1786 Major Esophageal Bleeding Secondary to Mechanical Injury From Esophageal Deviation During Pulmonary Vein Isolation

Abstract

INTRODUCTION: Radiofrequency catheter ablation and pulmonary vein isolation (PVI) are electrophysiologic interventions frequently performed for the management of atrial fibrillation (AF). Given the anatomic proximity of the esophagus and left atrium, the former is prone to thermal injury which can lead to peri-esophageal nerve injury, pain, dysphagia, and atrio-esophageal fistula formation. Mechanical deflection of the esophagus away from the ablation site is being used to minimize such complications. We present a case of major esophageal bleeding secondary to mechanical trauma in the setting of esophageal deviation during AF ablation. CASE DESCRIPTION/METHODS: 60 yo female with past medical history significant for obstructive sleep apnea, pulmonary hypertension, AF with multiple direct current cardioversion attempts, underwent elective PVI using an esophageal deviation stylet (EsoSure, Northeast Scientific, Waterbury, CT). After PVI, a small amount of blood was noted as a result of suction using an orogastric tube. CT chest ruled out esophageal pathology including perforation. Subsequent upper endoscopy showed small mucosal tears in middle third of esophagus and at the esophago-gastric junction (EGJ) (Figure 1). She was discharged on daily proton pump inhibitor and remained on anticoagulation. Five days later, she presented to the emergency room with complaints of weakness, fatigue, melena and non-radiating substernal sharp chest pain. Blood pressure was 64/35. Hemoglobin was 6.4 g/dL compared to 10.3 g/dL upon discharge. Shortly after arrival, the patient had an episode of large volume hematemesis. She was urgently intubated for airway protection and volume resuscitation was initiated. Emergent upper endoscopy reveled an actively bleeding superficial mucosal tear at the EGJ which was treated successfully with epinephrine injection followed by hemostatic clip placement (Figures 2 and 3). After transfusion of 3 units of packed red blood cells, repeat Hgb improved to 8.8 g/dL and remained stable. Patient was extubated, remained clinically stable and was discharged. DISCUSSION: Mechanical displacement of the esophagus away from an atrial ablation site is being used more frequently in electrophysiologic interventions, as it reduces ablation-related esophageal thermal injury. Despite newer esophageal retractors which retain less heat and are less bulky, vigilance should be practiced to avoid mechanical esophageal trauma.