Oesophageal Injury During AF Ablation: Techniques For Prevention

Jorge Romero

Ricardo Avendano

Michael Grushko

Juan Carlos Diaz

Xianfeng Du

Carola Gianni

Andrea Natale

Luigi Di Biase


Arrhythmia & Electrophysiology Review 2018;7(1):24–31.


Abstract

Atrial fibrillation remains the most common arrhythmia worldwide, with pulmonary vein isolation (PVI) being an essential component in the treatment of this arrhythmia. In view of the close proximity of the oesophagus with the posterior wall of the left atrium, oesophageal injury prevention has become a major concern during PVI procedures. Oesophageal changes varying from erythema to fistulas have been reported, with atrio-oesophageal fistulas being the most feared as they are associated with major morbidity and mortality. This review article provides a detailed description of the risk factors associated with oesophageal injury during ablation, along with an overview of the currently available techniques to prevent oesophageal injury. We expect that this state of the art review will deliver the tools to help electrophysiologists prevent potential oesophageal injuries, as well as increase the focus on research areas in which evidence is lacking.


Conclusion

Though rare, serious oesophageal injury during PVI and posterior wall ablation is still a major concern among electrophysiologists, particularly if left untreated, with a mortality rate of up to 100 % associated with atrio-oesophageal fistulas. In our practice and experience, we rely on a stepwise approach to prevent these potential complications. Several techniques have been described to prevent such injuries. We suggest obtaining pre- and intra-procedural oesophageal imaging to provide valuable information for ablation, given the high variability of oesophageal anatomy among patients. Despite its controversy, our group encourages the routine use of oesophageal intraluminal temperature monitoring probes during AF ablation. Mechanical displacement of the oesophagus appears feasible, safe and efficacious; nevertheless, randomised data are missing to evaluate the different tools available. Consistently in our procedures, when performing ablation lesions to the posterior wall, we prefer to use low irrigation parameters as this technique has been shown to be effective and seems to be a promising way to avoid oesophageal damage. We do not routinely use cryothermal energy ablation; however, it has been shown to have a lower incidence of oesophageal injury,64 though the data is not without debate and efficacy may be less than RFA. Given the low incidence of clinically significant events, such as atrio-oesophageal fistula, the development of strategies for the prevention of these potential complications is limited. As discussed in this review, the use of different surrogates, such as variation in oesophageal luminal temperature, remains controversial and more studies are needed to evaluate oesophageal injury prevention systems.


Read the full article here: https://www.aerjournal.com/articles/oesophageal-injury-during-af-ablation

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