This Article Full Text Full Text (PDF) All Versions of this Article: 112/4/459    most recent CIRCULATIONAHA.104.509612v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cummings, J. E. Articles by Natale, A. Search for Related Content PubMed PubMed Citation Articles by Cummings, J. E. Articles by Natale, A. Related Collections Arrhythmias, clinical electrophysiology, drugs Ablation/ICD/surgery Other diagnostic testing

(Circulation. 2005;112:459-464.)
© 2005 American Heart Association, Inc.

Arrhythmia/Electrophysiology

Assessment of Temperature, Proximity, and Course of the Esophagus During Radiofrequency Ablation Within the Left Atrium

Jennifer E. Cummings, MD; Robert A. Schweikert, MD; Walid I. Saliba, MD; J. David Burkhardt, MD; Johannes Brachmann, MD; Jens Gunther, MD; Volker Schibgilla, MD; Atul Verma, MD; MarkAlain Dery, DO, MPH; John L. Drago; Fethi Kilicaslan, MD; Andrea Natale, MD

From the Department of Cardiovascular Medicine (J.E.C., R.A.S., W.I.S., J.D.B., A.V., M.A.D., J.L.D., F.K., A.N.), Section of Pacing and Electrophysiology, The Cleveland Clinic Foundation, Cleveland, Ohio, and Klinicum Coburg (J.B., J.G., V.S.), Coburg, Germany.

Correspondence to Andrea Natale, MD, Co-Section Head of Pacing and Electrophysiology, Director, Electrophysiology Laboratory, Medical Director, Center for Atrial Fibrillation, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Desk F-15, 9500 Euclid Ave, Cleveland, OH 44195. E-mail natalea{at}ccf.org

Received September 27, 2004; revision received April 1, 2005; accepted April 12, 2005.

Background— Left atrioesophageal fistula is a devastating complication of atrial fibrillation ablation. There is no standard approach for avoiding this complication, which is caused by thermal injury during ablation. The objectives of this study were to evaluate the course of the esophagus and the temperature within the esophagus during pulmonary vein antrum isolation (PVAI) and correlate these data with esophagus tissue damage.

Methods and Results— Eight-one patients presenting for PVAI underwent esophagus evaluation that included temperature probe placement. Esophagus course was obtained with computed tomography, 3D imaging (NAVX), or intracardiac echocardiography. For each lesion, the power, catheter and esophagus temperature, location, and presence of microbubbles were recorded. Lesion location and esophagus course were defined with 6 predetermined left atrial anatomic segments. Endoscopy evaluated tissue changes during and after PVAI. Of 81 patients, the esophagus coursed near the right pulmonary veins in 23 (28.4%), left pulmonary veins in 31 (38.3%), and mid-posterior wall in 27 (33%). Esophagus temperature was significantly higher during left atrial lesions along its course than with lesions elsewhere (38.9±1.4°C, 36.8±0.5°C, P<0.01). Lesions that generated microbubbles had higher esophagus temperatures than those without (39.3±1.5°C, 38.5±0.9°C, P<0.01). Power was not predictive of esophagus temperatures. Distance between the esophagus and left atrium was 4.4±1.2 mm.

Conclusions— Lesions near the course of the esophagus that generated microbubbles significantly increased esophagus temperature compared with lesions that did not. Power did not correlate with esophagus temperatures. Esophagus variability makes the avoidance of lesions along its course difficult. Rather than avoiding posterior lesions, emphasis could be placed on better esophagus monitoring for creation of safer lesions.

Key Words: ablation • catheter ablation • complications • fistula, atrioesophageal • pulmonary veins

This article has been cited by other articles:

				M. Schmidt, G. Nolker, H. Marschang, K.-J. Gutleben, V. Schibgilla, H. Rittger, A.-M. Sinha, G. Ritscher, D. Mayer, J. Brachmann, et al. Incidence of oesophageal wall injury post-pulmonary vein antrum isolation for treatment of patients with atrial fibrillation Europace, February 1, 2008; 10(2): 205 - 209. [Abstract] [Full Text] [PDF]

				H. Calkins, J. Brugada, D. L. Packer, R. Cappato, S.-A. Chen, H. J.G. Crijns, R. J. Damiano Jr, D. W. Davies, D. E. Haines, M. Haissaguerre, et al. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace, June 1, 2007; 9(6): 335 - 379. [Full Text] [PDF]

				O. M. Wazni, H.-M. Tsao, S.-A. Chen, H.-H. Chuang, W. Saliba, A. Natale, and A. L. Klein Cardiovascular Imaging in the Management of Atrial Fibrillation J. Am. Coll. Cardiol., November 21, 2006; 48(10): 2077 - 2084. [Abstract] [Full Text] [PDF]

				L. J. Gula, A. C. Skanes, E. Posan, A. D. Krahn, R. Yee, and G. J. Klein Gastroesophageal Reflux Facilitates Esophageal Imaging During Pulmonary Vein Ablation Circulation, August 8, 2006; 114(6): e235 - e236. [Full Text] [PDF]

				J. E. Cummings, R. A. Schweikert, W. I. Saliba, J. D. Burkhardt, F. Kilikaslan, E. Saad, and A. Natale Brief communication: atrial-esophageal fistulas after radiofrequency ablation. Ann Intern Med, April 18, 2006; 144(8): 572 - 574. [Abstract] [Full Text] [PDF]