Esophageal Thermal Injury after Catheter Ablation for Atrial Fibrillation with High-Power (50 Watts) Radiofrequency Energy

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF) However AF recurrence after a single ablation procedure is common and often attributed to ineffective lesion delivery during PVI. In this issue of the Journal of Cardiovascular Electrophysiology, Chen et al reported their experience with 122 patients who underwent an ablation index-high power (AI-HP) strategy RF ablation for AF using 50W power, targeting AI values of 550 on the anterior left atrium (LA), 400 on the posterior wall and inter-lesion distance (ILD) 6mm. They achieved 1st pass PVI in 96.7% of cases, mean RF time was 11.5min and total procedure time was only 55.8min. All patients had 72h-Holter monitor and trans-telephonic follow up. They reported 89.4% arrhythmia free survival among patients with paroxysmal AF and 80.4% among patients with persistent AF at 15-month follow up. Sixty (49%) patients had luminal esophageal temperature (LET) >390C out of which 3 (2.5%) had asymptomatic endoscopic esophageal erosions/erythema. Four (3%) patients had clinically apparent steam pops during ablation with no adverse clinical sequela. While AI-HP guided RF ablation may be an attractive strategy for PVI that likely reduces procedure times and probably has comparable efficacy to conventional ablation settings, its safety requires further evaluation. Feedback from the ablated tissue may need to be incorporated into optimized ablation energy parameters to further improve outcomes.

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Efficacy and safety of 50-60 Watt high-power short-duration radiofrequency catheter ablation of atrial fibrillation: A propensity score matching study

EP Europace ◽

10.1093/europace/euab116.210 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

HN Pak ◽

SY Yang ◽

M Kim ◽

HT Yu ◽

TH Kim ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Propensity Score ◽

Propensity Score Matching ◽

Short Duration ◽

High Power ◽

Volume Index ◽

Ablation Lesion ◽

Efficacy And Safety ◽

Clinical Recurrence

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Although high-power short-duration (HPSD) radiofrequency (RF) energy is commonly utilized in atrial fibrillation (AF) catheter ablation (CA), its efficacy, safety, and autonomic neural effects have not yet been evaluated in a large patient number. We compared HPSD-AFCA and conventional power (ConvP)-AFCA after propensity score matching. Methods Among 3,221 consecutive AF ablation patients, we included 1,720 patients (74.4% male, 59 ± 10 years old, 56.5% paroxysmal type) who underwent AFCA after propensity score matching: 430 in 50∼60W HPSD group vs. 1,290 in the ConvP group. We evaluated the procedural factors, complication risk, rhythm outcome, and 3-month heart rate variability (HRV) between the two groups and subgroups. Results Procedure times were significantly shorter in the HPSD group (p < 0.001), but the complication rate (p = 0.088) and the 3rd-month HRV did not differ between the two groups. At the 12-month follow-up, rhythm outcomes did not differ between the two groups (Overall, Log-rank p = 0.212; anti-arrhythmic drug off Log rank p = 0.246). These efficacy and safety outcomes were consistently similar regardless of the AF type or ablation lesion set. In the Cox regression analysis, the left atrium volume index measured by computed tomography (HR 1.009 [1.003-1.015]), p = 0.005) and extra-pulmonary vein triggers (HR 1.587 [1.033-2.440], p = 0.035) were independently associated with 1-year clinical recurrence, while the HPSD strategy was not (HR 1.188 [0.903-1.564], p = 0.218). Conclusions HPSD-AFCA significantly shortened the procedure time with similar rhythm outcomes, complication risks, and autonomic neural effects as ConvP-AFCA, regardless of the AF type or ablation lesion set. Abstract Figure.

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Abstract 16605: The Effectiveness and Safety of the Esophageal Temperature Monitoring During Catheter Ablation of Atrial Fibrillation

Circulation ◽

10.1161/circ.142.suppl_3.16605 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Miwa Ito ◽

Hisanori Kanazawa ◽

Tadashi Hoshiyama ◽

Yusei Kawahara ◽

Kenichi Tsujita

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Characteristic Curve ◽

Predictive Marker ◽

Patient Characteristics ◽

Temperature Monitoring ◽

Esophageal Injury ◽

Radiofrequency Energy ◽

Esophageal Temperature ◽

Significant Difference

Introduction: Esophageal injury is known to be a serious complication occurs after catheter ablation (CA) of atrial fibrillation (AF). Hypothesis: We investigated the factors associated with the occurrence of EI after CA. Also esophageal temperature monitoring (ETM) can be useful, multiple factors such as patient characteristics and specific strategies for radiofrequency energy delivery also merit consideration. Methods: Among 508 patients who underwent CA of AF, endoscopy was performed the next day after CA to examine for EI. The incidence of EI was compared between 200 patients who done ETM (ETM group) and 308 patients who didn’t done ETM (Non-ETM group) during CA. The Shortest Distance between esophagus and posterior left atrium measured on contrast Computed Tomography (SD-CT) was also compared between both groups. Results: No differences were observed between both groups in total amount of radiofrequency energy applications. However, EI occurred more frequently in Non-ETM group (8/200 patients; 4.0 % vs 27/308 patients; 8.8 %, p=0.042). There was no significant difference in SD-CT between ETM and Non-ETM group. However, SD-CT in patients with EI was significantly shorter than SD-CT in patients without EI, both in ETM (2.4±0.7 vs 4.3±0.9 mm, p<0.001) and in Non-ETM group (2.5±0.2 vs 4.2±0.9 mm, p=0.017), respectively. Multiple regression analysis revealed that only SD-CT significantly correlated with EI. The area under a receiver operating characteristic curve using ST-CT as a predictive marker in EI patients was 0.968 (p<0.001). When the cut-off value of EI was set at 2.9mm, the sensitivity and specificity for EI diagnosis were 96.6% and 87.5%. Conclusions: The use of ETM is absolutely safe and necessary in order to prevent the occurrence of thermal EI.

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Impact of epicardial fat on the duration of radiofrequency energy delivery during catheter ablation of atrial fibrillation

IJC Heart & Vasculature ◽

10.1016/j.ijcha.2020.100555 ◽

2020 ◽

Vol 29 ◽

pp. 100555

Author(s):

Victor Oudin ◽

Claude Marcus ◽

Laurent Faroux ◽

Madeline Espinosa ◽

Damien Metz ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Epicardial Fat ◽

Radiofrequency Energy ◽

Energy Delivery ◽

Radiofrequency Energy Delivery

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High-Power Radiofrequency Catheter Ablation of Atrial Fibrillation

JACC: Clinical Electrophysiology ◽

10.1016/j.jacep.2018.07.017 ◽

2018 ◽

Vol 4 (12) ◽

pp. 1583-1594 ◽

Cited By ~ 22

Author(s):

Alex Baher ◽

Mobin Kheirkhahan ◽

Stephen J. Rechenmacher ◽

Qussay Marashly ◽

Eugene G. Kholmovski ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

High Power ◽

Radiofrequency Catheter Ablation

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Significance of Contact Force on Esophageal Thermal Injury During Relative High-Power Short-Duration Ablation of Atrial Fibrillation

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.121.009897 ◽

2021 ◽

Author(s):

Takashi Kaneshiro ◽

Kazuaki Amami ◽

Naoko Hijioka ◽

Minoru Nodera ◽

Shinya Yamada ◽

...

Keyword(s):

Atrial Fibrillation ◽

Short Duration ◽

Contact Force ◽

High Power ◽

Thermal Injury

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Abstract 3231: Esophageal Capsule Endoscopy: Different Findings Based On The Anesthesia Protocol

Circulation ◽

10.1161/circ.116.suppl_16.ii_727 ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Luigi Di Biase ◽

Stacy Poe ◽

Luis Carlos Saenz ◽

Miguel Vacca ◽

Mauricio Cabrales ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

General Anesthesia ◽

Capsule Endoscopy ◽

Conscious Sedation ◽

Radiofrequency Energy ◽

List Type ◽

Esophageal Temperature ◽

Atrioesophageal Fistula ◽

Esophageal Capsule

Introduction: Left atrioesophageal fistula is a rare but devastating complication that can occur following catheter ablation of atrial fibrillation. Methods : Fifty patients undergoing AF ablation for paroxysmal and persistent/permanent symptomatic atrial fibrillation refractory to AAD have been enrolled and randomized into 2 groups: those undergoing the procedure under conscious sedation with fentanil or midazolam (25 patients, group and those receiving general anesthesia (25 patients, group All patients underwent esophageal temperature monitoring during the procedure. Radiofrequency energy was discontinued when the luminal temperature reached 39 C. After ablation all patients had capsule endoscopy to assess the presence for endoluminal tissue damage of the esophagus. Results : The results are shown in the table below Conclusion : The use of general anesthesia increases the risk of positive esophageal findings by capsule endoscopy

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Characteristics of Esophageal Injury in Ablation of Atrial Fibrillation Using a High-Power Short-Duration Setting

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.120.008602 ◽

2020 ◽

Vol 13 (10) ◽

Cited By ~ 1

Author(s):

Takashi Kaneshiro ◽

Masashi Kamioka ◽

Naoko Hijioka ◽

Shinya Yamada ◽

Tetsuro Yokokawa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Pulmonary Vein ◽

Short Duration ◽

Pulmonary Vein Isolation ◽

High Power ◽

Thermal Injury ◽

Low Voltage ◽

Conventional Group ◽

Esophageal Injury

Background: The mechanism of esophageal thermal injury (ETI; esophageal mucosal injury and periesophageal nerve injury leading to gastric hypomotility) remains unknown when using a high-power short-duration (HP-SD) setting. This study sought to evaluate the characteristics of esophageal injuries in atrial fibrillation ablation using a HP-SD setting. Methods: After exclusion of 5 patients with their esophagus at the right portion of left atrium and 21 patients with additional ablations such as box isolation and low voltage area ablation in left atrium posterior wall, 271 consecutive patients (62±10 years, 56 women) who underwent pulmonary vein isolation by radiofrequency catheter ablation were analyzed. In the 101 patients, a HP-SD setting at 45 to 50 W with an Ablation Index module was used (HP-SD group). In the remaining 170 patients before introduction of the HP-SD setting, a conventional power setting of 20 to 30 W with contact force monitoring was used (conventional group). We performed esophagogastroduodenoscopy after pulmonary vein isolation in all patients and investigated the incidence and characteristics of ETI. Results: Although the incidence of ETI was significantly higher in the HP-SD group compared with the conventional group (37% versus 22%, P =0.011), the prevalence of esophageal lesions did not differ between the groups (7% versus 8%). Multivariate logistic regression analysis revealed that the use of the HP-SD setting (odds ratio, 6.09, P <0.001), and the parameters that suggest anatomic proximity surrounding the esophagus, were independent predictors of ETI. However, the majority of ETI in the HP-SD group was gastric hypomotility, and the thermal injury was limited to the shallow layer of the periesophageal wall using the HP-SD setting. Conclusions: Although the use of the HP-SD setting was a strong predictor of ETI, it could avoid deeper thermal injuries that reach the esophageal mucosal layer.

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