Abstract 5656: Low Incidence of Esophageal After Ablation of Atrial Fibrillation - High Rate of Ulcerations in a Subgroup with General Anesthesia and Nasogastric Tubes
Atrio-esophageal fistula is an uncommon but often lethal complication of atrial fibrillation (AF) ablation. The incidence of asymptomatic esophageal ulcerations (EU), as a possible precursor lesion, is high (35.7– 47%) as recently reported. The purpose of our study was to investigate if direct visualisation of the esophagus can prevent EU. 123 patients (81 paroxysmal, 42 persistent AF; 80% male) underwent AF ablation and esophagoscopy 24 hours thereafter. We performed a 2:1:1 3-arm randomization as follows: Group 0: Ablation without visualisation of the esophagus using 25W power limit on the posterior wall (PW), n=70; Group 1: Ablation guided by barium swallowing and visualisation of the esophageal course by fluoroscopy using a maximum of 15W on the PW, n=21; Group 2: Ablation guided by barium swallowing and visualisation using 25 W on the PW and “short burns” (max. 5 sec energy application at one spot), n=32; Ablation was performed with a 3.5mm-tip open irrigation catheter with a target temperature of 43°C. 3D electroanatomic mapping with CT integration was used, either CartoXP or NavX. Conscious sedation with midazolam and propofol was performed in 104 patients (85%) and general anesthesia in 19 patients (15%). In the latter group we used a nasogastric tube for visualisation of the esophagus in 6 patients randomized to groups 1 or 2. In total we found 5 out of 123 patients (2 paroxysmal, 3 persistent AF) presenting EU on endoscopy (4.1%). 1 patient belonged to the group 0 without visualisation and 4 patients to the group 2 with visualisation. The subgroup of patients with general anesthesia and a nasogastric tube for esophageal visualization had the highest risk for developing EU (3 out of 6; 50%). The subgroup of patients with conscious sedation only showed an EU rate of 1.9%. We found no significant difference between energies delivered on the PW comparing groups with and without EU. Ablation guided by real-time visualisation of the esophagus was not able to prevent EU in every patient, but with a power limitation to 25W on the PW we discovered a much lower rate of EU than reported in other series. We identified a subgroup of patients with general anesthesia and a nasogastric tube as a high risk population for EU.