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Ablation Approaches and Imaging Modalities to Lower Risk of Atrioesophageal Injury During Catheter Ablation for Atrial Fibrillation

Abstract

Purpose of Review

Atrioesophageal fistula (AEF) is a rare yet catastrophic complication of atrial fibrillation (AF) ablation. Limited data exists on measures to prevent AEF. This review focuses on AF ablation approaches, esophageal protective strategies, and imaging modalities that can be utilized to reduce the risk of AEF.

Recent Findings

AEF has been reported to occur in less than 0.1% of AF ablation cases. Left untreated, it is associated with 100% mortality. Diagnosing AEF requires a high index of suspicion as symptoms are usually nonspecific. Several AF ablation techniques might reduce the risk of esophageal thermal injury (ETI): high-power short-duration radiofrequency ablation, implementation of time-to-isolation ablation strategy with cryoablation, and electroporation. Various esophageal protective approaches have been investigated. Although luminal esophageal temperature monitoring is widely used, data on its efficacy is conflicting. Esophageal cooling and esophageal deviation strategies have been shown to be effective in reducing the risk of ETI. Late gadolinium enhancement magnetic resonance imaging (LGE-MRI) is a noninvasive imaging modality that seems to have high sensitivity for detecting and quantifying the degree of ETI.

Summary

Variable approaches have been reported to reduce the risk of esophageal injury. These approaches focus mainly on modulating ablation parameters and esophageal luminal temperature. Imaging modalities such as LGE-MRI can potentially identify early signs of ETI. Electroporation is a promising ablation technique that exhibits high tissue selectivity and can potentially reduce risk of esophageal injury.

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Fig. 1

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. JAMA : J Am Med Assoc. 2001;285(18):2370–5.

  2. 2.

    Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. 1998;82(8A):2N–9N.

  3. 3.

    Wang TJ, Larson MG, Levy D, Vasan RS, Leip EP, Wolf PA, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham heart study. Circulation. 2003;107(23):2920–5.

  4. 4.

    Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study. Am J Med. 2002;113(5):359–64.

  5. 5.

    January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1–76.

  6. 6.

    Deshmukh A, Patel NJ, Pant S, Shah N, Chothani A, Mehta K, et al. In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: analysis of 93 801 procedures. Circulation. 2013;128(19):2104–12.

  7. 7.

    Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA. 2019;321(13):1261–74.

  8. 8.

    Mark DB, Anstrom KJ, Sheng S, Piccini JP, Baloch KN, Monahan KH, et al. Effect of catheter ablation vs medical therapy on quality of life among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA. 2019;321(13):1275–85.

  9. 9.

    Blomstrom-Lundqvist C, Gizurarson S, Schwieler J, Jensen SM, Bergfeldt L, Kenneback G, et al. Effect of catheter ablation vs antiarrhythmic medication on quality of life in patients with atrial fibrillation: the CAPTAF randomized clinical trial. JAMA : J Am Med Assoc. 2019;321(11):1059–68.

  10. 10.

    •• Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378(5):417–27 This is the first multicenter, randomized, controlled trial showing a significant reduction in death or hospitalizations for heart failure with catheter ablation in patients with heart failure with reduced ejection fraction and atrial fibrillation.

  11. 11.

    Hunter RJ, Berriman TJ, Diab I, Kamdar R, Richmond L, Baker V, et al. A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial). Circ Arrhythm Electrophysiol. 2014;7(1):31–8.

  12. 12.

    Khan MN, Jais P, Cummings J, Di Biase L, Sanders P, Martin DO, et al. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med. 2008;359(17):1778–85.

  13. 13.

    January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130(23):2071–104.

  14. 14.

    Wazni OM, Marrouche NF, Martin DO, Verma A, Bhargava M, Saliba W, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA. 2005;293(21):2634–40.

  15. 15.

    Shah RU, Freeman JV, Shilane D, Wang PJ, Go AS, Hlatky MA. Procedural complications, rehospitalizations, and repeat procedures after catheter ablation for atrial fibrillation. J Am Coll Cardiol. 2012;59(2):143–9.

  16. 16.

    Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(1):32–8.

  17. 17.

    Arbelo E, Brugada J, Hindricks G, Maggioni A, Tavazzi L, Vardas P, et al. ESC-EURObservational research programme: the atrial fibrillation ablation pilot study, conducted by the European heart rhythm association. Europace. 2012;14(8):1094–103.

  18. 18.

    Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol. 2012;33(2):171–257.

  19. 19.

    Gupta A, Perera T, Ganesan A, Sullivan T, Lau DH, Roberts-Thomson KC, et al. Complications of catheter ablation of atrial fibrillation: a systematic review. Circ Arrhythm Electrophysiol. 2013;6(6):1082–8.

  20. 20.

    Kapur S, Barbhaiya C, Deneke T, Michaud GF. Esophageal injury and atrioesophageal fistula caused by ablation for atrial fibrillation. Circulation. 2017;136(13):1247–55.

  21. 21.

    Han HC, Ha FJ, Sanders P, Spencer R, Teh AW, O'Donnell D, et al. Atrioesophageal fistula:clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes. Circ Arrhythm Electrophysiol. 2017;10(11).

  22. 22.

    Ghia KK, Chugh A, Good E, Pelosi F, Jongnarangsin K, Bogun F, et al. A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation. J Interv Card Electrophysiol. 2009;24(1):33–6.

  23. 23.

    Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, et al. Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. J Am Coll Cardiol. 2009;53(19):1798–803.

  24. 24.

    Malamis AP, Kirshenbaum KJ, Nadimpalli S. CT radiographic findings: atrio-esophageal fistula after transcatheter percutaneous ablation of atrial fibrillation. J Thorac Imaging. 2007;22(2):188–91.

  25. 25.

    Preis O, Digumarthy SR, Wright CD, Shepard JA. Atrioesophageal fistula after catheter pulmonary venous ablation for atrial fibrillation: imaging features. J Thorac Imaging. 2007;22(3):283–5.

  26. 26.

    Pappone C, Oral H, Santinelli V, Vicedomini G, Lang CC, Manguso F, et al. Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation. 2004;109(22):2724–6.

  27. 27.

    Wazni O, Wilkoff B, Saliba W. Catheter ablation for atrial fibrillation. N Engl J Med. 2011;365(24):2296–304.

  28. 28.

    Garg L, Garg J, Gupta N, Shah N, Krishnamoorthy P, Palaniswamy C, et al. Gastrointestinal complications associated with catheter ablation for atrial fibrillation. Int J Cardiol. 2016;224:424–30.

  29. 29.

    Kiuchi K, Okajima K, Shimane A, Kanda G, Yokoi K, Teranishi J, et al. Incidence of esophageal injury after pulmonary vein isolation in patients with a low body mass index and esophageal temperature monitoring at a 39 °C setting. J Arrhythm. 2015;31(1):12–7.

  30. 30.

    Tilz RR, Chun KR, Metzner A, Burchard A, Wissner E, Koektuerk B, et al. Unexpected high incidence of esophageal injury following pulmonary vein isolation using robotic navigation. J Cardiovasc Electrophysiol. 2010;21(8):853–8.

  31. 31.

    Kim YG, Shim J, Kim DH, Choi JI, Park SW, Pak HN, et al. Characteristics of atrial fibrillation patients suffering atrioesophageal fistula after radiofrequency catheter ablation. J Cardiovasc Electrophysiol. 2018;29(10):1343–51.

  32. 32.

    Di Biase L, Saenz LC, Burkhardt DJ, Vacca M, Elayi CS, Barrett CD, et al. Esophageal capsule endoscopy after radiofrequency catheter ablation for atrial fibrillation: documented higher risk of luminal esophageal damage with general anesthesia as compared with conscious sedation. Circ Arrhythm Electrophysiol. 2009;2(2):108–12.

  33. 33.

    Ha FJ, Han HC, Sanders P, Teh AW, O'Donnell D, Farouque O, et al. Prevalence and prevention of oesophageal injury during atrial fibrillation ablation: a systematic review and meta-analysis. Europace. 2019;21(1):80–90.

  34. 34.

    Halm U, Gaspar T, Zachäus M, Sack S, Arya A, Piorkowski C, et al. Thermal esophageal lesions after radiofrequency catheter ablation of left atrial arrhythmias. Am J Gastroenterol. 2010;105(3):551–6.

  35. 35.

    Yamasaki H, Tada H, Sekiguchi Y, Igarashi M, Arimoto T, Machino T, et al. Prevalence and characteristics of asymptomatic excessive transmural injury after radiofrequency catheter ablation of atrial fibrillation. Heart Rhythm. 2011;8(6):826–32.

  36. 36.

    Martinek M, Meyer C, Hassanein S, Aichinger J, Bencsik G, Schoefl R, et al. Identification of a high-risk population for esophageal injury during radiofrequency catheter ablation of atrial fibrillation: procedural and anatomical considerations. Heart Rhythm. 2010;7(9):1224–30.

  37. 37.

    John RM, Kapur S, Ellenbogen KA, Koneru JN. Atrioesophageal fistula formation with cryoballoon ablation is most commonly related to the left inferior pulmonary vein. Heart Rhythm. 2017;14(2):184–9.

  38. 38.

    Nair GM, Nery PB, Redpath CJ, Lam BK, Birnie DH. Atrioesophageal fistula in the era of atrial fibrillation ablation: a review. Can J Cardiol. 2014;30(4):388–95.

  39. 39.

    Berjano EJ, Hornero F. A cooled intraesophageal balloon to prevent thermal injury during endocardial surgical radiofrequency ablation of the left atrium: a finite element study. Phys Med Biol. 2005;50(20):N269–79.

  40. 40.

    Tsuchiya T, Ashikaga K, Nakagawa S, Hayashida K, Kugimiya H. Atrial fibrillation ablation with esophageal cooling with a cooled water-irrigated intraesophageal balloon: a pilot study. J Cardiovasc Electrophysiol. 2007;18(2):145–50.

  41. 41.

    Sohara H, Satake S, Takeda H, Yamaguchi Y, Nagasu N. Prevalence of esophageal ulceration after atrial fibrillation ablation with the hot balloon ablation catheter: what is the value of esophageal cooling? J Cardiovasc Electrophysiol. 2014;25(7):686–92.

  42. 42.

    Arruda MS, Armaganijan L, Di Biase L, Rashidi R, Natale A. Feasibility and safety of using an esophageal protective system to eliminate esophageal thermal injury: implications on atrial-esophageal fistula following AF ablation. J Cardiovasc Electrophysiol. 2009;20(11):1272–8.

  43. 43.

    Montoya MM, Mickelsen S, Clark B, Arnold M, Hanks J, Sauter E, et al. Protecting the esophagus from thermal injury during radiofrequency ablation with an esophageal cooling device. J Atr Fibrillation. 2019;11(5):2110.

  44. 44.

    Kuwahara T, Takahashi A, Okubo K, Takagi K, Yamao K, Nakashima E, et al. Oesophageal cooling with ice water does not reduce the incidence of oesophageal lesions complicating catheter ablation of atrial fibrillation: randomized controlled study. Europace. 2014;16(6):834–9.

  45. 45.

    Palaniswamy C, Koruth JS, Mittnacht AJ, Miller MA, Choudry S, Bhardwaj R, et al. The extent of mechanical esophageal deviation to avoid esophageal heating during catheter ablation of atrial fibrillation. JACC Clin Electrophysiol. 2017;3(10):1146–54.

  46. 46.

    Maenosono R, Oketani N, Ishida S, Iriki Y, Ichiki H, Okui H, et al. Effectiveness of esophagus detection by three-dimensional electroanatomical mapping to avoid esophageal injury during ablation of atrial fibrillation. J Cardiol. 2012;60(2):119–25.

  47. 47.

    Herweg B, Johnson N, Postler G, Curtis AB, Barold SS, Ilercil A. Mechanical esophageal deflection during ablation of atrial fibrillation. Pacing Clin Electrophysiol. 2006;29(9):957–61.

  48. 48.

    Chugh A, Rubenstein J, Good E, Ebinger M, Jongnarangsin K, Fortino J, et al. Mechanical displacement of the esophagus in patients undergoing left atrial ablation of atrial fibrillation. Heart Rhythm. 2009;6(3):319–22.

  49. 49.

    Parikh V, Swarup V, Hantla J, Vuddanda V, Dar T, Yarlagadda B, et al. Feasibility, safety, and efficacy of a novel preshaped nitinol esophageal deviator to successfully deflect the esophagus and ablate left atrium without esophageal temperature rise during atrial fibrillation ablation: the DEFLECT GUT study. Heart Rhythm. 2018;15(9):1321–7.

  50. 50.

    Koruth JS, Reddy VY, Miller MA, Patel KK, Coffey JO, Fischer A, et al. Mechanical esophageal displacement during catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2012;23(2):147–54.

  51. 51.

    Bhardwaj R, Naniwadekar A, Whang W, Mittnacht AJ, Palaniswamy C, Koruth JS, et al. Esophageal deviation during atrial fibrillation ablation: clinical experience with a dedicated esophageal balloon retractor. JACC Clin Electrophysiol. 2018;4(8):1020–30.

  52. 52.

    Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2018;20(1):e1–e160.

  53. 53.

    Singh SM, d'Avila A, Doshi SK, Brugge WR, Bedford RA, Mela T, et al. Esophageal injury and temperature monitoring during atrial fibrillation ablation. Circ Arrhythm Electrophysiol. 2008;1(3):162–8.

  54. 54.

    Müller P, Dietrich JW, Halbfass P, Abouarab A, Fochler F, Szöllösi A, et al. Higher incidence of esophageal lesions after ablation of atrial fibrillation related to the use of esophageal temperature probes. Heart Rhythm. 2015;12(7):1464–9.

  55. 55.

    Halbfass P, Müller P, Nentwich K, Krug J, Roos M, Hamm K, et al. Incidence of asymptomatic oesophageal lesions after atrial fibrillation ablation using an oesophageal temperature probe with insulated thermocouples: a comparative controlled study. Europace. 2017;19(3):385–91.

  56. 56.

    Rillig A, Meyerfeldt U, Birkemeyer R, Wiest S, Sauer BM, Staritz M, et al. Oesophageal temperature monitoring and incidence of oesophageal lesions after pulmonary vein isolation using a remote robotic navigation system. Europace. 2010;12(5):655–61.

  57. 57.

    Deneke T, Bünz K, Bastian A, Päsler M, Anders H, Lehmann R, et al. Utility of esophageal temperature monitoring during pulmonary vein isolation for atrial fibrillation using duty-cycled phased radiofrequency ablation. J Cardiovasc Electrophysiol. 2011;22(3):255–61.

  58. 58.

    Kiuchi K, Okajima K, Shimane A, Kanda G, Yokoi K, Teranishi J, et al. Impact of esophageal temperature monitoring guided atrial fibrillation ablation on preventing asymptomatic excessive transmural injury. J Arrhythm. 2016;32(1):36–41.

  59. 59.

    Koranne K, Basu-Ray I, Parikh V, Pollet M, Wang S, Mathuria N, et al. Esophageal temperature monitoring during radiofrequency ablation of atrial fibrillation: a meta-analysis. J Atr Fibrillation. 2016;9(4):1452.

  60. 60.

    Kadado AJ, Akar JG, Hummel JP. Luminal esophageal temperature monitoring to reduce esophageal thermal injury during catheter ablation for atrial fibrillation: a review. Trends Cardiovasc Med. 2019;29(5):264–71.

  61. 61.

    Back Sternick E, Cohen Persiano A, Arantes V. Is it safe to monitor oesophageal temperature during AF ablation? Europace. 2012;14(10):1432.

  62. 62.

    Cummings JE, Barrett CD, Litwak KN, DI Biase L, Chowdhury P, Oh S, et al. Esophageal luminal temperature measurement underestimates esophageal tissue temperature during radiofrequency ablation within the canine left atrium: comparison between 8 mm tip and open irrigation catheters. J Cardiovasc Electrophysiol. 2008;19(6):641–4.

  63. 63.

    Carroll BJ, Contreras-Valdes FM, Heist EK, Barrett CD, Danik SB, Ruskin JN, et al. Multi-sensor esophageal temperature probe used during radiofrequency ablation for atrial fibrillation is associated with increased intraluminal temperature detection and increased risk of esophageal injury compared to single-sensor probe. J Cardiovasc Electrophysiol. 2013;24(9):958–64.

  64. 64.

    Kuwahara T, Takahashi A, Takahashi Y, Okubo K, Takagi K, Fujino T, et al. Incidences of esophageal injury during esophageal temperature monitoring: a comparative study of a multi-thermocouple temperature probe and a deflectable temperature probe in atrial fibrillation ablation. J Interv Card Electrophysiol. 2014;39(3):251–7.

  65. 65.

    Sandhu A, Zipse MM, Borne RT, Aleong RG, Tompkins C, Schuller J, et al. Esophageal position, measured luminal temperatures, and risk of atrioesophageal fistula with atrial fibrillation ablation. Pacing Clin Electrophysiol. 2019;42(4):458–63.

  66. 66.

    Daly MG, Melton I, Roper G, Lim G, Crozier IG. High-resolution infrared thermography of esophageal temperature during radiofrequency ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2018;11(2):e005667.

  67. 67.

    Deneke T, Nentwich K, Berkovitz A, Sonne K, Ene E, Pavlov B, et al. High-resolution infrared thermal imaging of the esophagus during atrial fibrillation ablation as a predictor of Endoscopically detected thermal lesions. Circ Arrhythm Electrophysiol. 2018;11(11):e006681.

  68. 68.

    Cappato R, Negroni S, Pecora D, Bentivegna S, Lupo PP, Carolei A, et al. Prospective assessment of late conduction recurrence across radiofrequency lesions producing electrical disconnection at the pulmonary vein ostium in patients with atrial fibrillation. Circulation. 2003;108(13):1599–604.

  69. 69.

    Callans DJ, Gerstenfeld EP, Dixit S, Zado E, Vanderhoff M, Ren JF, et al. Efficacy of repeat pulmonary vein isolation procedures in patients with recurrent atrial fibrillation. J Cardiovasc Electrophysiol. 2004;15(9):1050–5.

  70. 70.

    Nanthakumar K, Plumb VJ, Epstein AE, Veenhuyzen GD, Link D, Kay GN. Resumption of electrical conduction in previously isolated pulmonary veins: rationale for a different strategy? Circulation. 2004;109(10):1226–9.

  71. 71.

    Ouyang F, Antz M, Ernst S, Hachiya H, Mavrakis H, Deger FT, et al. Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins: lessons from double lasso technique. Circulation. 2005;111(2):127–35.

  72. 72.

    Martinek M, Bencsik G, Aichinger J, Hassanein S, Schoefl R, Kuchinka P, et al. Esophageal damage during radiofrequency ablation of atrial fibrillation: impact of energy settings, lesion sets, and esophageal visualization. J Cardiovasc Electrophysiol. 2009;20(7):726–33.

  73. 73.

    • Leshem E, Zilberman I, Tschabrunn CM, Barkagan M, Contreras-Valdes FM, Govari A, et al. High-power and short-duration ablation for pulmonary vein isolation: biophysical characterization. JACC Clin Electrophysiol. 2018;4(4):467–79 Leshem et al evaluated the biophysical characteristics of high-power, short duration ablation. They have demonstrated that high-power, short duration ablation allows larger immediate tissue heating while reducing passive heating and further heat conduction.

  74. 74.

    Haines DE. The biophysics of radiofrequency catheter ablation in the heart: the importance of temperature monitoring. Pacing Clin Electrophysiol. 1993;16(3 Pt 2):586–91.

  75. 75.

    Marrouche NF, Guenther J, Segerson NM, Daccarett M, Rittger H, Marschang H, et al. Randomized comparison between open irrigation technology and intracardiac-echo-guided energy delivery for pulmonary vein antrum isolation: procedural parameters, outcomes, and the effect on esophageal injury. J Cardiovasc Electrophysiol. 2007;18(6):583–8.

  76. 76.

    Kuck KH, Reddy VY, Schmidt B, Natale A, Neuzil P, Saoudi N, et al. A novel radiofrequency ablation catheter using contact force sensing: Toccata study. Heart Rhythm. 2012;9(1):18–23.

  77. 77.

    Reddy VY, Shah D, Kautzner J, Schmidt B, Saoudi N, Herrera C, et al. The relationship between contact force and clinical outcome during radiofrequency catheter ablation of atrial fibrillation in the TOCCATA study. Heart Rhythm. 2012;9(11):1789–95.

  78. 78.

    Black-Maier E, Pokorney SD, Barnett AS, Zeitler EP, Sun AY, Jackson KP, et al. Risk of atrioesophageal fistula formation with contact force-sensing catheters. Heart Rhythm. 2017;14(9):1328–33.

  79. 79.

    Blockhaus C, Müller P, Vom Dahl S, Leonhardt S, Häussinger D, Gerguri S, et al. Low incidence of esophageal lesions after pulmonary vein isolation using contact-force sensing catheter without esophageal temperature probe. Int Heart J. 2017;58(6):880–4.

  80. 80.

    • Chelu MG, Morris AK, Kholmovski EG, King JB, Kaur G, Silver MA, et al. Durable lesion formation while avoiding esophageal injury during ablation of atrial fibrillation: lessons learned from late gadolinium MR imaging. J Cardiovasc Electrophysiol. 2018;29(3):385–92 Chelu et al have shown that contact-force greater than 11–12 g delivered at high power (50 W) and short duration (6 seconds) has been demonstrated to be adequate for creating durable ablation lesions, while contact-force of more than 15 g was associated with an increased risk of developing esophageal enhancement in LGE-MRI.

  81. 81.

    • Baher A, Kheirkhahan M, Rechenmacher SJ, Marashly Q, Kholmovski EG, Siebermair J, et al. High-power radiofrequency catheter ablation of atrial fibrillation: using late gadolinium enhancement magnetic resonance imaging as a novel index of esophageal injury. JACC Clin Electrophysiol. 2018;4(12):1583–94 The authors have shown that high power, short duration radiofrequency ablation leads to significant reduction in procedure time. Esophageal thermal injury patterns, as evlauated by late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) was similar among patients who underwent high power short durtion ablaiton and patient who underwent standard ablation.

  82. 82.

    Winkle RA, Mohanty S, Patrawala RA, Mead RH, Kong MH, Engel G, et al. Low complication rates using high power (45-50 W) for short duration for atrial fibrillation ablations. Heart Rhythm. 2019;16(2):165–9.

  83. 83.

    • Reddy VY, Grimaldi M, De Potter T, Vijgen JM, Bulava A, Duytschaever MF, et al. Pulmonary vein isolation with very high power, short duration, temperature-controlled lesions: the QDOT-FAST trial. JACC Clin Electrophysiol. 2019;5(7):778–86 Reddy et al demonstrated the safetly and short-term efficacy of very high poswer, short duration, temperature controlled ablation. The authors have shown a significant reduction in preocedure and flouroscopy times compared to standard ablation.

  84. 84.

    Mörtsell D, Arbelo E, Dagres N, Brugada J, Laroche C, Trines SA, et al. Cryoballoon vs. radiofrequency ablation for atrial fibrillation: a study of outcome and safety based on the ESC-EHRA atrial fibrillation ablation long-term registry and the Swedish catheter ablation registry. Europace. 2019;21(4):581–9.

  85. 85.

    Akkaya E, Berkowitsch A, Zaltsberg S, Greiss H, Hamm CW, Sperzel J, et al. Five-year outcome and predictors of success after second-generation cryoballoon ablation for treatment of symptomatic atrial fibrillation. Int J Cardiol. 2018;266:106–11.

  86. 86.

    • Knight BP, Novak PG, Sangrigoli R, Champagne J, Dubuc M, Adler SW, et al. Long-term outcomes after ablation for paroxysmal atrial fibrillation using the second-generation Cryoballoon: final results from STOP AF post-approval study. JACC Clin Electrophysiol. 2019;5(3):306–14 This is the largest multicenter study to show the safety and efficay of second generation cryoballoon ablation.

  87. 87.

    Canpolat U, Kocyigit D, Yalcin MU, Coteli C, Sener YZ, Oksul M, et al. Long-term outcomes of pulmonary vein isolation using second-generation cryoballoon during atrial fibrillation ablation. Pacing Clin Electrophysiol. 2019;42(7):910–21.

  88. 88.

    Okumura K, Matsumoto K, Kobayashi Y, Nogami A, Hokanson RB, Kueffer F, et al. Safety and efficacy of Cryoballoon ablation for paroxysmal atrial fibrillation in Japan - results from the Japanese prospective post-market surveillance study. Circ J. 2016;80(8):1744–9.

  89. 89.

    DE Regibus V, Mugnai G, Moran D, Hünük B, Ströker E, Hacioglu E, et al. Second-generation cryoballoon ablation in the setting of lone paroxysmal atrial fibrillation: single procedural outcome at 12 months. J Cardiovasc Electrophysiol. 2016;27(6):677–82.

  90. 90.

    Tscholl V, Lsharaf AK, Lin T, Bellmann B, Biewener S, Nagel P, et al. Two years outcome in patients with persistent atrial fibrillation after pulmonary vein isolation using the second-generation 28-mm cryoballoon. Heart Rhythm. 2016;13(9):1817–22.

  91. 91.

    Viladés Medel D, Marti-Almor J, Montiel Serrano J, Sionis A, Leta PR. Atrioesophageal fistula secondary to pulmonary vein cryoablation. Eur Heart J Cardiovasc Imaging. 2014;15(1):116.

  92. 92.

    Stöckigt F, Schrickel JW, Andrié R, Lickfett L. Atrioesophageal fistula after cryoballoon pulmonary vein isolation. J Cardiovasc Electrophysiol. 2012;23(11):1254–7.

  93. 93.

    Kawasaki R, Gauri A, Elmouchi D, Duggal M, Bhan A. Atrioesophageal fistula complicating cryoballoon pulmonary vein isolation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2014;25(7):787–92.

  94. 94.

    Metzner A, Burchard A, Wohlmuth P, Rausch P, Bardyszewski A, Gienapp C, et al. Increased incidence of esophageal thermal lesions using the second-generation 28-mm cryoballoon. Circ Arrhythm Electrophysiol. 2013;6(4):769–75.

  95. 95.

    Fürnkranz A, Bordignon S, Böhmig M, Konstantinou A, Dugo D, Perrotta L, et al. Reduced incidence of esophageal lesions by luminal esophageal temperature-guided second-generation cryoballoon ablation. Heart Rhythm. 2015;12(2):268–74.

  96. 96.

    Miyazaki S, Nakamura H, Taniguchi H, Takagi T, Iwasawa J, Watanabe T, et al. Esophagus-related complications during second-generation Cryoballoon ablation-insight from simultaneous esophageal temperature monitoring from 2 esophageal probes. J Cardiovasc Electrophysiol. 2016;27(9):1038–44.

  97. 97.

    Cordes F, Ellermann C, Dechering DG, Frommeyer G, Kochhäuser S, Lange PS, et al. Time-to-isolation-guided cryoballoon ablation reduces oesophageal and mediastinal alterations detected by endoscopic ultrasound: results of the MADE-PVI trial. Europace. 2019.

  98. 98.

    Aryana A, Kenigsberg DN, Kowalski M, Koo CH, Lim HW, O'Neill PG, et al. Verification of a novel atrial fibrillation cryoablation dosing algorithm guided by time-to-pulmonary vein isolation: results from the Cryo-DOSING study (cryoballoon-ablation DOSING based on the assessment of time-to-effect and pulmonary vein isolation guidance). Heart Rhythm. 2017;14(9):1319–25.

  99. 99.

    Yalin K, Lyan E, Abdin A, Heeger CH, Vogler J, Liosis S, et al. Second-generation cryoballoon for pulmonary vein isolation in patients with pulmonary vein abnormality: safety, efficacy and lessons from re-ablation procedures. Int J Cardiol. 2018;272:142–8.

  100. 100.

    •• Reddy VY, Neuzil P, Koruth JS, Petru J, Funosako M, Cochet H, et al. Pulsed field ablation for pulmonary vein isolation in atrial fibrillation. J am Coll Cardiol. 2019;74(3):315–26 Reddy et al demonstrated the preferential effect of pulsed electric fields (PEF) ablation on myocardial tissue. The authors have shown the PEF ablation lesions exibit excellent durability.

  101. 101.

    Tieleman DP, Leontiadou H, Mark AE, Marrink SJ. Simulation of pore formation in lipid bilayers by mechanical stress and electric fields. J Am Chem Soc. 2003;125(21):6382–3.

  102. 102.

    Davalos RV, Mir IL, Rubinsky B. Tissue ablation with irreversible electroporation. Ann Biomed Eng. 2005;33(2):223–31.

  103. 103.

    Kaminska I, Kotulska M, Stecka A, Saczko J, Drag-Zalesinska M, Wysocka T, et al. Electroporation-induced changes in normal immature rat myoblasts (H9C2). Gen Physiol Biophys. 2012;31(1):19–25.

  104. 104.

    •• Reddy VY, Koruth J, Jais P, Petru J, Timko F, Skalsky I, et al. Ablation of atrial fibrillation with pulsed electric fields: an ultra-rapid, tissue-selective modality for cardiac ablation. JACC Clin Electrophysiol. 2018;4(8):987–95 Reddy at al demonstrated the safety, feasibilty, and efficacy of pulsed electric fields (PEF) ablation in AF patients. This is the first-in-human study to evaluated PEF abaltion.

  105. 105.

    Neven K, van Es R, van Driel V, van Wessel H, Fidder H, Vink A, et al. Acute and long-term effects of full-power electroporation ablation directly on the porcine esophagus. Circ Arrhythm Electrophysiol. 2017;10(5).

  106. 106.

    van Driel VJ, Neven K, van Wessel H, Vink A, Doevendans PA, Wittkampf FH. Low vulnerability of the right phrenic nerve to electroporation ablation. Heart Rhythm. 2015;12(8):1838–44.

  107. 107.

    Yarlagadda B, Deneke T, Turagam M, Dar T, Paleti S, Parikh V, et al. Temporal relationships between esophageal injury type and progression in patients undergoing atrial fibrillation catheter ablation. Heart Rhythm. 2019;16(2):204–12.

  108. 108.

    Badger TJ, Adjei-Poku YA, Burgon NS, Kalvaitis S, Shaaban A, Sommers DN, et al. Initial experience of assessing esophageal tissue injury and recovery using delayed-enhancement MRI after atrial fibrillation ablation. Circ Arrhythm Electrophysiol. 2009;2(6):620–5.

  109. 109.

    Gorman DR, Peterson KA, Fang J, Olpin J, Sommers DO, McFadden M, et al. Cross-sectional imaging obtained immediately following radiofrequency atrial fibrillation ablation does not predict endoscopic evidence of esophageal injury. Dig Dis Sci. 2011;56(12):3453–8.

  110. 110.

    Pollak SJ, Monir G, Chernoby MS, Elenberger CD. Novel imaging techniques of the esophagus enhancing safety of left atrial ablation. J Cardiovasc Electrophysiol. 2005;16(3):244–8.

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Correspondence to Mihail G. Chelu.

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Marashly, Q., Chelu, M.G. Ablation Approaches and Imaging Modalities to Lower Risk of Atrioesophageal Injury During Catheter Ablation for Atrial Fibrillation. Curr Cardiovasc Risk Rep 14, 1 (2020). https://doi.org/10.1007/s12170-019-0635-8

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Keywords

  • Atrioesophageal fistula
  • Esophageal thermal injury
  • Catheter ablation
  • Esophageal deviation
  • Esophageal luminal temperature
  • Electroporation
  • Late gadolinium enhancement magnetic resonance imaging (LGE-MRI)