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Retro-cardiac esophageal mobility and deflection to prevent thermal injury during atrial fibrillation ablation: an anatomic feasibility study

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Abstract

Background

Atrial fibrillation (AF) ablation often causes minor esophageal (ESO) injury, and sometimes lethal posterior left atria (PLA)-ESO fistula. Avoidance techniques (energy reduction and/or complete target avoidance) provide questionable ESO protective value, and are likely associated with increased AF recurrence.

Methods and results

Potential independent mobility, deflectability and age-related anatomic factors, assessed by multi-position, and age-progressive thoracic computed tomography scans, show (1) mobility of the retro-cardiac ESO-PLA juxtaposition, (2) age-related increased thermal ablation vulnerability; and also, age-increased potential for retro-cardiac ESO mobility and deflectability to avoid collateral injury; and that (3) the retro-cardiac vertebral bodies and the descending aorta create a patient-specific esophageal corridor which defines the resting supine esophageal position and the subsequent PLA-ESO crossing points.

Conclusion

A small, 1–3 mm, increase in separation of the ESO relative to the PLA occurs when moving the patient from supine to lateral and from supine to prone position. Because of the concave spine; the PLA-ESO area of apposition increases. Patient rotation of 90° and 180° does not create enough passive PLA-ESO separation to avoid collateral ESO thermal energy; but, active repositioning lateral and out of ESO corridor appears feasible.

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References

  1. Bunch, T. J., Weiss, J. P., Crandall, B. G., May, H. T., Bair, T. L., Osborn, J. S., et al. (2010). Long-term clinical efficacy and risk of catheter ablation for atrial fibrillation in octogenarians. Pacing Clin Electrophysiol, 33(2), 146–152.

    Article  PubMed  Google Scholar 

  2. Bonanno, C., Paccanaro, M., La Vecchia, L., Ometto, R., & Fontanelli, A. (2010). Efficacy and safety of catheter ablation versus antiarrhythmic drugs for atrial fibrillation: a meta-analysis of randomized trials. J Cardiovasc Med, 11(6), 408–418.

    Article  Google Scholar 

  3. Chugh, A., & Oral, H. (2010). Circumferential pulmonary vein ablation for atrial fibrillation: back to the future? Europace, 12(2), 149–150.

    Article  PubMed  Google Scholar 

  4. Eitel, C., Hindricks, G., Sommer, P., Gaspar, T., Kircher, S., Wetzel, U., et al. (2010). Circumferential pulmonary vein isolation and linear left atrial ablation as a single-catheter technique to achieve bidirectional conduction block: the pace-and-ablate approach. Heart Rhythm, 7(2), 157–164.

    Article  PubMed  Google Scholar 

  5. Gillinov, A. M., Pettersson, G., & Rice, T. W. (2001). Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg, 122, 1239–1240.

    Article  CAS  PubMed  Google Scholar 

  6. Sra, J., Krum, D., Malloy, A., Bhatia, A., Cooley, R., Blanck, Z., et al. (2006). Posterior left atrial-esophageal relationship throughout the cardiac cycle. J Interv Card Electrophysiol, 16(2), 73–80.

    Article  PubMed  Google Scholar 

  7. Scanavacca, M. I., D'avila, A., Parga, J., & Sosa, E. (2004). Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol, 15, 960–962.

    Article  PubMed  Google Scholar 

  8. Pappone, C., Oral, H., Santinelli, V., Vicedomini, G., Lang, C. C., Manguso, F., et al. (2004). Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation, 109(22), 2724–2726.

    Article  PubMed  Google Scholar 

  9. Martinek, M., Hassanein, S., Bencsik, G., Aichinger, J., Schoefl, R., Bachl, A., et al. (2009). Acute development of gastroesophageal reflux after nradiofrequency catheter ablation of atrial fibrillation. Heart Rhythm, 6(10), 1457–1462.

    Article  PubMed  Google Scholar 

  10. Di Biase, L., Saenz, L. C., Burkhardt, D. J., Vacca, M., Elayi, C. S., Barrett, C. D., et al. (2009). Esophagealcapsule endoscopy after radiofrequency catheter ablation for atrial fibrillation: documented higher risk of luminal esophageal damage with general anesthesia ascompared with conscious sedation. Circ Arrhythm Electrophysiol, 2(2), 108–112.

    Article  PubMed  Google Scholar 

  11. Hoffmeister, P. S., Chaudhry, G. M., Mendel, J., Almasry, I., Tahir, S., Marchese, T., et al. (2007). Evaluation of left atrial and posterior mediastinal anatomy by multidetector helical computed tomography imaging: relevance to ablation. J Interv Card Electrophysiol, 18(3), 217–223. Epub 2007 May 22.

    Article  PubMed  Google Scholar 

  12. Hornero, F., & Berjano, E. J. (2006). Esophageal temperature during radiofrequency-catheter ablation of left atrium: a three-dimensional computer modeling study. J Cardiovasc Electrophysiol, 17(4), 405–410.

    Article  PubMed  Google Scholar 

  13. Arruda, M. S., Armaganijan, L., Di Biase, L., Rashidi, R., & Natale, A. (2009). Feasibility and safety of using an esophageal protective system to eliminate esophageal thermal injury: implications on atrial-esophageal fistula following AF ablation. J Cardiovasc Electrophysiol, 20(11), 1272–1278.

    Article  PubMed  Google Scholar 

  14. Ren, J. F., Lin, D., Marchlinski, F. E., Callans, D. J., & Patel, V. (2006). Esophageal imaging and strategies for avoiding injury during left atrial ablation for atrialfibrillation. Heart Rhythm, 3(10), 1156–1161.

    Article  PubMed  Google Scholar 

  15. Martinek, M., Bencsik, G., Aichinger, J., Hassanein, S., Schoefl, R., Kuchinka, P., et al. (2009). Esophageal damage during radiofrequency ablation of atrial fibrillation: impact of energy settings, lesion sets, and esophageal visualization. J Cardiovasc Electrophysiol, 20(7), 726–733.

    Article  CAS  PubMed  Google Scholar 

  16. Sherzer, A. I., Feigenblum, D. Y., Kulkarni, S., Pina, J. W., Casey, J. L., Salka, K. A., et al. (2007). Continuous nonfluoroscopic localization of the esophagus during radiofrequency catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol, 18(2), 157–160.

    Article  PubMed  Google Scholar 

  17. Hall, B., Shah, A., Huang, D., Rosero, S., & Daubert, J. (2005). Visualization of the esophagus during catheter ablation of atrial fibrillation. J Interv Card Electrophysiol, 13(2), 135–137.

    Article  PubMed  Google Scholar 

  18. Benussi, S., Nascimbene, S., Calvi, S., & Alfieri, O. (2003). A tailored anatomical approach to prevent complications during left atrial ablation. Ann Thorac Surg, 75(6), 1979–1981.

    Article  PubMed  Google Scholar 

  19. Thomas, S. P., Lim, T. W., McCall, R., Seow, S. C., & Ross, D. L. (2007). Electrical isolation of the posterior left atrial wall and pulmonary veins for atrial fibrillation feasibility of and rationale for a single-ring approach. Heart Rhythm, 4(6), 722–730.

    Article  PubMed  Google Scholar 

  20. Tsao, H. M., Wu, M. H., Chern, M. S., Tai, C. T., Lin, Y. J., Chang, S. L., et al. (2006). Anatomic proximity of the esophagus to the coronary sinus: implication for catheter ablation within the coronary sinus. J Cardiovasc Electrophysiol, 17(3), 266–269.

    Article  PubMed  Google Scholar 

  21. Tsuchiya, T., Ashikaga, K., Nakagawa, S., Hayashida, K., & Kugimiya, H. (2007). Atrial fibrillation ablation with esophageal cooling with a cooled waterirrigated intraesophageal balloon: a pilot study. J Cardiovasc Electrophysiol, 18(2), 145–150.

    Article  PubMed  Google Scholar 

  22. Berjano, E. J., & Hornero, F. (2005). A cooled intraesophageal balloon to prevent thermal injury during endocardial surgical radiofrequency ablation of the left atrium: a finite element study. Phys Med Biol, 50(20), N269–N279.

    Article  PubMed  Google Scholar 

  23. Sohara, H., Takeda, H., Ueno, H., Oda, T., & Satake, S. (2009). Feasibility of the radiofrequency hot balloon catheter for isolation of the posterior left atrium and pulmonary veins for the treatment of atrial fibrillation. Circ Arrhythm Electrophysiol, 2(3), 225–232.

    Article  PubMed  Google Scholar 

  24. Evonich, R. F., 3rd, Nori, D. M., & Haines, D. E. (2007). A randomized trial comparing effects of radiofrequency and cryoablation on the structural integrity of esophageal tissue. J Interv Card Electrophysiol, 19(2), 77–83.

    Article  PubMed  Google Scholar 

  25. Ripley, K. L., Gage, A. A., Olsen, D. B., Van Vleet, J. F., Lau, C. P., & Tse, H. F. (2007). Time course of esophageal lesions after catheter ablation with cryothermal and radiofrequency ablation: implication for atrio-esophageal fistula formation after catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol, 18(6), 642–646.

    Article  PubMed  Google Scholar 

  26. Aupperle, H., Doll, N., Walther, T., Kornherr, P., Ullmann, C., Schoon, H. A., et al. (2005). Ablation of atrial fibrillation and esophageal injury: effects of energy source and ablation technique. J Thorac Cardiovasc Surg, 130(6), 1549–1554.

    Article  PubMed  Google Scholar 

  27. Reddy, V. Y., Neuzil, P., d'Avila, A., Laragy, M., Malchano, Z. J., Kralovec, S., et al. (2008). Balloon catheter ablation to treat paroxysmal atrial fibrillation. what is the level of pulmonary venous isolation? Heart Rhythm, 5(3), 353–360.

    Article  PubMed  Google Scholar 

  28. Keane, D. (2002). New catheter ablation techniques for the treatment of cardiac arrhythmias. Card Electrophysiol Rev, 6(4), 341–348.

    Article  PubMed  Google Scholar 

  29. Meng, J., Peters, D. C., Hsing, J. M., Chuang, M. L., Chan, J., Fish, A., et al. (2010). Late gadolinium enhancement of the esophagus is common on cardiac MR several months after pulmonary vein isolation: preliminary observations. Pacing Clin Electrophysiol, 33(6), 661–666.

    Article  PubMed  Google Scholar 

  30. Herweg, B., Johnson, N., Postler, G., Curtis, A. B., Barold, S. S., & Ilercil, A. (2006). Mechanical esophageal deflection during ablation of atrial fibrillation. Pacing Clin Electrophysiol, 29, 957–961.

    Article  PubMed  Google Scholar 

  31. Herweg, B., Ali, R., Khan, N., Ilercil, A., & Barold, S. S. (2009). Esophageal contour changes during cryoablation of atrial fibrillation. Pacing Clin Electrophysiol, 32(6), 711–716.

    Article  PubMed  Google Scholar 

  32. Good, E., Oral, H., Lemola, K., Han, J., Tamirisa, K., Igic, P., et al. (2005). Movement of the esophagus during left atrial catheter ablation for atrial fibrillation. J Am Coll Cardiol, 46(11), 2107–2110.

    Article  PubMed  Google Scholar 

  33. Kobza, R., Schoenenberger, A. W., & Erne, P. (2009). Esophagus imaging for catheter ablation of atrial fibrillation: comparison of two methods with showing of esophageal movement. J Interv Card Electrophysiol, 26(3), 159–164.

    Article  PubMed  Google Scholar 

  34. Kottkamp, H., Piorkowski, C., Tanner, H., Kobza, R., Dorszewski, A., Schirdewahn, P., et al. (2005). Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation. J Cardiovasc Electrophysiol, 16(2), 146–150.

    Article  PubMed  Google Scholar 

  35. Lemola, K., Sneider, M., Desjardins, B., Case, I., Han, J., Good, E., et al. (2004). Computed tomographic analysis of the anatomy of the left atrium and the esophagus: implications for left atrial catheter ablation. Circulation, 110(24), 3655–3660.

    Article  PubMed  Google Scholar 

  36. Bahnson, T. D. (2009). Strategies to minimize the risk of esophageal injury during catheter ablation for atrial fibrillation. Pacing Clin Electrophysiol, 32(2), 248–260.

    Article  PubMed  Google Scholar 

  37. Ghia, K. K., Chugh, A., Good, E., Pelosi, F., Jongnarangsin, K., Bogun, F., et al. (2009). A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation. J Interv Card Electrophysiol, 24(1), 33–36.

    Article  PubMed  Google Scholar 

  38. Tsao, H. M., Wu, M. H., Higa, S., Lee, K. T., Tai, C. T., Hsu, N. W., et al. (2005). Anatomic relationship of the esophagus and left atrium: implication for catheter ablation of atrial fibrillation. Chest, 128(4), 2581–2587.

    Article  PubMed  Google Scholar 

  39. Krishnan, S. C., Salazar, M., & Narula, N. (2008). Anatomical basis for the mobility of the esophagus: implications for catheter ablation of atrial fibrillation. Indian Pacing Electrophysiol J, 8(1), 66–68.

    PubMed  Google Scholar 

  40. Perzanowski, C., Teplitsky, L., Hranitzky, P. M., & Bahnson, T. D. (2006). Real-time monitoring ofluminal esophageal temperature during left atrial radiofrequency catheterablation for atrial fibrillation: observations about esophageal heating during ablation at the pulmonary vein ostia and posterior left atrium. J Cardiovasc Electrophysiol, 17(2), 166–170.

    Article  PubMed  Google Scholar 

  41. Lim, K. T., Ja, P., & Hassaguerre, M. (2007). Randomized comparison between open irrigation technology and intracardiac-echo-guided energy delivery for pulmonary vein antrum isolation: procedural parameters, outcomes, and the effect on esophageal injury. J Cardiovasc Electrophysiol, 18(6), 589–591.

    Article  PubMed  Google Scholar 

  42. Nakagawa, H. (2008). Role of contact force in esophageal injury during left atrial radiofrequency ablation. Heart Rhythm, 5, S317–S317.

    Google Scholar 

  43. Kowal, R. C. (2009). Predicting outcome from AF ablation: size of the chamber, or is tissue the issue? J Cardiovasc Electrophysiol, 20(9), 1011–1013.

    Article  PubMed  Google Scholar 

  44. Ejima, K. (2008). Simple maneuver for preventing atrio-esophageal fistula during pulmonary vein isolation. Heart Rhythm, 5, S405–S405.

    Google Scholar 

  45. Ejima, K., Shoda, M., Futagawa, K., Kimura, R., Manaka, T., Hagiwara, N., et al. (2009). Transverse shifting of the esophagus according to the patient’s position helped achieve a safe and successful pulmonary vein isolation procedure. Heart Vessels, 24(4), 317–319.

    Article  PubMed  Google Scholar 

  46. Chugh, A., Rubenstein, J., Good, E., Ebinger, M., Jongnarangsin, K., Fortino, J., et al. (2009). Mechanical displacement of the esophagus in patients undergoing left atrial ablation of atrial fibrillation. Heart Rhythm, 6(3), 319–322.

    Article  PubMed  Google Scholar 

  47. Nakagawa, H. (2008). Role of contact force in esophageal injury during left atrialradiofrequency ablation. Heart Rhythm, 5, S317–S317.

    Google Scholar 

  48. Arruda, M. S. (2008). Pre clinical “in vivo” evaluation of an esophageal protective system: Implications on esophageal thermal injury during AF ablation. Heart Rhythm, 5, S16–S16.

    Google Scholar 

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Author information

Authors and Affiliations

  1. The University of Toledo, Toledo, OH, USA

    Khalil Kanjwal, Richard Yeasting & Carlos Baptista

  2. VA Hospital Thoracic Surgery, Madison, WI, USA

    James D. Maloney III

  3. Cardiothoracic Surgery, The University of Wisconsin, Madison, Wi, USA

    James D. Maloney III

  4. Division of Cardiology, Section of Electrophysiology, Toledo, OH, USA

    Khalil Kanjwal

  5. The Department of Neurosciences, Toledo, OH, USA

    Richard Yeasting & Carlos Baptista

  6. Department of Radiology, University of Toledo, Toledo, OH, USA

    Haitham Elsamaloty

  7. Division of Internal Medicine, The University of Toledo, Toledo, OH, USA

    Mujeeb Sheikh

  8. Mechanical Engineering Department, The University of Toledo, Toledo, OH, USA

    Mohammad Elahinia & Walter Anderson

  9. Sarasota Arrhythmia Institute, Sarasota, FL, USA

    James D. Maloney

  10. 1587 Bell Road, Chagrin Falls, OH, 44022, USA

    James D. Maloney

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  1. Khalil Kanjwal
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Kanjwal, K., Yeasting, R., Maloney, J.D. et al. Retro-cardiac esophageal mobility and deflection to prevent thermal injury during atrial fibrillation ablation: an anatomic feasibility study. J Interv Card Electrophysiol 30, 45–53 (2011). https://doi.org/10.1007/s10840-010-9524-2

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  • DOI: https://doi.org/10.1007/s10840-010-9524-2

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