Left Atrial Reverse Remodeling Following the Modified Box Isolation with Centerline in Patients with Persistent Atrial Fibrillation.

Esophageal injury is a rare but serious complication of atrial fibrillation (AF) ablation. To minimize esophageal injury, our persistent AF (PerAF) protocol involves complete left atrial posterior wall (LAPW) and pulmonary vein (PV) isolation (box isolation), with a centerline away from the esophagus. However, there has been a concern that extensive LA isolation might deteriorate LA function. There has been a paucity of data on LA remodeling after box isolation. Therefore, we compared LA size pre- and post-box isolation with an LAPW centerline in patients with PerAF.Patients who underwent catheter ablation (CA) for PerAF between November 2016 and December 2018 were retrospectively evaluated.The LAPW, including all PVs, was completely isolated in 105 consecutive patients (75 men; mean age: 68 ± 10 years) with PerAF, including 58 patients with long-standing PerAF. During a follow-up of 660 ± 332 days, 76 patients (72%) were arrhythmia-free. The LA dimension (38 ± 6 mm versus 42 ± 7 mm; P < 0.0001) and volume index (38 ± 13 mL/m2 versus 47 ± 14 mL/m2; P < 0.0001) at 6 months post-ablation were significantly decreased in patients who maintained sinus rhythm compared to pre-ablation. In patients with recurrent AF/atrial tachycardia (AT), these parameters were also significantly decreased (P < 0.001, respectively).Box isolation with a posterior centerline has no esophageal complications and a high clinical success rate in patients with PerAF. Reverse remodeling could be achieved even when using extensive isolation of the PV and LAPW in patients with PerAF.

Esophageal Deviation During Atrial Fibrillation Ablation: Clinical Experience With a Dedicated Esophageal Balloon Retractor.

OBJECTIVES: The goal of this study was to determine the safety and feasibility of a novel esophageal balloon retractor (DV8) for MED during PVI. BACKGROUND: The authors previously showed that mechanical esophageal deviation (MED) is feasible using an off-the-shelf metal stylet to allow uninterrupted ablation along the posterior left atrium during pulmonary vein isolation (PVI). Although it is an attractive strategy to avoid esophageal thermal injury, this technique was hampered by both the propensity for oropharyngeal trauma from the stiff stylet and the limited lateral esophageal displacement. METHODS: In 200 consecutive patients undergoing atrial fibrillation ablation, the DV8 balloon retractor was used for MED; contrast was instilled into the esophagus to accurately delineate the trailing esophageal edge. Deviation was performed to maximize the distance from the trailing esophageal edge to the closest point of the ablation line (MEDEffective) and correlated to occurrences of luminal esophageal temperature elevation. RESULTS: In patients undergoing MED during a first-ever PVI of 304 vein pairs, the MEDEffective during right and left PVI were 21.2 ± 8.7 mm and 15.5 ± 6.8 mm, respectively. Deviation of at least 5 mm of MEDEffective was achievable in 97.7%. Luminal esophageal temperature increases universally occurred (100%) at MEDEffective <5 mm, less often (28%) at MEDEffective 5 to 20 mm, and rarely (1.9%) at MEDEffective >20 mm. There were no esophageal complications, but 2 patients experienced oropharyngeal bleeding due to trauma related to device placement. CONCLUSIONS: MED with the balloon retractor safely moved the esophagus away from the site of energy delivery during atrial fibrillation ablation.

The dose-response relationship between the amount of straw provided on the floor and gastric ulceration of pars oesophagea in growing pigs.

The aim of the present study was (1) to determine the dose-response relationship between the amount of straw provided on the floor and oesophageal ulceration in pigs kept under typical Danish production conditions (18 pigs/pen, 0.7m2/pig, partly slatted floor, ad libitum access to feed), (2) to reveal whether straw ingestion explains the effect of straw provision on the stomach health and (3) to elucidate the effect of straw ingestion on the stomach conditions. Data were collected at slaughter (approximately 100kg body weight) on pigs provided with straw amounts in the range 10g to 500g wheat straw/pig/day from 30kg body weight and fed a wheat-based pelleted feed added 15% non-heated and non-pelleted rolled barley. Aims (1) and (2) included 712 pigs kept in 42 pens, whereas (3) was studied on a subset of 37 pigs with either none or obvious amounts of straw in the stomach. The amount of straw provided affected stomach health in a curvilinear manner. Provision of up to approximately 300gstraw/pig/day progressively decreased the risk of oesophageal ulceration and scarring. At larger amounts of straw the ulceroprotective effect of straw was reduced which requires further investigation. Straw ingestion appeared to be an essential intermediary factor for the improvement of stomach health. The number of pigs without straw in the stomach decreased linearly with the logarithm of the amount of straw provided, which explained the effect of straw provision on stomach health. The structure of the stomach contents increased as revealed by the increased weight and dry matter content and decreased sedimentation of the digesta. Provision of approximately 300gstraw/pig/day on the floor may be a potential strategy to reduce, but not inevitably eliminate, oesophageal ulceration in pigs in commercial pig production.

[An improved method of risk prediction and prevention of esophagogastroduodenal bleeding in geriatric urology].

With the aim of prediction and prevention of early postoperative esophagogastroduodenal bleeding (EPEGDB), 1296 elderly patients with BPH were examined during the preoperative period before isolated or simultaneous operations. Patients in group 1 (n=357) with a history of gastric or duodenal ulcer underwent esophagogastroduodenoscopy (EGDS). In group 2 (n=522) EGDS was performed and gastric acidity was determined using AGM-03 acid-gastrometer. Patients of group 3 (n=417) underwent EGDS and gastric acidity was determined by hromogastroscopy. The differentiated approach to treating patients of group 3 on the basis of preoperative comprehensive examination resulted in preventing severe complications such as EPEGDB. Prevention of EPEGDB in this category of geriatric patients should be as mandatory as preventing thromboembolic, respiratory, cardiovascular and septic complications.

[Oesophageal diseases: gastroesophageal reflux disease, Barrett's disease, achalasia and eosinophilic oesophagitis]. / Enfermedades esofágicas: enfermedad por reflujo gastroesofágico, Barrett, acalasia y esofagitis eosinofílica.

The most important novel findings presented on oesophageal disease in DDW 2015 were the following: 1) GERD: a) hypervigilance seems to be a key pathogenic factor in reflux symptoms refractory to PPI; b) post-reflux swallowing-induced peristaltic waves could be an excellent diagnostic criterion for GERD; c) laryngeal pH-metry is not useful in the diagnosis of extra-oesophageal symptoms; d) the recommendation of weight loss adequately recorded in the clinical reports of patients with GERD and obesity or overweight is an excellent quality indicator and is associated with better outcomes. 2) Barrett's oesophagus: a) persistent low-grade dysplasia in more than one endoscopy and a diagnosis of "indefinite for dysplasia" are associated with a high risk of neoplastic progression; b) narrow-band imaging allows areas of dysplasia on Barrett's oesophagus to be identified with high sensitivity and specificity; c) initial endoscopy fails to identify a high percentage of advanced neoplasms in Barrett's oesophagus. Early re-endoscopy should be considered; d) endoscopists specialized in Barret's oesophagus obtain a much higher yield in the diagnosis of advanced lesions. Patients at high risk-men, older patients, smokers and those with long-segment Barrett's oesophagus-could benefit from follow-up in a referral center. 3) Achalasia: POEM seems safe and effective, independently from patient characteristics (age, comorbidity) and the technical variations used. 4) Eosinophilic esophagitis: topical budesonide and exclusion diets are reasonably effective in PPI non-responders.

Reduced incidence of esophageal lesions by luminal esophageal temperature-guided second-generation cryoballoon ablation.

BACKGROUND: An increased incidence of esophageal lesions (EL) after pulmonary vein isolation (PVI) using the second-generation cryoballoon (CB2) has been described. We hypothesized that luminal esophageal temperature (LET)-guided PVI reduces the incidence of EL. OBJECTIVE: The aim of this study was to investigate the incidence of EL after LET-guided PVI using the CB2. METHODS: Ninety-four consecutive patients underwent CB2-PVI for paroxysmal or persistent atrial fibrillation. Target freezing time was 2 × 240 seconds. LET was continuously measured by a probe with 3 thermocouples. Early freezing interruption was performed when LET reached a prespecified cutoff temperature. A group of 32 patients who underwent CB2-PVI with observational LET measurement served as the control group. Postprocedural esophagoscopy was performed in all patients. RESULTS: Compared with observational LET measurement, a strategy of LET-guided CB-PVI significantly reduced the incidence of EL from 18.8% to 3.2% (P = .008). A progressive decline in the incidence of EL was observed with an increasing LET cutoff: 7.1% (2/28 patients, 12°C cutoff) and 1.5% (1/66 patients, 15°C cutoff, P = .005 vs control). Despite early freezing interruption at a single pulmonary vein in 27% (25/94) of patients, complete PVI was achieved in all patients using the 28 mm balloon. Repeat esophagoscopy confirmed healing of EL after 1 week. After a mean of 268 ± 119 days, 87% (76/87) of patients were free of recurrent atrial fibrillation or atrial tachycardia following a 90-days blanking period. CONCLUSION: LET-guided CB2-PVI significantly reduced the incidence of thermal EL. Interrupting cryoablation at 15°C LET was associated with the lowest incidence of esophageal injury.

Diet and esophageal disease.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on macronutrients, dietary patterns, and risk of adenocarcinoma in Barrett's esophagus; micronutrients, trace elements, and risk of Barrett's esophagus and esophageal adenocarcinoma; the role of mate consumption in the development of squamous cell carcinoma; the relationship between energy excess and development of esophageal adenocarcinoma; and the nutritional management of the esophageal cancer patient.

Oesophageal cooling with ice water does not reduce the incidence of oesophageal lesions complicating catheter ablation of atrial fibrillation: randomized controlled study.

AIM: Atrial fibrillation (AF) ablation can result in oesophageal injuries that lead to atrio-oesophageal fistulae, a life-threatening complication. This study aimed to evaluate whether oesophageal cooling could prevent oesophageal lesions complicating AF ablation. METHODS AND RESULTS: We randomly assigned 100 patients with drug-resistant AF to an oesophageal cooling group or a control group. In the oesophageal cooling group, we injected 5 mL of ice water into the oesophagus prior to radiofrequency (RF) energy delivery adjacent to the oesophagus. If the oesophageal temperature reached 42°C, the RF energy delivery was stopped, and the ice water injection was repeated. In the control group, oesophageal cooling was not applied. Oesophageal endoscopy was performed 1 day after the catheter ablation, and lesions were qualitatively assessed as mild, moderate, or severe. The numbers of ablation sites with an oesophageal temperature of >42°C were 1.7 ± 1.4 and 2.6 ± 1.7 in the oesophageal cooling group and the control group, respectively (P = 0.04), and the maximal oesophageal temperature at those sites was 43.0 ± 0.6 and 44.7 ± 0.9°C (P < 0.0001). Oesophageal lesions occurred almost equally between the oesophageal cooling group [10 of 50 patients (20%)] and the control group [11 of 50 patients (22%)]. However, the severity of the oesophageal lesions was slightly milder in the oesophageal cooling group (three moderate, seven mild) than in the control group (three severe, one moderate, seven mild). CONCLUSION: Oesophageal cooling may alleviate the severity of oesophageal lesions but does not reduce the incidence of this complication under the specific protocol evaluated here.

Continuous straw provision reduces prevalence of oesophago-gastric ulcer in pigs slaughtered at 170 kg (heavy pigs).

Adopting a 2 × 2 × 2 factorial design, this study evaluated whether continuous straw provision by racks, tail docking and gender (barrows vs. females) have an effect on the prevalence of lung lesions and oesophago-gastric ulcer (OGU) visually scored at slaughter in 635 Italian heavy pigs (169 ± 4 kg). The lung lesions were very low (72% of pigs with score 0), and were not significantly different among the experimental groups. Overall, OGU was diagnosed in 47% of the pigs. The consumption of small amounts of straw (70 g/day/pig) represented a protective factor against the onset of OGU (OR: 0.27). Barrows were more likely than females to have OGU (OR: 1.52), while no significant differences between docked and undocked pigs were detected. Nevertheless, the presence of straw acted as a protective factor particularly in undocked pigs (OR: 0.16), suggesting that in this group the absence of rooting material may have a stronger effect on welfare.

[Estimation of the risk and prevention of postoperative esophagogastroduodenal hemorrhage in elderly urological patients].

Open transvesical adenomectomy was made in 853 old males with prostatic adenoma in Samara Hospital for Veterans from 1995 to 2010. The age of the patients ranged from 60 to 89 years, of them 389 (45.6%) were from 60 to 75 years of age, 464 (54.4%) - 75 to 89 years. Elective simultaneous operations were conducted in 104 (12.2%) of the above patients. It is shown that early postoperative esophagogastroduodenal hemorrhage after adenomectomy occurs in 7% old patients. Endoscopic parietal pH-metry is "a gold standard" in selective sensitive diagnosis of acid-dependent conditions in presenile and senile patients with prostatic adenoma. The proposed method of prediction of the risk of early postoperative esophagogastroduodenal hemorrhage provides realization of the principle of a differential approach to effective prevention of the hemorrhage in old patients with prostatic adenoma. Complex preoperative preparation using adequate antisecretory therapy in old patients with prostatic adenoma with the risk of early postoperative esophagogastroduodenal hemorrhage decreases hemorrhage rate from 7 to 0.4%. Prevention of early postoperative esophagogastroduodenal hemorrhage in old patients with prostatic adenoma should become as obligatory as prevention of cardiovascular, thromboembolic, pulmonary and pyoseptic complications.

Identification of a high-risk population for esophageal injury during radiofrequency catheter ablation of atrial fibrillation: procedural and anatomical considerations.

BACKGROUND: Atrioesophageal fistula is an uncommon but life-threatening complication of atrial fibrillation (AF) ablation. Esophageal ulcerations (ESUL) have been proposed to be potential precursor lesions. OBJECTIVE: The purpose of our study was to prospectively investigate the incidence of ESUL in a large patient population undergoing radiofrequency catheter ablation (RFA). Additionally, we aimed to link demographic data and lesion sets with anatomical information given by multislice computed tomography imaging and to correlate these data with the development of ESUL. METHODS: This study included 267 patients and consecutively screened all individuals for evidence of ESUL 24 h after RFA of AF by endoscopy of the esophagus. A standardized ablation approach using a 25-W energy maximum at the posterior left atrial (LA) wall without esophagus visualization, temperature monitoring, or intracardiac ultrasound was performed. RESULTS: In total, we found 2.2% of patients (6 of 267) presenting with ESUL. Parameters exposing a specific patient to risk of developing ESUL in univariate analysis were persistent AF (5 of 95, P = .023), additional lines performed (roofline: 6 of 114, P = .006; LA isthmus: 4 of 49, P = .011; coronary sinus: 5 of 66, P = .004), and LA enlargement (P = .001) leading to sandwiching of the esophagus between the LA and thoracic spine. Multivariate analysis revealed LA-to-esophagus distance as the only significant risk factor. CONCLUSION: This study is the first to link anatomical information and procedural considerations to the development of ESUL in radiofrequency ablation for AF. Furthermore, it reveals the correlation and individual impact of these factors. Not a single patient with pulmonary vein isolation alone developed ESUL.

Feasibility and safety of using an esophageal protective system to eliminate esophageal thermal injury: implications on atrial-esophageal fistula following AF ablation.

BACKGROUND: Ablation for atrial fibrillation (AF) requires energy delivery in close proximity to the esophagus (Eso) which has accounted for the LA-Eso fistula, a rare but life-threatening complication. PURPOSE: We evaluated an Eso cooling system to protect the Eso during RF ablation. METHODS AND RESULTS: An "in vitro" heart-Eso preparation was initially used to test a temperature-controlled fluid-circulating system (EPSac [esophageal protective system]-RossHart Technologies Inc.) and an expandable compliant Eso sac during cardiac RF delivery (4 mm tip, perpendicular to the heart, 15 g pressure) at 25, 35, and 45 W, 100 +/- 5 Omega for 30 seconds with the EPSac at 25, 15, 10, and 5 degrees C. All cardiac lesions were transmural. Eso thermal injury could only be avoided with the EPSac at 10 and 5 degrees C. The system was then tested in 6 closed chest dogs, each receiving 12 RFs (LA aiming at the Eso) for 30 seconds: without EPSac (control) at 35 W (1 dog); at 45 W with EPSac at 25 degrees C (1 dog), 10 degrees C (2 dogs), and 5 degrees C (2 dogs). The EPSac volume was intentionally increased to displace the Eso toward the LA (2 dogs 5 and 10 degrees C). Eso injured control and EPSac at 25 degrees C; Eso spared EPSac at 5 and 10 degrees C, without Eso displacement. Shallow external Eso injury noted when intentionally displacing the Eso toward the LA. CONCLUSIONS: The EPSac spares the Eso from collateral thermal injury. It requires circulating fluid at 5 or 10 degrees C and a compliant sac to avoid displacement of the Eso. Its safety and efficacy remain to be demonstrated in patients undergoing AF ablation.

Real-time 3-dimensional imaging of the esophagus and left atrium with a noncontact mapping system.

BACKGROUND: Recognizing the relative location of the esophagus to the left atrial posterior wall (LAPW) is required to avoid esophageal injury during atrial fibrillation ablation. METHODS AND RESULTS: The 24 patients undergoing circumferential pulmonary vein isolation (CPVI) each had the geometry of their left atrium (LA) and esophagus constructed by a noncontact mapping system with EnSite version 6.0J. The esophageal course relative to the LAPW was found to be to the left in 12, middle in 8, right in 2, and obliquely left-to-right in 2 patients, and in 13 patients (54%) it was located on or near either the left or right CPVI line. The mean distance between the esophagus and LAPW was shorter at the bottom line of the LAPW connecting both inferior pulmonary veins (3 +/- 3 mm) than at the LA roof line connecting both superior pulmonary veins (6 +/- 6 mm, P<0.01). CONCLUSIONS: The location of the esophagus relative to the LAPW varies with the patient, but a close location to either CPVI line was found in approximately 50% and a close location between the esophagus and LAPW was found in the inferior and middle locations in most patients.

Esophageal damage during radiofrequency ablation of atrial fibrillation: impact of energy settings, lesion sets, and esophageal visualization.

INTRODUCTION: Atrioesophageal fistula is an uncommon but often lethal complication of atrial fibrillation (AF) ablation. The purpose of our study was to prospectively investigate the incidence of esophageal ulcerations (ESUL) as well as the impact of energy settings, radiofrequency lesion sets, and direct visualization of the esophagus on esophageal wall injury. METHODS AND RESULTS: One hundred seventy-five patients, 57.1% paroxysmal AF, 78.5% male, underwent AF ablation and esophagoscopy 24 hours thereafter. We performed a 2:1:1-randomization as follows: CONTROL GROUP: Ablation without visualization of the esophagus using 25 Watt (W) power limit on the posterior wall, n = 70. Visualization and 15 W maximum: Ablation guided by barium visualization of the esophageal course using a limit of 15 W, n = 35. Visualization and 25 W "short burns": Ablation guided by barium visualization using 25 W and "short burns" (max. 5 sec), n = 35. Patients performed under general anesthesia (n = 35) were separated as a nasogastric tube for visualization of the esophagus was used. In total, we found 2.9% of patients (5/175) presenting ESUL. Parameters discriminating the development of ESUL in a specific patient were type of AF, maximum energy delivered, usage of a nasogastric tube, and additional left atrial lines. Visualization of the esophageal course by barium contrast was not able to prevent ESUL. CONCLUSION: ESUL is a rare finding when using a reasonable energy maximum of 25 W with open-irrigated tip catheters at the posterior wall. Lower energy settings may increase safety without losing efficacy. Additional linear radiofrequency lesions increase the risk of ESUL development.

Micafungin: a review of its use in adults for the treatment of invasive and oesophageal candidiasis, and as prophylaxis against Candida infections.

Intravenous micafungin (Mycamine; Fungard), an echinocandin, inhibits the synthesis of 1,3-beta-D-glucan, an essential cell wall component in many fungi. It is approved in adults (focus of this review) and in neonates and paediatric patients (Pediatric Drugs [in press]) in the EU and elsewhere for the treatment of invasive candidiasis and oesophageal candidiasis, and as prophylactic treatment to prevent Candida infections in haematopoietic stem cell transplant (HSCT) recipients.Intravenous micafungin shows very good activity against clinically relevant isolates of Candida spp. Furthermore, the pharmacokinetic profile of micafungin permits once-daily treatment and means that it is associated with relatively few drug-drug interactions. However, like all of the echinocandins and all formulations of amphotericin B, micafungin must be given intravenously. In large, well designed clinical trials in adult patients (>or=16 years of age) with invasive candidiasis, intravenous micafungin was shown to be noninferior to intravenous caspofungin or liposomal amphotericin B. In similarly designed trials in adult patients with oesophageal candidiasis, intravenous micafungin was shown to be noninferior to fluconazole or caspofungin treatment. As prophylactic treatment in adult and paediatric patients who had undergone HSCT, micafungin was superior to fluconazole therapy in a large, well designed trial. Micafungin was generally well tolerated by participants in these clinical trials. Furthermore, it was as well tolerated as caspofungin and fluconazole, and better tolerated than liposomal amphotericin B. The position of micafungin relative to newer antifungal therapies, such as anidulafungin, voriconazole and posaconazole, remains to be fully determined. Thus, micafungin is an emerging option for the treatment of adult patients with invasive or oesophageal candidiasis, and as prophylaxis against Candida infections in HSCT recipients.