Impact of preprocedural upper gastrointestinal endoscopy for pulmonary vein isolation - single-center experience of 400 patients

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Mucosal esophageal lesions (ELs) are reported in 10-40% after pulmonary vein isolation (PVI) and may be precursors of (almost always lethal) atrio-esophageal fistula (AEF). Although mechanisms of lesion progression are not completely understood, inflammation (e.g. by acidic reflux) is thought to be a major contributor. However, ELs may also be preexisting or due to mechanical instrumentation rather than ablation-induced, and these lesions are not prone to progression. On the other hand, preexisting reflux-induced esophagitis might facilitate lesion generation during ablation. Therefore, esophagogastroscopy (EGD) before PVI might reveal important information regarding preexisting vulnerability that needs to be considered/is relevant for ablation procedure planning. Purpose (1) To study the incidence of preexisting esophageal and upper gastrointestinal pathology detected by EGD in patients undergoing PVI. (2) To assess the impact of preprocedural EGD on procedure planning. Methods All consecutive patients undergoing PVI (radiofrequency energy PVI or cryoablation) had routine pre- and post-procedural EGD. The preexisting EGD-findings were analyzed with regard to their impact on PVI planning, postprocedural ELs, and additional endoscopic workup. Results From 08/2018 to 08/2021, 396 patients (66 ± 9 years, 58% male) were included. During preprocedural EGD, 207 patients (52%) had esophageal and extraesophageal abnormalities. In 57 patients, the findings influenced the procedure strategy (e.g. in the presence of inflammation of the lower third of the esophagus, maximum power at the posterior left atrial wall was reduced from 25 to 20 Watts). 9/29 patients with new ELs in postprocedural EGD had preexisting esophagitis. Ablation was postponed for five patients, thereof two with candida esophagitis, two with gastral and one with duodenal ulcer, respectively). 16 patients received further endoscopic workup with identification of a gastric carcinoma in one. Endoscopic ultrasound identified a patient with a pancreatic head neoplasia. There were no procedure-related complications of EGDs. Discussion and Conclusion In an unselected cohort, preprocedural EGD showed incidental findings in a half of the patients, and one-fourth of these were considered to be relevant for procedural aspects of PVI. Of particular interest is the absence of inflammation of the esophageal wall. Ulcer do not affect the safety of the PVI directly, but have impact on anticoagulation issues. EGD before PVI merits consideration. Abstract Figure. EGD-findings before PVI