Esophageal Protection and Temperature Monitoring Using the Circa S-Cath™ Temperature Probe during Epicardial Radiofrequency Ablation of the Pulmonary Veins and Posterior Left Atrium

Abstract

Although epicardial bipolar radiofrequency ablation should diminish the risk of esophageal thermal injury in comparison to an endocardial ablation, cases of lethal atrio-esophageal fistula have been reported. To better understand this risk and to reduce the possibility of a thermal injury, we monitored the esophageal temperature with the Circa S-Cath™ temperature probe during and immediately after the ablation while implementing three procedural safety measures. Twenty patients (15 males; 63 ± 10 years) were prospectively enrolled (November 2019-February 2021). All patients underwent an epicardial ablation procedure, including an antral left and right pulmonary vein isolation with bidirectional bipolar clamping, and a roof and inferior line using unidirectional bipolar radiofrequency. Three procedural preventive mitigations were implemented: (1) transesophageal echocardiographic visualization of the atrio-esophageal interface, with probe retraction before the energy delivery; (2) lifting the ablated tissue away from the esophagus during an energy application; and (3) a 30 s cool-off and irrigation period after the energy delivery. The esophageal temperature was recorded using an insulated multisensory intraluminal esophageal temperature probe (Circa S-Cath™). Of the 20 patients enrolled, 7 patients had paroxysmal atrial fibrillation (AF), 8 persistent AF and 5 longstanding persistent AF. The average maximum luminal esophageal temperature observed was 36.2 ± 0.7 °C (34.8-38.2 °C). In our clinical experience, no abrupt increase in the luminal esophageal temperature above the baseline was observed. Since no measurements exceeded the threshold of 39 °C, no prompt interruption of energy delivery was required. Intraluminal esophageal temperature monitoring is feasible and can be helpful in confirming correct catheter position and safe energy application in bipolar epicardial left atrial ablation. Intra-procedural preventive mitigations should be implemented to reduce the risk of esophageal temperature rises.