doi: 10.1161/CIRCULATIONAHA.106.614735
(Circulation. 2006;114:e235-e236.)
© 2006 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Gastroesophageal Reflux Facilitates Esophageal Imaging During Pulmonary Vein Ablation
From the Department of Medicine, Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
Correspondence to Dr Lorne J. Gula, London Health Sciences Centre, Arrhythmia Service, 339 Windermere Rd, London, Ontario, Canada N6A 5A5. E-mail lgula{at}uwo.ca
A 45-year-old man with gastric esophageal reflux disease underwent pulmonary vein ablation for the management of paroxysmal atrial fibrillation. Because of recent reports of esophageal perforation with ablation at the posterior wall of the left atrium,1 the patient was given 30 mL of barium (Ezem Inc, Anjou, Quebec, Canada) to swallow before administration of general anesthesia, and a temperature monitor (Mallinkrodt Inc, St Louis, Mo) was positioned in the esophagus. Typical staining of endothelial folds of the esophagus was observed immediately after barium administration (Figure 1). After barium cleared from the esophagus and pooled in the stomach, reflux of the barium into the esophagus was observed (Figure 2), opacifying the entire esophageal lumen for the 5-hour duration of the procedure.
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Pulmonary vein ablation has been increasingly recognized as an important and effective option for the management of atrial fibrillation. Esophageal perforation is a life-threatening complication of this procedure and has resulted in a widespread interest in defining the anatomic relationship between the left atrium and the esophagus.2–6 Real-time imaging of the esophagus during ablation has been achieved with barium and by observing the position of a temperature monitor placed in the esophagus. The latter also permits cessation of energy delivery if esophageal temperature rises.2,7 The reflux of barium in this case, which opacified the entire lumen of the esophagus, illustrates the limitations of usual anatomic imaging. The true width of the esophagus, which is at risk behind the left atrial wall, is considerably underrepresented by both the barium-stained endothelium and the narrow caliber of the esophageal probe. There are clearly regions of the esophagus that would appear safe for ablation but are, in fact, in apposition to the esophagus, as revealed by the barium reflux. Real-time imaging that reveals the true extent of the esophageal lumen, as demonstrated in this case, continues to be an elusive but important goal for catheter-based therapy of atrial fibrillation.
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