Esophageal Findings in the Setting of a Novel Preventive Strategy to Avoid Thermal Lesions during Hybrid Thoracoscopic Radiofrequency Ablation for Atrial Fibrillation.

Rani Kronenberger,Ines Van Loo,Mark La Meir,Maridi Aerts,Sandro Gelsomino,Carlo De Asmundis,Gian-Battista Chierchia,Vincent Umbrain

doi:10.3390/jcm10214981

Abstract

Purpose The development of an atrio-esophageal fistula, a rare yet potentially lethal complication of ablation for atrial fibrillation, could be related to direct tissue heat transfer during and immediately after the ablation. We therefore studied the postoperative esophageal findings by esophagogastroduodenoscopy in patients that underwent a hybrid ablation procedure using a novel preventive strategy to avoid thermal lesions. Methods Thirty-four patients (28 males; 65 years ± 9 years) were retrospectively included. All underwent a hybrid ablation in our center between April 2015 and November 2019 and agreed to an esophagogastroduodenoscopy within 0–14 days (mean: 5 days) following the ablation. To reduce the incidence of thermal lesions three procedural preventive strategies were introduced: (i) videoscopic intrathoracic transesophageal echocardiographic probe visualization to understand the relationship between posterior left atrial wall and esophagus, with probe retraction before ablation; (ii) lifting the cardiac tissue away from the esophagus during energy application; and (iii) a 30-s cool-off period after energy delivery with irrigation of the device, the ablated tissue, and the surrounding tissues. Results No esophageal thermal lesions were observed. One third of patients were diagnosed with incidental esophageal findings unrelated to the ablation procedure (11; 32.4%). Conclusion Novel preventive strategies by visualization and by avoiding contact between the ablation catheter or ablated tissue and the pericardium, seems to eliminate the potential risk of esophageal thermal lesions in the setting of hybrid ablation. Since one third of patients had preexisting esophageal disease, a more comprehensive pre-operative screening could be important to reduce the risk.

Highlights

Hybrid ablation, defined by the 2012 and 2017 HRS/EHRA/ECAS expert consensus [1,2] as a joint thoracoscopic and transvenous ablation procedure through a partnership between the surgeon and the electrophysiologist in a one- or two-stage procedure, has become a well-accepted procedure for the treatment of symptomatic atrial fibrillation (AF) in patients with persistent or long-standing persistent AF
When performing an epicardial roof line ablation by connecting the superior pulmonary vein (PV) just below the Bachmann bundle, typically in a more anterior position compared to an endocardial roof line, little risk of thermal injury is to be expected since there is a sufficient space between the ablation tool and the esophagus
Thirty-four patients treated for symptomatic AF from April 2015 to November 2019 agreed to a postoperative esophagogastroduodenoscopy (EGD) to assess for esophageal thermal lesions (ETL) after having undergone an epicardial thoracoscopic ablation with, if needed, a periprocedural endocardial touch-up

Summary

Introduction

Hybrid ablation, defined by the 2012 and 2017 HRS/EHRA/ECAS expert consensus [1,2] as a joint thoracoscopic and transvenous ablation procedure through a partnership between the surgeon and the electrophysiologist in a one- or two-stage procedure, has become a well-accepted procedure for the treatment of symptomatic atrial fibrillation (AF) in patients with persistent or long-standing persistent AF This treatment modality has an excellent safety profile and low complication risk in experienced centers, the risk of the development of an atrio-esophageal fistula (AEF) could be increased when compared to endocardial and epicardial ablation alone since ablations are performed from both sides. The left atrial roof line performed from the epicardium is never in close contact with the esophagus, and as such, not a risk for AEF

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