Abstract
BackgroundAtrio-esophageal fistula formation following radiofrequency ablation of left atrial tachyarrhythmias is a rare but devastating complication. Esophageal injuries are believed to be precursors of fistula formation and reported to occur in up to 47% of patients. This study investigates the incidence of esophageal lesions when real time esophageal temperature monitoring and temperature limitation is used.Methods184 consecutive patients underwent open irrigated radiofrequency ablation of left atrial tachyarrhythmias. An esophageal temperature probe consisting of three independent thermocouples was used for temperature monitoring. A temperature limit of 40°C was defined to interrupt energy delivery. All patients underwent esophageal endoscopy the next day.ResultsEndoscopy revealed ulcer formation in 3/184 patients (1.6%). No patient developed atrio-esophageal fistula. Patient and disease characteristics had no influence on ulcer formation. The temperature threshold of 40°C was reached in 157/184 patients. A temperature overshoot after cessation of energy delivery was observed frequently. The mean maximal temperature was 40.8°C. Using a multiple regression analysis creating a box lesion that implies superior- and inferior lines at the posterior wall connecting the right and left encircling was an independent predictor of temperature. Six month follow-up showed an overall success rate of 78% documented as sinus rhythm in seven-day holter ECG.ConclusionLimitation of esophageal temperature to 40°C is associated with the lowest incidence of esophageal lesion formation published so far. This approach may contribute to increase the safety profile of radiofrequency ablation in the left atrium.
Highlights
Atrio-esophageal fistula formation following radiofrequency ablation of left atrial tachyarrhythmias is a rare but devastating complication
Pulmonary vein antrum isolation using radiofrequency ablation has become an effective therapy in symptomatic patients with atrial fibrillation
Pulmonary vein isolation Radiofrequency ablation was performed in conscious sedation or general anaesthesia (10 patients)
Summary
Atrio-esophageal fistula formation following radiofrequency ablation of left atrial tachyarrhythmias is a rare but devastating complication. Esophageal injuries are believed to be precursors of fistula formation and reported to occur in up to 47% of patients. Pulmonary vein antrum isolation using radiofrequency ablation has become an effective therapy in symptomatic patients with atrial fibrillation. Non-lethal complications such as cardiac perforation, stroke and pulmonary vein stenosis have been reported to occur with rates of 1.3%, 0.2% and 1.3% respectively [1,2]. A recently reported complication describes esophageal injury leading to left atrial significant reduction of intraluminal esophageal temperature [11,12]. Post ablation esophageal wall changes (erosion or ulceration) are reported to occur in up to 47% of patients [13]. Real time temperature monitoring can detect rapid esophageal heating during radiofrequency ablation [14]
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