centra Health, Centra Lynchburg General Hospital and Centra Specialty Hospital, Lynchburg, Virginia, USA
| | - Richard Kuk
- Centra Health, Centra Lynchburg General Hospital and Centra Specialty Hospital, Lynchburg, Virginia, USA
| | - Julia McHugh
- Centra Health, Centra Lynchburg General Hospital and Centra Specialty Hospital, Lynchburg, Virginia, USA
| | - Babette Brumback
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Shirley Park
- Kaiser Permanente, Santa Clara Medical Center, Santa Clara, California, USA
| | - Robert Hayward
- Kaiser Permanente, Santa Clara Medical Center, Santa Clara, California, USA
| | - Taresh Taneja
- Kaiser Permanente, Santa Clara Medical Center, Santa Clara, California, USA
| | - Andrew Vu
- Kaiser Permanente, Santa Clara Medical Center, Santa Clara, California, USA
| | - Taylor Liu
- Kaiser Permanente, Santa Clara Medical Center, Santa Clara, California, USA
| | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Tonko JB, Silberbauer J, Mann I. How to ablate the septo-pulmonary bundle: a case-based review of percutaneous ablation strategies to achieve roof line block. Europace 2023; 25:euad283. [PMID: 37713215 PMCID: PMC10558061 DOI: 10.1093/europace/euad283] [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: 06/27/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
Electrical conduction through cardiac muscle fibres separated from the main myocardial wall by layers of interposed adipose tissue are notoriously difficult to target by endocardial ablation alone. They are a recognised important cause for procedural failure due to the difficulties of delivering sufficient energy via the endocardial radiofrequency catheter to reach the outer epicardial layer without risking adverse events of the otherwise thin walled atria. Left atrial ablations for atrial fibrillation (AF) and tachycardia are commonly affected by the presence of several epicardial structures, with the septo-pulmonary bundle (SPB), Bachmann's bundle, and the ligament of Marshall all posing substantial challenges for endocardial procedures. Delivery of a transmural lesion set is essential for sustained pulmonary vein isolation and for conduction block across linear atrial lines which in turn has been described to translate into a reduced AF/atrial tachycardia recurrence rate. To overcome the limitations of endocardial-only approaches, surgical ablation techniques for epicardial or combined hybrid endo-epicardial ablations have been described to successfully target these connections. Yet, these techniques confer an increase in procedure complexity, duration, cost, and morbidity. Alternatively, coronary venous system ethanol ablation has been successfully employed by sub-selecting the vein of Marshall to facilitate mitral isthmus line block, although this approach is naturally limited to this area by the coronary venous anatomy. Increased awareness of the pathophysiological relevance of these epicardial structures and their intracardiac conduction patterns in the era of high-resolution 3D electro-anatomical mapping technology has allowed greater understanding of their contribution to the persistence of AF as well as failure to achieve transmural block by traditional ablation approaches. This might translate into novel catheter ablation strategies with procedural success rates comparable to surgical 'cut-and-sew' techniques. This review aims to give an overview of percutaneous catheter ablation strategies to target the SPB, an important cause of failed block across the roof line and isolation of the left atrial posterior wall and/or the pulmonary veins. Existing and investigational technologies will be discussed and an outlook of future approaches provided.
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Affiliation(s)
- Johanna Bérénice Tonko
- Institute for Cardiovascular Science, University College London, 5 University Street, WC1E 6JF London, UK
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
| | - John Silberbauer
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
| | - Ian Mann
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
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Joseph C, Nazari J, Zagrodzky J, Brumback B, Sherman J, Zagrodzky W, Bailey S, Kulstad E, Metzl M. Improved 1-year outcomes after active cooling during left atrial radiofrequency ablation. J Interv Card Electrophysiol 2023; 66:1621-1629. [PMID: 36670327 PMCID: PMC10359433 DOI: 10.1007/s10840-023-01474-3] [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: 10/20/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Active esophageal cooling during pulmonary vein isolation (PVI) with radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF) is increasingly being utilized to reduce esophageal injury and atrioesophageal fistula formation. Randomized controlled data also show trends towards increased freedom from AF when using active cooling. This study aimed to compare 1-year arrhythmia recurrence rates between patients treated with luminal esophageal temperature (LET) monitoring versus active esophageal cooling during left atrial ablation. METHOD Data from two healthcare systems (including 3 hospitals and 4 electrophysiologists) were reviewed for patient rhythm status at 1-year follow-up after receiving PVI for the treatment of AF. Results were compared between patients receiving active esophageal cooling (ensoETM, Attune Medical, Chicago, IL) and those treated with traditional LET monitoring using Kaplan-Meier estimates. RESULTS A total of 513 patients were reviewed; 253 received LET monitoring using either single or multi-sensor temperature probes; and 260 received active cooling. The mean age was 66.8 (SD ± 10) years, and 36.8% were female. Arrhythmias were 60.1% paroxysmal AF, 34.3% persistent AF, and 5.6% long-standing persistent AF, with no significant difference between groups. At 1-year follow-up, KM estimates for freedom from AF were 58.2% for LET-monitored patients and 72.2% for actively cooled patients, for an absolute increase in freedom from AF of 14% with active esophageal cooling (p = .03). Adjustment for the confounders of patient age, gender, type of AF, and operator with an inverse probability of treatment weighted Cox proportional hazards model yielded a hazard ratio of 0.6 for the effect of cooling on AF recurrence (p = 0.045). CONCLUSIONS In this first study to date of the association between esophageal protection strategy and long-term efficacy of left atrial RF ablation, a clinically and statistically significant improvement in freedom from atrial arrhythmia at 1 year was found in patients treated with active esophageal cooling when compared to patients who received LET monitoring. More rigorous prospective studies or randomized studies are required to validate the findings of the current study.
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Affiliation(s)
| | - Jose Nazari
- NorthShore University Health System, Evanston, IL, USA
| | - Jason Zagrodzky
- Texas Cardiac Arrhythmia Institute, St. David's South Austin Medical Center, 901 W Ben White Blvd, Austin, TX, 78704, USA
| | - Babette Brumback
- Department of Biostatistics, College of Public Health & Health Professions, College of Medicine, University of Florida, Gainesville, USA
| | - Jacob Sherman
- Washington University in Saint Louis, 1 Brookings Dr, MO, 63130, St. Louis, USA
| | - William Zagrodzky
- Colorado College, 14 E Cache La Poudre St, Colorado Springs, CO, 80903, USA
| | - Shane Bailey
- Texas Cardiac Arrhythmia Institute, St. David's South Austin Medical Center, 901 W Ben White Blvd, Austin, TX, 78704, USA
| | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
| | - Mark Metzl
- NorthShore University Health System, Evanston, IL, USA
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Leung LWM, Akhtar Z, Gallagher MM. Letter to the editor: oesophageal cooling for protection during left atrial ablations. Europace 2023; 25:euad153. [PMID: 37294672 PMCID: PMC10254069 DOI: 10.1093/europace/euad153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023] Open
Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Zaki Akhtar
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
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Preventing atrioesophageal fistula. JAAPA 2023; 36:1. [PMID: 36573822 DOI: 10.1097/01.jaa.0000902928.46762.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Joseph C, Cooper J, Sikka R, Zagrodzky J, Turer RW, McDonald SA, Kulstad E, Daniels J. Improved hospital discharge and cost savings with esophageal cooling during left atrial ablation. J Med Econ 2023; 26:158-167. [PMID: 36537305 DOI: 10.1080/13696998.2022.2160596] [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] [Indexed: 12/24/2022]
Abstract
BACKGROUND Left atrial ablation to obtain pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) is a technologically intensive procedure utilizing innovative and continually improving technology. Changes in the technology utilized for PVI can in turn lead to changes in procedure costs. Because of the proximity of the esophagus to the posterior wall of the left atrium, various technologies have been utilized to protect against thermal injury during ablation. The impact on hospital costs during PVI ablation from utilization of different technologies for esophageal protection during ablation has not previously been evaluated. OBJECTIVE To compare the costs of active esophageal cooling to luminal esophageal temperature (LET) monitoring during left atrial ablation. METHODS We performed a time-driven activity-based costing (TDABC) analysis to determine costs for PVI procedures. Published data and literature review were utilized to determine differences in procedure time and same-day discharge rates using different esophageal protection technologies and to determine the cost impacts of same-day discharge versus overnight hospitalization after PVI procedures. The total costs were then compared between cases using active esophageal cooling to those using LET monitoring. RESULTS The effect of implementing active esophageal cooling was associated with up to a 24.7% reduction in mean total procedure time, and an 18% increase in same-day discharge rate. TDABC analysis identified a $681 reduction in procedure costs associated with the use of active esophageal cooling after including the cost of the esophageal cooling device. Factoring in the 18% increase in same-day discharge resulted in an increased cost savings of $2,135 per procedure. CONCLUSIONS The use of active esophageal cooling is associated with significant cost-savings when compared to traditional LET monitoring, even after accounting for the additional cost of the cooling device. These savings originate from a per-patient procedural time savings and a per-population improvement in same-day discharge rate.
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Affiliation(s)
| | - Julie Cooper
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rishi Sikka
- Policy and Practice, Brown University School of Public Health, Providence, RI, USA
- Lifeforce Capital, San Francisco, CA, USA
| | - Jason Zagrodzky
- Texas Cardiac Arrhythmia Institute, St. David's South Austin Medical Center, Austin, TX, USA
| | - Robert W Turer
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Daniels
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Cooper J, Joseph C, Zagrodzky J, Woods C, Metzl M, Turer RW, McDonald SA, Kulstad E, Daniels J. Active esophageal cooling during radiofrequency ablation of the left atrium: data review and update. Expert Rev Med Devices 2022; 19:949-957. [PMID: 36413154 PMCID: PMC9839561 DOI: 10.1080/17434440.2022.2150930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Radiofrequency (RF) ablation of the left atrium of the heart is increasingly used to treat atrial fibrillation (AF). Unfortunately, inadvertent thermal injury to the esophagus can occur during this procedure, potentially creating an atrioesophageal fistula (AEF) which is 80% fatal. The ensoETM (Attune Medical, Chicago, IL), is an esophageal cooling device that has been shown to reduce thermal injury to the esophagus during RF ablation. AREAS COVERED This review summarizes growing evidence related to active esophageal cooling during RF ablation for the treatment of AF. The review presents data demonstrating improved outcomes related to patient safety and procedural efficiency and suggests directions for future research. EXPERT OPINION The use of active esophageal cooling during RF ablation reduces esophageal injury, reduces or eliminates fluoroscopy requirements, reduces procedure duration and post-operative pain, and increases long-term freedom from arrhythmia. These effects in turn increase patient same-day discharge rates, decrease operator cognitive load, and reduce cost. These findings are likely to further accelerate the adoption of active esophageal cooling.
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Affiliation(s)
- Julie Cooper
- University of Texas Southwestern Medical Center, Dallas, TX 75390
| | | | - Jason Zagrodzky
- Texas Cardiac Arrhythmia Institute, St. David’s South Austin Medical Center, Austin, TX 78704
| | | | - Mark Metzl
- NorthShore University Health System, 2650 Ridge Avenue, Evanston, IL 60201
| | - Robert W. Turer
- University of Texas Southwestern Medical Center, Dallas, TX 75390
| | | | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - James Daniels
- University of Texas Southwestern Medical Center, Dallas, TX 75390
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Montoya MM, Bustamante TG, Berjano E, Mickelsen SR, Daniels JD, Arango PH, Schieber J, Kulstad E. Proactive esophageal cooling protects against thermal insults during high-power short-duration radiofrequency cardiac ablation. Int J Hyperthermia 2022; 39:1202-1212. [PMID: 36104029 PMCID: PMC9771690 DOI: 10.1080/02656736.2022.2121860] [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] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Proactive cooling with a novel cooling device has been shown to reduce endoscopically identified thermal injury during radiofrequency (RF) ablation for the treatment of atrial fibrillation using medium power settings. We aimed to evaluate the effects of proactive cooling during high-power short-duration (HPSD) ablation. METHODS A computer model accounting for the left atrium (1.5 mm thickness) and esophagus including the active cooling device was created. We used the Arrhenius equation to estimate the esophageal thermal damage during 50 W/ 10 s and 90 W/ 4 s RF ablations. RESULTS With proactive esophageal cooling in place, temperatures in the esophageal tissue were significantly reduced from control conditions without cooling, and the resulting percentage of damage to the esophageal wall was reduced around 50%, restricting damage to the epi-esophageal region and consequently sparing the remainder of the esophageal tissue, including the mucosal surface. Lesions in the atrial wall remained transmural despite cooling, and maximum width barely changed (<0.8 mm). CONCLUSIONS Proactive esophageal cooling significantly reduces temperatures and the resulting fraction of damage in the esophagus during HPSD ablation. These findings offer a mechanistic rationale explaining the high degree of safety encountered to date using proactive esophageal cooling, and further underscore the fact that temperature monitoring is inadequate to avoid thermal damage to the esophagus.
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Affiliation(s)
| | | | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Spain
| | | | - James D. Daniels
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Jay Schieber
- Illinois Institute of Technology, Chicago, IL, USA
| | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Procedural time reduction associated with active esophageal cooling during pulmonary vein isolation. J Interv Card Electrophysiol 2022; 65:617-623. [PMID: 35416632 PMCID: PMC9726815 DOI: 10.1007/s10840-022-01204-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/28/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Active esophageal cooling is increasingly utilized as an alternative to luminal esophageal temperature (LET) monitoring for protection against thermal injury during pulmonary vein isolation (PVI) when treating atrial fibrillation (AF). Published data demonstrate the efficacy of active cooling in reducing thermal injury, but impacts on procedural efficiency are not as well characterized. LET monitoring compels pauses in ablation due to heat stacking and temperature overheating alarms that in turn delay progress of the PVI procedure, whereas active esophageal cooling allows avoidance of this phenomenon. Our objective was to measure the change in PVI procedure duration after implementation of active esophageal cooling as a protective measure against esophageal injury. METHODS We performed a retrospective review under IRB approval of patients with AF undergoing PVI between January 2018 and February 2020. For each patient, we recorded age, gender, and total procedure time. We then compared procedure times before and after the implementation of active esophageal cooling as a replacement for LET monitoring. RESULTS A total of 373 patients received PVI over the study period. LET monitoring using a multi-sensor probe was performed in 198 patients, and active esophageal cooling using a dedicated device was performed in 175 patients. Patient characteristics did not significantly differ between groups (mean age of 67 years, and gender 37.4% female). Mean procedure time was 146 ± 51 min in the LET-monitored patients, and 110 ± 39 min in the actively cooled patients, representing a reduction of 36 min, or 24.7% of total procedure time (p < .001). Median procedure time was 141 [IQR 104 to 174] min in the LET-monitored patients and 100 [IQR 84 to 122] min in the actively cooled patients, for a reduction of 41 min, or 29.1% of total procedure time (p < .001). CONCLUSIONS Implementation of active esophageal cooling for protection against esophageal injury during PVI was associated with a significantly large reduction in procedure duration.
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Mansour M. Letter from the Editor in Chief. J Innov Card Rhythm Manag 2021; 12:A7. [PMID: 34858673 PMCID: PMC8631369 DOI: 10.19102/icrm.2021.121107] [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: 11/18/2022] Open
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