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.

Selecting persistent atrial fibrillation patients for pulmonary vein isolation based on the response to amiodarone: efficacy of the "one step back" strategy.

PURPOSE: Pulmonary vein isolation (PVI) by catheter ablation has reduced efficacy for the treatment of persistent atrial fibrillation (persAF), as compared to paroxysmal atrial fibrillation (paroxAF). We investigated whether the selection of persAF patients for PVI who "step back" to the paroxysmal stage on amiodarone offers a success rate comparable to that of patients with paroxAF. METHODS: Sixty-two consecutive persAF patients and 62 matched control patients with paroxAF were included. Persistent patients were started on amiodarone and cardioverted to sinus rhythm (SR). PVI was performed after 3 months in those who "stepped back" and had sustained SR and in all paroxAF patients. RESULTS: Five of the 62 (8%) study patients returned to persAF after cardioversion; despite amiodarone, they did not undergo PVI. The rest received PVI and was followed for a mean of 31 ± 14 months. Redo procedures were performed in 44% and 29% in the persAF and paroxAF group (p = 0.093), respectively. The recurrence rate after multiple procedures without antiarrhythmic drugs was similar among the persAF and paroxAF patients (11% and 7%) at 6 months (p = 0.510), but increased in the persAF group at 1 year (21% and 9%, p = 0.065) and exceeded that of the paroxAF group at the end of the follow-up (26% and 12%, p = 0.046). Kaplan-Meier survival analysis showed shorter time to recurrence in the persAF group (p = 0.045). CONCLUSION: PersAF patients who "step back" to the paroxysmal stage on amiodarone can expect long-term success of a PVI-only strategy in more than 70% of the time. However, late recurrences are more common compared to paroxAF.