Massive Hiatal Hernia and Thoracic Stomach Illustrated by Barium Swallow During Left Atrial Catheter Ablation for Atrial Fibrillation
Left atrial radiofrequency catheter ablation was planned in a 68-year-old man with chronic atrial fibrillation refractory to medical therapy and cardioversion. After the transseptal puncture and before conscious sedation, the patient was asked to swallow 5 mL of barium paste (E-Z-EM, Lake Success, NY) so that the location of the esophagus in relation to the left atrium could be visualized.1 The esophagogram delineated a massive hiatal hernia that resulted in an intrathoracic stomach that was in apposition to the entire posterior left atrium (Figure 1). Because of this marked anatomic abnormality and proximity of the posterior wall of the left atrium to the stomach and the esophagus, the procedure was postponed so that radiofrequency energy would not be delivered over these structures until the anatomic abnormality was corrected. A double-contrast esophagogram and CT scan confirmed the close relationship between the intrathoracic stomach and posterior left atrium and spontaneous gastroesophageal reflux to the level of the thoracic inlet (Figures 2 and 3⇓).
This case illustrates several important points relative to hiatal hernias and catheter ablation in the left atrium: First, it emphasizes the importance of completely visualizing the esophageal lumen during left atrial ablation and the limitations of utilizing an esophageal probe to do so. Had a probe been used instead of barium, the extent of herniation might not have been appreciated, and radiofrequency energy may have been delivered inadvertently over the esophagus and the stomach. Second, when available, review of the nonsegmented CT scan of the chest before registration into a 3D electroanatomic mapping system can be helpful to recognize variations in intrathoracic anatomy. Lastly, severe gastroparesis has been reported as a complication of left atrial radiofrequency catheter ablation. It is possible that applications of radiofrequency energy along the posterior wall adjacent to paraesophageal and gastric autonomic plexi may impair innervation of the stomach, resulting in delayed gastric emptying.2
Drs Oral and Morady are founders and equity owners of Ablation Frontiers, Inc. The other authors report no conflicts.