Primum Non Nocere: The Paramount Importance of Esophageal Protection.

Abstract

> Prediction, not narration, is the real test of our understanding of the world . > > —Nassim Nicholas Taleb, The Black Swan: The Impact of the Highly Improbable Pulmonary vein stenosis and atrioesophageal fistula (AEF) are iatrogenic pathological entities attributed to misadventures during atrial fibrillation ablation; the former can cause significant morbidity; the latter is ominous in its potential for mortality. The exact pathogenesis of AEF during radiofrequency (RF) ablation is not known, but it is believed that direct thermal injury and necrosis with adherence and fistulous track formation likely play a key role. A second proposed mechanism is injury to the esophageal vasculature with late esophageal necrosis. The low incidence of this dangerous complication makes it difficult to identify intraprocedural variables that can predict its occurrence. AEF may occur during minimally invasive surgical atrial fibrillation ablation and cryoballoon ablation, as well. See Article by Halbfass et al Halbfass et al, in this edition of the journal, sought to identify intraoperative and endoscopic characteristics that could predict the occurrence of AEF.1 The current study is a large single-center retrospective registry, and the study cohort contained 832 patients who underwent RF ablation with either single electrode or multielectrode open-irrigated catheters. Esophageal temperature monitoring was performed with insulated temperature probes. Esophagogastroduodenoscopy (EGD) was performed within 7 days of ablation. Asymptomatic endoscopically detected esophageal lesions (EDEL) were systematically characterized as erythema/erosion or ulceration. The incidence of EDEL was 18% in patients undergoing a de novo atrial fibrillation ablation, one third being ulcerous lesions. Almost 10% of ulcerous lesions but none of the erythema/erosion lesions progressed to esophageal perforation or fistula. An esophageal intraluminal temperature between 40.5°C and 41.5°C correlated with EDEL. This study reiterates findings of some earlier studies, showing that the incidence of esophageal perforation was 0.6% and the incidence of fatality with …