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Koruth JS, Kuroki K, Kawamura I, Brose R, Viswanathan R, Buck ED, Donskoy E, Neuzil P, Dukkipati SR, Reddy VY. Pulsed Field Ablation Versus Radiofrequency Ablation: Esophageal Injury in a Novel Porcine Model. Circ Arrhythm Electrophysiol 2020; 13:e008303. [PMID: 31977250 PMCID: PMC7069397 DOI: 10.1161/circep.119.008303] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 01/24/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pulsed field ablation (PFA) can be myocardium selective, potentially sparing the esophagus during left atrial ablation. In an in vivo porcine esophageal injury model, we compared the effects of newer biphasic PFA with radiofrequency ablation (RFA). METHODS In 10 animals, under general anesthesia, the lower esophagus was deflected toward the inferior vena cava using an esophageal deviation balloon, and ablation was performed from within the inferior vena cava at areas of esophageal contact. Four discrete esophageal sites were targeted in each animal: 6 animals received 8 PFA applications/site (2 kV, multispline catheter), and 4 animals received 6 clusters of irrigated RFA applications (30 W×30 seconds, 3.5 mm catheter). All animals were survived to 25 days, sacrificed, and the esophagus submitted for pathological examination, including 10 discrete histological sections/esophagus. RESULTS The animals weight increased by 13.7±6.2% and 6.8±6.3% (P=0.343) in the PFA and RFA cohorts, respectively. No PFA animals (0 of 6, 0%) developed abnormal in-life observations, but 1 of 4 RFA animals (25%) developed fever and dyspnea. On necropsy, no PFA animals (0 of 6, 0%) demonstrated esophageal lesions. In contrast, esophageal injury occurred in all RFA animals (4 of 4, 100%; P=0.005): a mean of 1.5 mucosal lesions/animal (length, -21.8±8.9 mm; width, -4.9±1.4 mm) were observed, including one esophago-pulmonary fistula and deep esophageal ulcers in the other animals. Histological examination demonstrated tissue necrosis surrounded by acute and chronic inflammation and fibrosis. The necrotic RFA lesions involved multiple esophageal tissue layers with evidence of arteriolar medial thickening and fibrosis of periesophageal nerves. Abscess formation and full-thickness esophageal wall disruptions were seen in areas of perforation/fistula. CONCLUSIONS In this novel porcine model of esophageal injury, biphasic PFA induced no chronic histopathologic esophageal changes, while RFA demonstrated a spectrum of esophageal lesions including fistula and deep esophageal ulcers and abscesses.
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Affiliation(s)
- Jacob S. Koruth
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
| | - Kenji Kuroki
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
| | - Iwanari Kawamura
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
| | | | | | - Eric D. Buck
- Farapulse, Inc, Menlo Park, CA (R.B., R.V., E.D.B.)
| | | | - Petr Neuzil
- Homolka Hospital, Prague, Czech Republic (P.N.)
| | - Srinivas R. Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
| | - Vivek Y. Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (J.S.K., K.K., I.K., S.R.D., V.Y.R.)
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Khan M, Rashid MU, Zafar H, Ullah W, Khan AH. A Rare Complication of Cardiac Ablation: Atrial-esophageal Fistula Presenting as Odynophagia. Cureus 2020; 12:e6871. [PMID: 32181101 PMCID: PMC7053677 DOI: 10.7759/cureus.6871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/04/2020] [Indexed: 11/14/2022] Open
Abstract
Radiofrequency catheter ablation has been commonly used for the treatment of drug-refractory atrial fibrillation. The esophageal injury along with the development of atrial-esophageal fistula (AE fistula) is fairly rare but is a devastating complication of catheter ablation. Described in 2004 for the first time, it is the most lethal of all the complications of catheter ablation with a high mortality rate. The clinical presentation of an AE fistula is variable, however, early diagnosis and treatment can prevent a fatality. We have reported a case of an AE fistula post catheter ablation for drug-resistant atrial fibrillation, along with its treatment, diagnosis, and possible preventive measures.
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Affiliation(s)
- Muzammil Khan
- Internal Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | | | | | - Waqas Ullah
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, USA
| | - Abu H Khan
- Gastroenterology, AdventHealth, Orlando, USA
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Koruth J, Kuroki K, Iwasawa J, Enomoto Y, Viswanathan R, Brose R, Buck ED, Speltz M, Dukkipati SR, Reddy VY. Preclinical Evaluation of Pulsed Field Ablation: Electrophysiological and Histological Assessment of Thoracic Vein Isolation. Circ Arrhythm Electrophysiol 2019; 12:e007781. [PMID: 31826647 PMCID: PMC6924932 DOI: 10.1161/circep.119.007781] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 10/16/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a uniquely tissue-selective, nonthermal cardiac ablation modality. Delivery parameters such as the electrical waveform composition and device design are critical to PFA's efficacy and safety, particularly tissue specificity. In a series of preclinical studies, we sought to examine the electrophysiological and histological effects of PFA and compare the safety and feasibility of durable pulmonary vein and superior vena cava (SVC) isolation between radiofrequency ablation and PFA waveforms. METHODS A femoral venous approach was used to gain right and left atrial access under general anesthesia in healthy swine. Baseline potentials in right superior pulmonary and inferior common vein and in SVC were assessed. Bipolar PFA was performed with monophasic (PFAMono) and biphasic (PFABi) waveforms in 7 and 7 swine sequentially and irrigated radiofrequency ablation in 3 swine. Vein potentials were then assessed acutely, and at ≈10 weeks; histology was obtained. RESULTS All targeted veins (n=46) were successfully isolated on the first attempt in all cohorts. The PFABi waveform induced significantly less skeletal muscle engagement. Pulmonary vein isolation durability was assessed in 28 veins: including the SVC, durability was significantly higher in the PFABi group (18/18 PFABi, 10/18 PFAMono, 3/6 radiofrequency, P=0.002). Transmurality rates were similar across groups with evidence of nerve damage only with radiofrequency. Pulmonary vein narrowing was noted only in the radiofrequency cohort. The phrenic nerve was spared in all cohorts but at the expense of incomplete SVC encirclement with radiofrequency. CONCLUSIONS In this chronic porcine study, PFA-based pulmonary vein and SVC isolation were safe and efficacious with demonstrable sparing of nerves and venous tissue. This preclinical study provided the scientific basis for the first-in-human endocardial PFA studies.
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Affiliation(s)
- Jacob Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (J.K., K.K., J.I., Y.E., S.R.D., V.Y.R.)
| | - Kenji Kuroki
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (J.K., K.K., J.I., Y.E., S.R.D., V.Y.R.)
| | - Jin Iwasawa
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (J.K., K.K., J.I., Y.E., S.R.D., V.Y.R.)
| | - Yoshinari Enomoto
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (J.K., K.K., J.I., Y.E., S.R.D., V.Y.R.)
| | | | | | - Eric D. Buck
- Farapulse, Inc, Menlo Park, CA (R.V., R.B., E.D.B.)
| | | | - Srinivas R. Dukkipati
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (J.K., K.K., J.I., Y.E., S.R.D., V.Y.R.)
| | - Vivek Y. Reddy
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (J.K., K.K., J.I., Y.E., S.R.D., V.Y.R.)
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Jehaludi A, Heist EK, Giveans MR, Anand R. Retrospective review of 65 atrioesophageal fistulas post atrial fibrillation ablation. Indian Pacing Electrophysiol J 2018; 18:100-107. [PMID: 29476903 PMCID: PMC5986301 DOI: 10.1016/j.ipej.2018.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 02/08/2018] [Indexed: 11/06/2022] Open
Abstract
Background Although a rare complication of catheter based ablation for atrial fibrillation (AF), atrioesophageal fistula (AEF) is a serious and fatal event [[1], [2], [3], [4], [5]]. Most reports of AEF are single cases or small case series. Objective The purpose of this study was to perform a comprehensive literature search of all published atrioesophageal fistula following catheter ablation for AF in order to identify the mortality rates associated with therapeutic modalities and suggest the most definitive management in reducing mortality. Methods A comprehensive literature review of reported observational cases of atrioesophageal fistula post catheter based ablation for atrial fibrillation was performed. Results Sixty-five cases of AEF post atrial fibrillation ablation were reviewed. The mean age was 55 years old. 73.8% (48/65) of the identified cases occurred in males (p < 0.001). Of the 65 cases, 13 underwent surgical radiofrequency ablation (RFA) and 52 underwent percutaneous RFA. Mortality resulted in 53.8% of those who underwent surgical RFA and in 55.8% of those who underwent percutaneous RFA (p = .888). The time range interval from procedure to onset of symptoms was 1–60 days. The most prevalent symptom, fever, occurred in 52 of the 65 cases, followed by neurological symptoms (n = 44). CT of the chest (n = 37), transthoracic echocardiogram (n = 21), and CT of the head (n = 18) were the preferred diagnostic modalities. Patients who underwent surgical correction with esophageal repair for treatment were more likely to survive, in comparison to patients who were treated with non-surgical interventions, such as antibiotic therapy, anticoagulation therapy or esophageal stenting. Of the total 34 patients who were treated surgically, 27 survived (79.4%). Of the total 31 patients who were treated non-surgically, only 2 survived (6.5%), reflecting significantly lower mortality with surgical versus non-surgical therapy (p < 0.001). Conclusion Atrioesophageal fistula is an uncommon but potentially fatal complication of atrial fibrillation ablation. Patients who underwent surgical repair were twelve times more likely to survive than those treated with stenting, antibiotic therapy or no intervention. Based on the observation that patients are 12 times more likely to survive an AEF with surgery than without, the authors believe that prompt surgical correction of AEF should be considered as standard of care when dealing with this dreaded complication.
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Affiliation(s)
- Ameena Jehaludi
- Electrophysiology Deptartment, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - E Kevin Heist
- Electrophysiology Deptartment, Massachusetts General Hospital, Boston, MA, USA
| | - M Russell Giveans
- Electrophysiology Deptartment, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Rishi Anand
- Electrophysiology Deptartment, Holy Cross Hospital, Fort Lauderdale, FL, USA.
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Katz-Agranov N, Nevah Rubin MI. Severe esophageal injury after radiofrequency ablation - a deadly complication. World J Gastroenterol 2017; 23:3374-3378. [PMID: 28566899 PMCID: PMC5434445 DOI: 10.3748/wjg.v23.i18.3374] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/18/2017] [Accepted: 02/08/2017] [Indexed: 02/06/2023] Open
Abstract
Various degrees of esophageal injury have been described after radiofrequency ablation performed for treatment of atrial fibrillation. The main mechanism of injury is thermal and may lead to a range of esophageal mucosal changes, some clinically insignificant, however when deep ulceration occurs, this may be further complicated by perforation and mediastinitis, a rare but life threatening sequelae. We present a case of a severe esophageal injury leading to mediastinitis, with interesting endoscopic findings.
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Renati S, Yang C, Walsh M, Trejo-Lopez J, Khanna A. Brain and spinal cord infarcts secondary to an atrial-esophageal fistula. Neurol Clin Pract 2017; 7:387-389. [PMID: 29620062 DOI: 10.1212/cpj.0000000000000332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/17/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Swetha Renati
- Departments of Neurology (SR, CY, AK) and Pathology (MW, JT-L), University of Florida, Gainesville
| | - Cui Yang
- Departments of Neurology (SR, CY, AK) and Pathology (MW, JT-L), University of Florida, Gainesville
| | - Meggen Walsh
- Departments of Neurology (SR, CY, AK) and Pathology (MW, JT-L), University of Florida, Gainesville
| | - Jorge Trejo-Lopez
- Departments of Neurology (SR, CY, AK) and Pathology (MW, JT-L), University of Florida, Gainesville
| | - Anna Khanna
- Departments of Neurology (SR, CY, AK) and Pathology (MW, JT-L), University of Florida, Gainesville
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