Mechanical Esophageal Deviation During AF Ablation

Study Questions:

How often can the esophagus be moved enough to avoid injury during radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF)?

Methods:

Luminal esophageal temperature (LET) was monitored during RFCA in 114 patients (mean age 62 years) with AF. Mechanical esophageal deviation (MED) was performed with a malleable stylet inside a plastic tube inserted into the esophagus. Barium was used to assess the response to MED.

Results:

The esophagus was always stretched by MED, such that the esophageal edge trailed the stylet by a distance of 0-10 mm in 27% of attempts, 10-15 mm in 29% of attempts, 15-20 mm in 22% of attempts, and >20 mm in 22% of attempts. Within these subgroups, the prevalence of LET rising above 38°C was 73%, 36%, 25%, and 4%, respectively. MED-related esophageal trauma occurred in 2.6% of patients.

Conclusions:

MED of >20 mm is necessary to avoid excessive heating of the esophagus during RFCA of AF. This extent of deflection often cannot be achieved using a metallic stylet.

Perspective:

Several strategies have been employed in an attempt to avoid esophageal injury during RFCA of AF, and none have proven to be both practical and highly effective. The most practical and effective approach for avoiding esophageal injury might be to simply assume that any RF energy application on the posterior wall could potentially injure the esophagus and to limit all applications to 20-25 W for ≤15 seconds, avoiding two consecutive applications that are close to each other.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Barium, Catheter Ablation, Esophagus, Heating, Monitoring, Physiologic


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