Esophageal Migration During Left Atrial Catheter Ablation for Atrial Fibrillation
Because of the risk of atrio-esophageal fistula, a 38-year-old man with paroxysmal atrial fibrillation was asked to swallow barium contrast (barium sulfate esophageal cream 60% with water, EZ-EM Canada) before undergoing a left atrial catheter ablation with an electroanatomic mapping system (CARTO, Biosense Webster) to identify the location of the esophagus in relation to the posterior left atrium (Figure 1A). The location of the esophagus was tagged on the electroanatomic map at sites where the catheter tip overlay the esophagus in 2 orthogonal fluoroscopic views (Figure 2). During the course of the study it was noted that the esophagus had moved from close to the left-sided pulmonary veins (PVs) to close to the right-sided PVs (Figures 1B and 2⇓). The location of the esophagus relative to the posterior left atrium can change during an ablation procedure. Therefore, fixed images such as tags on electroanatomic maps or digital image fusion technology may not be sufficient to prevent inadvertent esophageal injury. It may be necessary to use real-time imaging either by fluoroscopic monitoring of a radiocontrast agent or a probe in the esophagus or by real-time MRI.