Association between proactive esophageal cooling and increased lab throughput.

INTRODUCTION: Proactive esophageal cooling has been FDA cleared to reduce the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures. Data suggest that procedure times for RF pulmonary vein isolation (PVI) also decrease when proactive esophageal cooling is employed instead of luminal esophageal temperature (LET) monitoring. Reduced procedure times may allow increased electrophysiology (EP) lab throughput. We aimed to quantify the change in EP lab throughput of PVI cases after the introduction of proactive esophageal cooling. METHODS: EP lab throughput data were obtained from three EP groups. We then compared EP lab throughput over equal time frames at each site before (pre-adoption) and after (post-adoption) the adoption of proactive esophageal cooling. RESULTS: Over the time frame of the study, a total of 2498 PVIs were performed over a combined 74 months, with cooling adopted in September 2021, November 2021, and March 2022 at each respective site. In the pre-adoption time frame, 1026 PVIs were performed using a combination of LET monitoring with the addition of esophageal deviation when deemed necessary by the operator. In the post-adoption time frame, 1472 PVIs were performed using exclusively proactive esophageal cooling, representing a mean 43% increase in throughput (p < .0001), despite the loss of two operators during the post-adoption time frame. CONCLUSION: Adoption of proactive esophageal cooling during PVI ablation procedures is associated with a significant increase in EP lab throughput, even after a reduction in total number of operating physicians in the post-adoption group.

Proactive esophageal cooling during laser cardiac ablation: A computer modeling study.

BACKGROUND AND OBJECTIVES: Laser ablation is increasingly used to treat atrial fibrillation (AF). However, atrioesophageal injury remains a potentially serious complication. While proactive esophageal cooling (PEC) reduces esophageal injury during radiofrequency ablation, the effects of PEC during laser ablation have not previously been determined. We aimed to evaluate the protective effects of PEC during laser ablation of AF by means of a theoretical study based on computer modeling. METHODS: Three-dimensional mathematical models were built for 20 different cases including a fragment of atrial wall (myocardium), epicardial fat (adipose tissue), connective tissue, and esophageal wall. The esophagus was considered with and without PEC. Laser-tissue interaction was modeled using Beer-Lambert's law, Pennes' Bioheat equation was used to compute the resultant heating, and the Arrhenius equation was used to estimate the fraction of tissue damage (FOD), assuming a threshold of 63% to assess induced necrosis. We modeled laser irradiation power of 8.5 W over 20 s. Thermal simulations extended up to 250 s to account for thermal latency. RESULTS: PEC significantly altered the temperature distribution around the cooling device, resulting in lower temperatures (around 22°C less in the esophagus and 9°C in the atrial wall) compared to the case without PEC. This thermal reduction translated into the absence of transmural lesions in the esophagus. The esophagus was thermally damaged only in the cases without PEC and with a distance equal to or shorter than 3.5 mm between the esophagus and endocardium (inner boundary of the atrial wall). Furthermore, PEC demonstrated minimal impact on the lesion created across the atrial wall, either in terms of maximum temperature or FOD. CONCLUSIONS: PEC reduces the potential for esophageal injury without degrading the intended cardiac lesions for a variety of different tissue thicknesses. Thermal latency may influence lesion formation during laser ablation and may play a part in any collateral damage.

Proactive esophageal cooling protects against thermal insults during high-power short-duration radiofrequency cardiac ablation.

BACKGROUND: Proactive cooling with a novel cooling device has been shown to reduce endoscopically identified thermal injury during radiofrequency (RF) ablation for the treatment of atrial fibrillation using medium power settings. We aimed to evaluate the effects of proactive cooling during high-power short-duration (HPSD) ablation. METHODS: A computer model accounting for the left atrium (1.5 mm thickness) and esophagus including the active cooling device was created. We used the Arrhenius equation to estimate the esophageal thermal damage during 50 W/ 10 s and 90 W/ 4 s RF ablations. RESULTS: With proactive esophageal cooling in place, temperatures in the esophageal tissue were significantly reduced from control conditions without cooling, and the resulting percentage of damage to the esophageal wall was reduced around 50%, restricting damage to the epi-esophageal region and consequently sparing the remainder of the esophageal tissue, including the mucosal surface. Lesions in the atrial wall remained transmural despite cooling, and maximum width barely changed (<0.8 mm). CONCLUSIONS: Proactive esophageal cooling significantly reduces temperatures and the resulting fraction of damage in the esophagus during HPSD ablation. These findings offer a mechanistic rationale explaining the high degree of safety encountered to date using proactive esophageal cooling, and further underscore the fact that temperature monitoring is inadequate to avoid thermal damage to the esophagus.

Possible effects of air temperature on COVID-19 disease severity and transmission rates.

Currently available data are consistent with increased severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replication at temperatures encountered in the upper airways (25-33°C when breathing room temperature air, 25°C) compared to those in the lower airways (37°C). One factor that may contribute to more rapid viral growth in the upper airways is the exponential increase in SARS-CoV-2 stability that occurs with reductions in temperature, as measured in vitro. Because SARS-CoV-2 frequently initiates infection in the upper airways before spreading through the body, increased upper airway viral growth early in the disease course may result in more rapid progression of disease and potentially contribute to more severe outcomes. Similarly, higher SARS-CoV-2 viral titer in the upper airways likely supports more efficient transmission. Conversely, the possible significance of air temperature to upper airway viral growth suggests that prolonged delivery of heated air might represent a preventative measure and prophylactic treatment for coronavirus disease 2019.

Modeling esophageal protection from radiofrequency ablation via a cooling device: an analysis of the effects of ablation power and heart wall dimensions.

BACKGROUND: Esophageal thermal injury can occur after radiofrequency (RF) ablation in the left atrium to treat atrial fibrillation. Existing methods to prevent esophageal injury have various limitations in deployment and uncertainty in efficacy. A new esophageal heat transfer device currently available for whole-body cooling or warming may offer an additional option to prevent esophageal injury. We sought to develop a mathematical model of this process to guide further studies and clinical investigations and compare results to real-world clinical data. RESULTS: The model predicts that the esophageal cooling device, even with body-temperature water flow (37 °C) provides a reduction in esophageal thermal injury compared to the case of the non-protected esophagus, with a non-linear direct relationship between lesion depth and the cooling water temperature. Ablation power and cooling water temperature have a significant influence on the peak temperature and the esophageal lesion depth, but even at high RF power up to 50 W, over durations up to 20 s, the cooling device can reduce thermal impact on the esophagus. The model concurs with recent clinical data showing an 83% reduction in transmural thermal injury when using typical operating parameters. CONCLUSIONS: An esophageal cooling device appears effective for esophageal protection during atrial fibrillation, with model output supporting clinical data. Analysis of the impact of ablation power and heart wall dimensions suggests that cooling water temperature can be adjusted for specific ablation parameters to assure the desired myocardial tissue ablation while keeping the esophagus protected.

An alternative for rapid administration of medication and fluids in the emergency setting using a novel device.

Routes of administration for medications and fluids in the acute care setting have primarily focused on oral, intravenous, or intraosseous routes, but, in many patients, none of these routes is optimal. A novel device (Macy Catheter; Hospi Corp) that offers an easy route for administration of medications or fluids via rectal mucosal absorption (proctoclysis) has recently become available in the palliative care market; we describe here the first known uses of this device in the emergency setting. Three patients presenting to the hospital with conditions limiting more typical routes of medication or fluid administration were treated with this new device; patients were administered water for hydration, lorazepam for treatment of alcohol withdrawal, ondansetron for nausea, acetaminophen for fever, aspirin for antiplatelet effect, and methimazole for hyperthyroidism. Placement of the device was straightforward, absorption of administered medications (judged by immediacy of effects, where observable) was rapid, and use of the device was well tolerated by patients, suggesting that this device may be an appealing alternative route to medication and fluid administration for a variety of indications in acute and critical care settings.

The complexity and challenges of the International Classification of Diseases, Ninth Revision, Clinical Modification to International Classification of Diseases, 10th Revision, Clinical Modification transition in EDs.

Beginning October 2015, the Center for Medicare and Medicaid Services will require medical providers to use the vastly expanded International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) system. Despite wide availability of information and mapping tools for the next generation of the ICD classification system, some of the challenges associated with transition from ICD-9-CM to ICD-10-CM are not well understood. To quantify the challenges faced by emergency physicians, we analyzed a subset of a 2010 Illinois Medicaid database of emergency department ICD-9-CM codes, seeking to determine the accuracy of existing mapping tools in order to better prepare emergency physicians for the change to the expanded ICD-10-CM system. We found that 27% of 1830 codes represented convoluted multidirectional mappings. We then analyzed the convoluted transitions and found that 8% of total visit encounters (23% of the convoluted transitions) were clinically incorrect. The ambiguity and inaccuracy of these mappings may impact the workflow associated with the translation process and affect the potential mapping between ICD codes and Current Procedural Codes, which determine physician reimbursement.

Temperature modulation with an esophageal heat transfer device - a pediatric swine model study.

BACKGROUND: An increasing number of conditions appear to benefit from control and modulation of temperature, but available techniques to control temperature often have limitations, particularly in smaller patients with high surface to mass ratios. We aimed to evaluate a new method of temperature modulation with an esophageal heat transfer device in a pediatric swine model, hypothesizing that clinically significant modulation in temperature (both increases and decreases of more than 1°C) would be possible. METHODS: Three female Yorkshire swine averaging 23 kg were anesthetized with inhalational isoflurane prior to placement of the esophageal device, which was powered by a commercially available heat exchanger. Swine temperature was measured rectally and cooling and warming were performed by selecting the appropriate external heat exchanger mode. Temperature was recorded over time in order to calculate rates of temperature change. Histopathology of esophageal tissue was performed after study completion. RESULTS: Average swine baseline temperature was 38.3°C. Swine #1 exhibited a cooling rate of 3.5°C/hr; however, passive cooling may have contributed to this rate. External warming blankets maintained thermal equilibrium in swine #2 and #3, demonstrating maximum temperature decrease of 1.7°C/hr. Warming rates averaged 0.29°C/hr. Histopathologic analysis of esophageal tissue showed no adverse effects. CONCLUSIONS: An esophageal heat transfer device successfully modulated the temperature in a pediatric swine model. This approach to temperature modulation may offer a useful new modality to control temperature in conditions warranting temperature management (such as maintenance of normothermia, induction of hypothermia, fever control, or malignant hyperthermia).

The role of prehospital electrocardiograms in the recognition of ST-segment elevation myocardial infarctions and reperfusion times.

BACKGROUND: Clinical outcomes in ST-segment elevation myocardial infarction (STEMI) are related to reperfusion times. Given the benefit of early recognition of STEMI and resulting ability to decrease reperfusion times and improve mortality, current prehospital recommendations are to obtain electrocardiograms (ECGs) in patients with concern for acute coronary syndrome. OBJECTIVES: We sought to determine the effect of wireless transmission of prehospital ECGs on STEMI recognition and reperfusion times. We hypothesized decreased reperfusion times in patients in whom prehospital ECGs were obtained. METHODS: We conducted a retrospective, observational study of patients who presented to our suburban, tertiary care, teaching hospital emergency department with STEMI on a prehospital ECG. RESULTS: Ninety-nine patients underwent reperfusion therapy. Patients with prehospital ECGs had a mean time to angioplasty suite of 43 min (95% confidence interval [CI] 31-54). Compared to patients with no prehospital ECG, mean time to angioplasty suite was 49 min (95% CI 41-57), p = 0.035. Patients with prehospital STEMI identification and catheterization laboratory activation had a mean time to angioplasty suite of 33 min (95% CI 25-41), p = 0.007. Patients with prehospital ECGs had a mean door-to-balloon time of 66 min (95% CI 53-79), whereas the control group had a mean door-to-balloon time of 79 min (95% CI 67-90), p = 0.024. Patients with prehospital STEMI identification and catheterization laboratory activation had a mean door-to-balloon time of 58 min (95% CI 48-68), p = 0.018. CONCLUSIONS: Prehospital STEMI identification allows for prompt catheterization laboratory activation, leading to decreased reperfusion times.

Hybrid convergent procedure with proactive oesophageal cooling for the treatment of long-standing persistent atrial fibrillation: a case series.

Background: The hybrid convergent procedure is approved to treat symptomatic patients with long-standing persistent atrial fibrillation (AF). Despite direct visualization during surgical ablation as well as the use of luminal oesophageal temperature (LET) monitoring, oesophageal injury is still possible. A dedicated device for proactive oesophageal cooling has recently been cleared by the Food and Drug Administration to reduce the likelihood of ablation-related oesophageal injury resulting from radiofrequency cardiac ablation procedures. This report describes the first uses of proactive oesophageal cooling for oesophageal protection during the epicardial ablation portion of hybrid convergent procedures. Case summary: Five patients with long-standing persistent AF underwent hybrid convergent ablations with the use of proactive oesophageal cooling as means of oesophageal protection. All cases were completed successfully with no adverse effects. Most notably, cases were shorter when compared to cases using LET monitoring, likely due to lack of pauses for overheating of the oesophagus that would otherwise be required to prevent damage to the oesophagus. Discussion: This report describes the first uses of proactive oesophageal cooling for oesophageal protection during the epicardial ablation portion of five hybrid convergent procedures. Use of cooling enabled uninhibited deployment of lesions without the need to pause energy delivery due to elevated temperatures in the oesophagus, providing a feasible alternative to LET monitoring.

Determination of Continuity Index Values in Atrial Fibrillation Ablation with Proactive Esophageal Cooling.

Radiofrequency (RF) ablation to perform pulmonary vein isolation (PVI) for the treatment of atrial fibrillation involves some risk to collateral structures, including the esophagus. Proactive esophageal cooling using a dedicated device has been granted marketing authorization by the Food and Drug Administration (FDA) to reduce the risk of ablation-related esophageal injury due to RF cardiac ablation procedures, and more recent data also suggest that esophageal cooling may contribute to improved long-term efficacy of treatment. A mechanistic underpinning explaining these findings exists through the quantification of lesion placement contiguity defined as the Continuity Index (CI). Kautzner et al. quantified the CI by the order of lesion placement, such that whenever a lesion is placed non-adjacent to the prior lesion, the CI is incremented by the number of segments the catheter tip has moved over. To facilitate real-time calculation of the CI and encourage further adoption of this instrument, we propose a modification in which the placement of non-adjacent lesions increments the CI by only one unit, avoiding the need to count potentially nebulous markers of atrial segmentation. The objective of this protocol is to describe the methods of calculating the CI both prospectively during real-time PVI cases and retrospectively using recorded case data. A comparison of the results obtained between cases that utilized proactive esophageal cooling and cases that used luminal esophageal temperature (LET) monitoring is then provided.

Reduced Continuity Index with Proactive Esophageal Cooling Compared to Luminal Temperature Monitoring During Radiofrequency Ablation: Improved Lesion Continuity with Esophageal Cooling.

Background: Proactive esophageal cooling is FDA cleared to reduce the likelihood of esophageal injury during radiofrequency ablation for treatment of atrial fibrillation (AF). Long-term follow-up data have also shown improved freedom from arrhythmia with proactive esophageal cooling compared to luminal esophageal temperature (LET) monitoring during pulmonary vein isolation (PVI). One hypothesized mechanism is improved lesion contiguity (as measured by the Continuity Index) with the use of cooling. We aimed to compare the Continuity Index of PVI cases using proactive esophageal cooling to those using LET monitoring. Methods: Continuity Index was calculated for PVI cases at two different hospitals within the same health system using a slightly modified Continuity Index to facilitate both real-time calculation during observation of PVI cases and retrospective determination from recorded cases. The results were then compared between proactively cooled cases and those using LET monitoring. Results: Continuity Indices for a total of 101 cases were obtained; 77 cases using proactive esophageal cooling and 24 cases using traditional LET monitoring. With proactive esophageal cooling, the average Continuity Index was 2.7 (1.3 on the left pulmonary vein, and 1.5 on the right pulmonary vein). With LET monitoring, the average Continuity Index was 27.3 (14.3 on the left, and 12.9 on the right), for a difference of 24.6 (p < 0.001). Conclusion: Proactive esophageal cooling during PVI is associated with significantly improved lesion contiguity when compared to LET monitoring. This finding may offer a mechanism for the greater freedom from arrhythmia seen with proactive cooling in long-term follow-up.

Mechanisms of action behind the protective effects of proactive esophageal cooling during radiofrequency catheter ablation in the left atrium.

Proactive esophageal cooling for the purpose of reducing the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures is increasingly being used and has been Food and Drug Administration cleared as a protective strategy during left atrial RF ablation for the treatment of atrial fibrillation. In this review, we examine the evidence supporting the use of proactive esophageal cooling and the potential mechanisms of action that reduce the likelihood of atrioesophageal fistula (AEF) formation. Although the pathophysiology behind AEF formation after thermal injury from RF ablation is not well studied, a robust literature on fistula formation in other conditions (eg, Crohn disease, cancer, and trauma) exists and the relationship to AEF formation is investigated in this review. Likewise, we examine the abundant data in the surgical literature on burn and thermal injury progression as well as the acute and chronic mitigating effects of cooling. We discuss the relationship of these data and maladaptive healing mechanisms to the well-recognized postablation pathophysiological effects after RF ablation. Finally, we review additional important considerations such as patient selection, clinical workflow, and implementation strategies for proactive esophageal cooling.

Improved hospital discharge and cost savings with esophageal cooling during left atrial ablation.

BACKGROUND: Left atrial ablation to obtain pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) is a technologically intensive procedure utilizing innovative and continually improving technology. Changes in the technology utilized for PVI can in turn lead to changes in procedure costs. Because of the proximity of the esophagus to the posterior wall of the left atrium, various technologies have been utilized to protect against thermal injury during ablation. The impact on hospital costs during PVI ablation from utilization of different technologies for esophageal protection during ablation has not previously been evaluated. OBJECTIVE: To compare the costs of active esophageal cooling to luminal esophageal temperature (LET) monitoring during left atrial ablation. METHODS: We performed a time-driven activity-based costing (TDABC) analysis to determine costs for PVI procedures. Published data and literature review were utilized to determine differences in procedure time and same-day discharge rates using different esophageal protection technologies and to determine the cost impacts of same-day discharge versus overnight hospitalization after PVI procedures. The total costs were then compared between cases using active esophageal cooling to those using LET monitoring. RESULTS: The effect of implementing active esophageal cooling was associated with up to a 24.7% reduction in mean total procedure time, and an 18% increase in same-day discharge rate. TDABC analysis identified a $681 reduction in procedure costs associated with the use of active esophageal cooling after including the cost of the esophageal cooling device. Factoring in the 18% increase in same-day discharge resulted in an increased cost savings of $2,135 per procedure. CONCLUSIONS: The use of active esophageal cooling is associated with significant cost-savings when compared to traditional LET monitoring, even after accounting for the additional cost of the cooling device. These savings originate from a per-patient procedural time savings and a per-population improvement in same-day discharge rate.

Core Warming of Coronavirus Disease 2019 Patients Undergoing Mechanical Ventilation: A Pilot Study.

Fever is a recognized protective factor in patients with sepsis, and growing data suggest beneficial effects on outcomes in sepsis with elevated temperature, with a recent pilot randomized controlled trial (RCT) showing lower mortality by warming afebrile sepsis patients in the intensive care unit (ICU). The objective of this prospective single-site RCT was to determine if core warming improves respiratory physiology of mechanically ventilated patients with coronavirus disease 2019 (COVID-19), allowing earlier weaning from ventilation, and greater overall survival. A total of 19 patients with mean age of 60.5 (±12.5) years, 37% female, mean weight 95.1 (±18.6) kg, and mean body mass index 34.5 (±5.9) kg/m2 with COVID-19 requiring mechanical ventilation were enrolled from September 2020 to February 2022. Patients were randomized 1:1 to standard of care or to receive core warming for 72 hours through an esophageal heat exchanger commonly utilized in critical care and surgical patients. The maximum target temperature was 39.8°C. A total of 10 patients received usual care and 9 patients received esophageal core warming. After 72 hours of warming, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratios were 197 (±32) and 134 (±13.4), cycle thresholds were 30.8 (±6.4) and 31.4 (±3.2), ICU mortalities were 40% and 44%, 30-day mortalities were 30% and 22%, and mean 30-day ventilator-free days were 11.9 (±12.6) and 6.8 (±10.2) for standard of care and warmed patients, respectively (p = NS). This pilot study suggests that core warming of patients with COVID-19 undergoing mechanical ventilation is feasible and appears safe. Optimizing time to achieve febrile-range temperature may require a multimodal temperature management strategy to further evaluate effects on outcome. ClinicalTrials.gov Identifier: NCT04494867.