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. 2012 Jun;8(6):414–416.

Esophageal Injury Following Left Atrial Ablation

Bashar J Qumseya 1, Fred Kusumoto 2,3, Herbert Wolfsen 1
PMCID: PMC3424481  PMID: 22933882

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical medicine. Current estimates suggest that 4—5 million individuals in the United States have AF. It has been projected that, because of changing demographics, this number will increase to 10 million in 20 years.1 A rate-control strategy is used to treat many patients with AF, although some patients require antiarrhythmic medications to maintain sinus rhythm. Unfortunately, antiarrhythmic medications are effective in only 40—70% of patients.

For patients who fail an antiarrhythmic drug trial due to inefficacy or drug intolerance, percutaneous catheter ablation has emerged as an important treatment option.2 Generally, ablation for AF is performed by placing a series of lesions around the pulmonary vein ostia in the posterior left atrium (LA). Initial single-center reports found success rates of 90% with AF ablation, but recent randomized multicenter studies using rigorous definitions for AF recurrence have found success rates ranging from 60% to 80%, depending on patient selection.35 Catheters used for AF ablation vary, and lesions can be produced with either cryoenergy or radiofrequency energy. However, most AF ablations are performed using radiofrequency energy in a monopolar configuration with current travelling from a small tip electrode within the heart (producing thermal injury to the cardiac tissue) to a larger return electrode placed on the skin. To produce a deeper lesion, the most commonly used catheter has a 4-mm tip electrode that is continuously irrigated with saline to produce higher tissue temperatures below the surface. Many techniques have been developed to control the size of the lesion created (eg, by varying the duration of energy application, changing the flow of irrigation, or modifying the amount of power used), but it is extremely difficult to predict the actual depth of lesion formation in real time while performing AF ablation.

Despite the relative safety of the procedure, 2—6% of patients may experience major complications, including stroke, cardiac tamponade, pulmonary vein stenosis, and extracardiac injury.6,7 The esophagus is separated from the posterior LA by a thin (0.9±0.2 mm) layer of fat. Therefore, the esophagus is particularly prone to thermal injury during AF ablation.8 Reported esophageal injuries include perforation, atrio-esophageal fistula formation, and peri-esophageal nerve injury.9 In particular, development of an atrio-esophageal fistula can be difficult to detect and is almost uniformly fatal if not treated promptly. The incidence of this complication is not well established but appears to be approximately 0.05%; the associated mortality rate reported in the literature is very high (93%), with 13 deaths occurring in 14 reported cases.10 Symptoms of esophageal injury are subtle but often include chest pain, hematemesis, and dysphagia. Development of atrio-esophageal fistula is often associated with neurologic abnormalities. These symptoms have been reported within 3 days of the initial procedure and up to 5 weeks afterward. Pappone and associates reported that 50% of patients with an atrio-esophageal fistula were not correctly diagnosed until autopsy.10

Esophageal changes have been reported after AF ablation in up to 47% of patients who underwent the proce-dure.11 Schmidt and colleagues performed endoscopic evaluations of 28 patients within 24 hours of AF ablation.11 They found erythema on the posterior wall of the esophagus in 29% of the patients and ulcer-like changes in 18% of the patients. Interestingly, the researchers reported that all of these patients complained of a reflux-like sensation.

Keshishian and associates reported on 3 patients with esophageal injury following AF ablation.12 The first patient presented with dysphagia and odynophagia the day after the procedure, and an endoscopy revealed a small ulcer. The authors suggested that this type of injury could be classified as a class I thermal injury. However, the presence of trans-esophageal injury resulting in mucosal ulceration is clearly evidence of more advanced injury, compared to the patients in the study by Schmidt and associates, who had only muco-sal erythema and no major symptoms.11 Perhaps patients with erythema, no ulcers, and no major symptoms are better classified as having a class I thermal injury.

This class of patients appears to do well, with no subsequent major complications. Although treatment with gastric acid blockers such as proton pump inhibitors (PPIs) is frequently recommended, it should be remembered that the injury is coming from deeper tissues. Thus, the use of PPIs in those patients may not be helpful. However, short-term therapy with PPIs is unlikely to be harmful. Additionally, such therapy may be reasonable, given the relative inexpense of generic PPIs. The critically important concern is that the presence of erythema within the lumen of the esophagus provides little appreciation for the deeper tissue injury. Since the catheter is in the LA, the mucosa of the esophagus is farthest from the heat source. Thus, significant injury has occurred to the outer layer of the esophagus if surface mucosal erythema or ulceration is visible on endoscopy. Serial computed tomography (CT) scans following ablation may be necessary to monitor the condition of these deeper tissues.

The second patient in the case series by Keshishian and coworkers presented with dysphagia 1 day after ablation.12 The patient had esophageal ulceration in 2 locations with what appeared to be a black spot. The authors suggested that such an injury should be classified as a class II thermal injury. This grade suggests that class II patients may have incurred more damage to the esophagus than class I patients. The authors suggested that such patients be treated with PPIs and sucralfate and undergo repeat endoscopy and close monitoring. In this situation, the use of PPIs is warranted, given the more severe injury to the esophagus. In our opinion, these patients should also be educated and encouraged to have a high level of suspicion for signs and symptoms of worsening esophageal injury; these patients must proceed to the emergency room if they have any signs of chest pain, continued dysphagia, fevers, or intestinal bleeding.

Keshishian and associates recommended keeping patients nil per os if their postablation endoscopy reveals eschar, large clots, or visible vessels.12 The authors also recommended that these patients start PPI therapy, undergo a CT chest scan, and consult a cardiothoracic surgeon. These steps were used in the management of the third patient in the case series by Keshishian and colleagues, but the patient developed an atrio-esophageal fistula by Day 17 postprocedure.12 Therefore, the question is: What else could have been done in this patient? Clearly, there have not been any randomized trials looking at such patients and optimal therapies. Keshishian and associates have suggested imaging the deeper tissues between the LA and the esophagus, as well as using endoscopic ultrasonography (EUS) to evaluate the depth of the injury.12 Based on our experience, it would be rather difficult to use EUS to assess the degree of acute injury following ablation. One possibility may be to insert covered, removable esophageal stents to seal the area prophylactically and prevent fistula formation in patients who are found to have stigmata for severe esophageal injury. However, further patient studies are needed before such interventions can be considered.

As always, an ounce of prevention is worth a pound of cure. The goal should be to prevent esophageal injury during AF ablation. Studies have looked at methods of minimizing damage to the esophagus during AF ablation, such as reducing power in the posterior LA wall (closest to the esophagus), monitoring temperature in the esophagus, and irrigating the esophagus with cool water.9,13,14 Alternatively, EUS could be used before the procedure to assess the actual size of the area between the LA and the esophagus. Such information is easily obtained via EUS and could identify patients at highest risk for injury post—AF ablation. In such patients, esophageal irrigation and reduction of the ablative power near the posterior LA wall are indicated.

References

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