A novel treatment for esophageal lesions following atrial fibrillation ablation

This study presents a novel technique for the treatment of a deep esophageal ulcer after ablation of paroxysmal atrial fibrillation (AF). Pulmonary vein isolation was performed using a radiofrequency irrigated tip catheter. On Day 5 of follow-up, a deep esophageal ulcer was observed. No significant visual improvement was observed after conventional treatment. Endoscopic negative pressure therapy in the esophagus was then applied for 5 days. A significant decrease in diameter and depth of the lesion was observed, possibly preventing perforation. Endoscopic negative pressure therapy can be used to heal thermal lesions after AF ablation procedures.     

Mechanical esophageal displacement during catheter ablation for atrial fibrillation

Esophageal Deviation in AF Ablation. Objective: To determine the feasibility and safety of esophageal displacement during atrial fibrillation (AF) ablation, to prevent thermal injury. Background: Patients undergoing AF ablation are at risk of esophageal thermal injury, which ranges from superficial ulceration, to gastroparesis, to the rare but catastrophic atrioesophageal fistula. A common approach to avoid damage is luminal esophageal temperature (LET) monitoring; however, (1) temperature rises mandate interruptions in energy delivery that interrupt workflow and potentially decrease procedural efficacy, and (2) esophageal fistulas have been reported even with LET monitoring. Methods: A cohort of 20 consecutive patients undergoing radiofrequency (RF) (16 patients) or laser balloon (4 patients) ablation of AF under general anesthesia. After barium instillation, the esophagus was deviated using an endotracheal stylet placed within a thoracic chest tube. LET monitoring was used during catheter ablation. Upper GI endoscopy was performed prior to discharge. Results: At the pulmonary vein level, leftward deviation measured 2.8 ± 1.6 cm (range: 0.4–5.7) and rightward deviation 2.8 ± 1.8 cm (range: 0.5–4.9). The temperature rose to >38.5 °C in 3/20 (15%) patients. In these 3 patients, there was an average of 2 applications/patient that recorded temperatures >38.5 °C. No patient had a temperature rise > 40 °C. Endoscopy revealed no esophageal ulceration from thermal injury in 18/19 (95%) patients; the sole patient with a thermally mediated ulceration had an unusual esophageal diverticulum fully across the posterior left atrium. Twelve patients (63%) exhibited trauma related to instrumentation with no clinical sequelae. Conclusions: Mechanical esophageal deviation is feasible and allows for uninterrupted energy delivery along the posterior wall during catheter ablation of AF. J Cardiovasc Electrophysiol, Vol. 23, pp. 147‐154, February 2012)     

Correlation of symptoms to ECG diagnosis following atrial fibrillation ablation

INTRODUCTION: Currently, definition of success following atrial fibrillation (AF) ablation is commonly based on the lack of symptoms. The purpose of this study was to evaluate the correlation between symptoms and the underlying rhythm after AF ablation. METHODS AND RESULTS: Eighty consecutive patients (pts) were treated for paroxysmal episodes of AF by segmental ostial ablation of all pulmonary veins and right atrial isthmus ablation. For 6 months pts transmitted transtelephonic (T-) ECG recordings in combination with comments daily or in the event of symptoms. Eligible comments were classified as: (1) asymptomatic, (2) symptomatic. Analysis was performed at 1-month intervals, defining an acute (first month) and chronic period (second to sixth month) after ablation. Overall 6,835 T-ECGs were analyzed. Of these 5,437 (79.5%) showed sinus rhythm (SR) and 1,398 (20.5%) showed AF. Pts in SR reported symptoms for 593 (10.9%) episodes, whereas 4,844 (89.1%) episodes were asymptomatic. During AF, 646 (46.2%) episodes were associated with symptoms, and 752 (53.8%) episodes remained asymptomatic. Exclusively asymptomatic were 7 (8.8%) pts. In 30 (52.6%) of 57 pts with AF, arrhythmic events were confined to the acute phase. Of the remaining 27 pts 14 (52%) reported an improvement, 12 (44%) the same, and 1 (4%) worsened symptoms after 3 months. A significant change (P < 0.01) toward more asymptomatic episodes from the acute (43.5%) to the chronic (57.5 +/- 4.5%) period was evident. CONCLUSION: Assessment of success after AF ablation cannot be based on the absence of symptoms due to a high prevalence of asymptomatic episodes.     

Total pulmonary vein occlusion as a consequence of catheter ablation for atrial fibrillation mimicking primary lung disease

INTRODUCTION: Catheter ablation has recently been used for curative treatment of atrial fibrillation. METHODS AND RESULTS: Three of 239 patients who underwent ablation close to the pulmonary vein (PV) ostia at our institute developed severe hemoptysis, dyspnea, and pneumonia as early as 1 week and as late as 6 months after the ablation. Because the patients were arrhythmia-free, the treating physician initially attributed the symptoms to new-onset pulmonary disease (e.g., bronchopulmonary neoplasm). After absent PV flow was confirmed by transesophageal echocardiography, transseptal contrast injection depicted a totally occluded PV in all three patients. Successful recanalization, even in chronically occluded Pvs, was performed in all patients. During follow-up, Doppler flow measurements by transesophageal echocardiography demonstrated restenosis in all primarily dilated PV, which led to stent implantation. CONCLUSION: PV stenosis/occlusion after catheter ablation of atrial fibrillation occurs in a subset of patients. However, because in-stent restenosis occurred in two patients after 6 to 10 weeks, final interventional strategy for PV stenosis or occlusion remains unclear. To prevent future PV stenosis or occlusion, a decrease in target temperature and energy of radiofrequency current or the use of new energy sources (ultrasound, cryothermia, microwave) seems necessary.     

Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: lessons from five cases

Introduction: The aim of the study was to identify criteria for rapid recognition and successful treatment of esophageal perforation after radiofrequency ablation for atrial fibrillation (AF).
Methods and Results: Esophageal perforation occurred in five patients after intraoperative (n = 4) or percutaneous (n = 1) AF ablation. Patients presented with high fever (n = 3) or severe chest/epigastric pain (n = 2) 8–28 days after ablation. WBC count was elevated at presentation in all patients (15,460 ± 2,910/μL), CRP showed a delayed rise. Thoracic CT detected free air in all. Neurologic complications occurred in three cases (60%) with a delay of 5–40 hours after first symptoms. Only one (20%) developed neurologic complications within the first 24 hours. Two patients (40%) died before surgery could be performed. In both, time from symptom onset to diagnosis was significant (24 and 36 hours). Three patients (60%) underwent esophageal resection and survived. In two of them, treatment was rapid with time from symptoms to surgery of 24 hours; they had favorable outcome. In the third surviving patient, surgery was late (5 days after first symptoms); permanent neurologic residues remained.
Conclusion: The leading symptom of esophageal perforation is high fever or severe chest/epigastric pain. Fever is not necessarily present. Leukocytosis is the earliest and most sensitive laboratory marker, thoracic CT the most valuable diagnostic examination. The dramatic neurologic complications occur with a delay of at least a few hours after first symptoms. Immediate surgery may prevent neurologic complications and could possibly result in a high survival rate without residues. Delay of treatment seems to have devastating results.     

Catheter ablation is preferred over surgery for persistent atrial fibrillation

There are important limitations that can hinder outcomes of surgical ablation in nonparoxysmal patients with atrial fibrillation (AF), which is the typical AF population undergoing concomitant cardiac surgery for valve or ischemic heart disease. Incomplete lesions with recovered conduction or gaps as well as arrhythmias originating from areas not targeted by surgical ablation are commonly seen at the time of recurrence. Therefore, while it might be reasonable to perform AF surgery in this cohort, it is important to know these limitations and establish adequate postoperative rhythm monitoring to detect recurrences, which can be effectively addressed by catheter ablation.     

Aorto-right atrial fistula following transseptal catheterization and catheter ablation for atrial fibrillation

Aorto-cameral fistula, either congenital or acquired, is an abnormal connection between the ascending aortic root and one of the cardiac chambers. We report a case of a 61-year-old male with history of atrial fibrillation and 2 radiofrequency ablation procedures, referred to us for surgical Cox Maze procedure. Preoperative cardiac computerized tomography revealed a fistulous connection between the aortic root and the right atrium. Later, the patient underwent successful surgical closure of the fistula during the Cox Maze procedure. In this paper, we also discuss the clinical presentation, natural history, anatomy of the interatrial septum, and management of aorto-cameral fistula.     

Atrial fibrillation ablation with esophageal cooling with a cooled water-irrigated intraesophageal balloon: a pilot study

Introduction: A left atrioesophageal fistula is an uncommon but devastating complication that may occur during atrial fibrillation (AF) ablation, and may be due to thermal injury occurring during the radiofrequency (RF) ablation. We examined the feasibility of an esophageal cooling (ECO) method using a cooled water-irrigated intraesophageal balloon (IB).
Methods and Results: Eight patients with drug-refractory AF underwent RF catheter ablation to encircle the ipsilateral pulmonary veins. During the RF ablation at the posterior left atrium, the esophageal lumen was cooled using a 9-Fr. IB catheter with a balloon length of 40 mm and diameter of 10 mm, in which cooled water, with a water temperature of 4.5 ± 3.1 °C, was irrigated while the luminal esophageal temperature (LET) was measured with an intraesophageal probe placed at a site close to the tip of the ablation catheter. In the control, the LET increased from 36.4 ± 0.8 °C to 40.5 ± 1.7 °C within 26.1 ± 8.2 seconds during 3.9 ± 1.2 RF energy applications, whereas with the ECO the LET decreased to 30.2 ± 2.9 °C at baseline (P<0.01 vs control), and increased only to 33.5 ± 2.9 °C (P<0.01 vs control) at most, within 30 seconds during 3.9 ± 1.2 RF energy applications. All pulmonary veins were successfully isolated in all patients without any complications. During a follow-up period of 3.1 ± 1.2 months, no esophageal injuries were observed and all but one patient have been free from any symptoms.
Conclusions: Use of an IB successfully lowers LET. This might have the potential of preventing esophageal injury, although further study is required.     

Approach and strategy for repeat catheter ablation of recurrent atrial fibrillation

Patients with atrial fibrillation often undergo repeat catheter ablation for the recurrence of tachyarrhythmia. If the pulmonary veins were isolated in prior procedure, the operator should focus on substrate homogenization with identification and ablation of only arrhythmogenic areas.     

Clinical outcome of very late recurrence of atrial fibrillation after catheter ablation of paroxysmal atrial fibrillation

INTRODUCTION: High recurrence rate is still a major problem associated with ablation of paroxysmal atrial fibrillation (AF). Most of the recurrences occur within 6 months after ablation. The characteristics of very late recurrent AF (>12 months after ablation) have not been reported. METHODS AND RESULTS: Two hundred seven patients with drug-refractory AF underwent successful focal ablation or isolation of AF foci. After the first ablation procedure, Holter monitoring and event recorders were used to evaluate symptomatic recurrent AF. A second ablation procedure was recommended if the antiarrhythmic drugs could not control recurrent AF. During long-term follow-up (mean 30 +/- 11 months, up to 51 months), 70 patients had recurrent AF, including 13 patients (6%) with very late (>12 months) recurrent AF (group 1) and 57 patients (28%) with late (within 12 months after ablation) recurrent AF (group 2). Group 1 patients had a significantly lower incidence of multiple (> or = 2) AF foci (23% vs 63%, P = 0.02) than group 2 patients. In addition, the incidence of antiarrhythmic drugs use (38% vs 84%, P = 0.001) to maintain sinus rhythm after the first episode of recurrent AF was significantly lower in group 1 than group 2 patients, and the incidence of a second intervention procedure (8% vs 35%, P = 0.051) tended to be lower in group 1 than group 2 patients. CONCLUSION: The incidence of very late recurrent AF after ablation of paroxysmal AF is very low, and the clinical outcome of patients with very late recurrent AF is benign.     

消融指数指导下高功率消融在老年心房颤动患者中的应用效果

目的 探讨消融指数指导下高功率消融在老年心房颤动(房颤)患者中的有效性和安全性.方法 选取2019年1月～2021年1月于山西医科大学第一医院行高功率(45 W)消融的老年房颤患者50例为高功率组,另选常规功率消融(35W)50例患者为常规功率组,2组相同消融指数指导消融.消融终点为双侧肺静脉隔离,比较2组手术相关参数...     

Predictors of recurrence following catheter ablation of atrial fibrillation using an irrigated-tip ablation catheter

INTRODUCTION: The aims of this study were to identify predictors of recurrence after catheter ablation of atrial fibrillation (AF) and to report the safety and efficacy of catheter ablation of AF using an irrigated-tip ablation catheter. METHODS AND RESULTS: Seventy-five consecutive patients (51 men [68%]; age 54 +/- 13 years) with symptomatic drug-refractory paroxysmal (42 patients), persistent (21 patients), or permanent (12 patients) AF underwent catheter ablation of AF using an irrigated-tip ablation catheter and a standard ablation strategy, which involved electrical isolation of all pulmonary veins (PVs) and creation of a cavotricuspid linear lesion. At 10.5 +/- 7.5 months of follow-up following a single (n = 75) or redo ablation procedure (n = 11), 39 (52%) of the 75 patients were free of AF, 10 were improved (13%), and 26 had experienced no benefit from the ablation procedure (35%). Seventy-six percent of patients with paroxysmal AF were free from recurrent AF. The most significant complications were two episodes of pericardial tamponade, mitral valve injury in one patient, two strokes, and complete but asymptomatic PV stenosis in one patient. Cox proportional hazards multivariate regression analysis identified the presence of persistent AF, permanent AF, and age >50 years prior to the ablation are the only independent predictors of AF recurrence after the first PV isolation procedure. CONCLUSION: Catheter ablation of AF using a strategy involving isolation of all PVs and creation of a linear lesion in the cavotricuspid isthmus using cooled radiofrequency energy is associated with moderate efficacy and an important risk for complications. The best results of this procedure are achieved in the subset of patients who are younger than 50 years and have only paroxysmal AF.     

Dual independent atrial tachycardias after ablation of chronic atrial fibrillation

We report the case of a 71-year-old man with two atrial tachycardias evolving simultaneously and independently in two dissociated regions after extensive ablation for chronic atrial fibrillation. One tachycardia was a focal tachycardia originating from the right inferior pulmonary vein and activating the posterior left atrium with a 2:1 conduction block, while the other tachycardia was an atrial flutter circulating around the tricuspid annulus, activating the right atrium and the anterior wall of the left atrium. These two atrial tachycardias were successfully ablated prior to restoration of sinus rhythm.     

Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation

Topography of the esophagus in atrial fibrillation ablation. INTRODUCTION: The close anatomic relationship of the posterior wall of the left atrium (LA) and the thermosensitive esophagus creates a potential hazard in catheter ablation procedures. METHODS AND RESULTS: In 30 patients (pts) with atrial fibrillation (AF) undergoing catheter ablation, we prospectively studied the course and contact of the esophagus in relation to LA and the topographic proximity to ablation lines encircling the right-sided and left-sided pulmonary veins (PV) as well as to the posterior line connecting the encircling lines using the electromagnetic mapping system for reconstruction of LA and for tagging of the esophagus. This new technique of anatomic tagging of the esophagus was validated against the CT scan as a standard imaging procedure. The esophageal course was highly variable, extending from courses in direct vicinity to the left- or right-sided PV as well as in the midportion of the posterior LA. In order to avoid energy application in direct proximity to the esophagus, adjustments of the left and right PV encircling lines were necessary in 14/30 pts (47%) and 3/30 (10%). In 30 pts (100%), the mid- to inferior areas of the posterior LA revealed contact with the esophagus. Therefore, posterior and inferior linear ablation lines were abandoned and shifted to superior in 29 pts (97%). CONCLUSIONS: Anatomic tagging of esophagus revealed a highly variable proximity to different areas of the posterior LA suggesting individual adjustment of encircling and linear ablation lines in AF ablation procedures to avoid the life threatening complication of esophagus perforation.     

心房颤动导管消融后心房食管瘘的研究概况

心房颤动(房颤)是较常见的一种心律失常,目前导管消融作为其治疗手段之一,已广泛应用于临床。心房食管瘘是房颤导管消融术的一种罕见并发症,但却是最可怕和致命的。因此,为了能降低其发生的风险,我们需要充分认识该并发症,并采取积极有效的预防措施。本文综述了心房食管瘘的发病机制、危险因素、诊断及治疗,以及目前可能有效的一些预防措施,以期为临床提供参考。     

Left atrial contractility is preserved after successful circumferential pulmonary vein ablation in patients with atrial fibrillation

Introduction: Circumferential pulmonary vein ablation (CPVA) for atrial fibrillation (AF) consists of creating extensive lesions in the left atrium (LA). The aim of the study was to evaluate changes in LA contractility after ablation and their relationship with procedure outcome.
Methods and Results: A series of 90 consecutive patients underwent cardiac magnetic resonance imaging (MRI) before and 4–6 months after CPVA. Only patients in sinus rhythm during both imaging acquisitions were included in the study to measure LA end-diastolic (LAmax) and LA end-systolic (LAmin) volumes. Fifty-five patients were finally analyzed (41 men, 52 ± 11 years, 74% paroxysmal AF). During a mean follow-up of 12 ± 7 months and after 1.2 ± 0.3 ablation procedures, 38 patients (69%) were arrhythmia-free (group I), and the remaining 17 patients had recurrences (group II). There was a significant decrease in mean LAmax volume in both groups, whereas mean LAmin volume only decreased in group I. Mean LA ejection fraction (EF) was preserved after CPVA in group I (40 ± 11% vs 38 ± 10%; P = 0.27) but decreased in patients with arrhythmia recurrences (37 ± 10% vs 27 ± 10%; P < 0.001). In fact, LA EF remained stable or increased in 68% of patients without arrhythmia recurrences.
Conclusions: LAmax volume reduction following CPVA occurs regardless of the clinical efficacy of the procedure, whereas mean LAmin volume only decreased in patients without recurrences. LA EF was preserved or even increased in most patients with successful CPVA.     

Complications of catheter ablation for atrial fibrillation: incidence and predictors

Introduction: Pulmonary vein (PV) isolation by catheter ablation is an increasingly used strategy to treat atrial fibrillation (AF). Complication rates from AF ablation reported in different case series vary widely. We conducted a retrospective analysis of 641 consecutive ablation procedures to assess complication rates, temporal trends, and clinical predictors of adverse outcomes.
Methods: All patients (n = 517) undergoing catheter ablation for AF at Johns Hopkins Hospital between February, 2001 and June, 2007 were prospectively enrolled in a database. Data from 641 consecutive procedures were analyzed and complications considered if they occurred within 30 days of ablation. Major complications were defined as those that required intervention, resulted in long-term disability, or prolonged hospitalization.
Results: Thirty-two major complications occurred in 641 procedures (5%). Among the patients with major complications, seven had cerebrovascular accident (CVA), eight had tamponade, one had PV occlusion with hemoptysis, and 11 had vascular injury requiring surgical repair and/or transfusion. No periprocedural deaths occurred, and no instances of esophageal injury were seen. Complication rates were higher during the first 100 cases (9.0%) than during the subsequent 541 (4.3%). Major adverse clinical events were associated with age > 70 years (P = 0.007; odds ratio 3.7, 95% confidence interval 1.4–9.6) and female gender (P = 0.014; odds ratio 3.0, 95% confidence interval 1.3–7.2). No other clinical or procedural predictors of complication were identified.
Conclusions: Complication rates from AF ablation remain significant, despite improved techniques and increased awareness of procedural risks. Both advanced age and female gender predict major adverse events, suggesting careful consideration of the risk/benefit profile in these patients prior to ablation.