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Relationship between the posterior atrial wall and the esophagus: esophageal position and temperature measurement during atrial fibrillation ablation (AWESOME-AF). A randomized controlled trial

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Abstract

Background

Pulmonary vein isolation (PVI) implies unavoidable ablation lesions to the left atrial posterior wall, which is closely related to the esophagus, leading to several potential complications. This study evaluates the usefulness of the esophageal fingerprint in avoiding temperature rises during paroxysmal atrial fibrillation (PAF) ablation.

Methods

Isodistance maps of the atrio-esophageal relationship (esophageal fingerprint) were derived from the preprocedural computerized tomography. Patients were randomized (1:1) into two groups: (1) PRINT group, the PVI line was modified according to the esophageal fingerprint; (2) CONTROL group, standard PVI with operator blinded to the fingerprint. The primary endpoint was temperature rise detected by intraluminal esophageal temperature probe monitoring. Ablation settings were as specified on the Ablate BY-LAW study protocol.

Results

Sixty consecutive patients referred for paroxysmal AF ablation were randomized (42 (70%) men, mean age 60 ± 11 years). Temperature rise (> 39.1 °C) occurred in 5 (16%) patients in the PRINT group vs. 17 (56%) in the CONTROL group (p < 0.01). Three AF recurrences were documented at a mean follow-up of 12 ± 3 months (one (3%) in the PRINT group and 2 (6.6%) in the CONTROL group, p = 0.4).

Conclusion

The esophageal fingerprint allows for a reliable identification of the esophageal position and its use for PVI line deployment results in less frequent esophageal temperature rises when compared to the standard approach. Further studies are needed to evaluate the impact of PVI line modification to avoid esophageal heating on long-term outcomes. The development of new imaging-derived tools could ultimately improve patient safety (NCT04394923).

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Abbreviations

AAD:

Antiarrhythmic drugs

AEF:

Atrio-esophageal fistula

AF:

Atrial fibrillation

FAM:

Fast anatomical map

LA:

Left atrium

LAWT:

Left atrial wall thickness

LET:

Luminal esophageal temperature

MDCT:

Multidetector computerized tomography

PAF:

Paroxysmal atrial fibrillation

PVI:

Pulmonary vein isolation

RF:

Radiofrequency

TOE:

Transesophageal echocardiography

References

  1. Chew DS, Jones KA, Loring Z, et al. Diagnosis-to-ablation time predicts recurrent atrial fibrillation and rehospitalization following catheter ablation. Heart Rhythm O2. 2022;3(1):23–31. https://doi.org/10.1016/j.hroo.2021.11.012.

    Article  Google Scholar 

  2. Iwasaki Y, Nishida K, Kato T, Nattel S. Atrial fibrillation pathophysiology: implications for management. Circulation. 2011;124(20):2264–74. https://doi.org/10.1161/CIRCULATIONAHA.111.019893.

    Article  CAS  Google Scholar 

  3. Kirchhof P, Camm AJ, Goette A, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med. 2020;383(14):1305–16. https://doi.org/10.1056/NEJMoa2019422.

    Article  Google Scholar 

  4. Hindricks G, Potpara T, Dagres N, et al. ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. August 2020. https://doi.org/10.1093/eurheartj/ehaa612

  5. Halbfass P, Pavlov B, Muller P, et al. Progression from esophageal thermal asymptomatic lesion to perforation complicating atrial fibrillation ablation: a single-center registry. Circ Arrhythm Electrophysiol. 2017;10(8). https://doi.org/10.1161/CIRCEP.117.005233

  6. Lakkireddy D, Reddy YM, Atkins D, et al. Effect of atrial fibrillation ablation on gastric motility: the atrial fibrillation gut study. Circ Arrhythm Electrophysiol. 2015;8(3):531–6. https://doi.org/10.1161/CIRCEP.114.002508.

    Article  Google Scholar 

  7. Kadado AJ, Akar JG, Hummel JP. Luminal esophageal temperature monitoring to reduce esophageal thermal injury during catheter ablation for atrial fibrillation: a review. Trends Cardiovasc Med. 2019;29(5):264–71. https://doi.org/10.1016/j.tcm.2018.09.010.

    Article  Google Scholar 

  8. Turagam MK, Miller S, Sharma SP, et al. Differences in transient thermal response of commercial esophageal temperature probes: insights from an experimental study. JACC Clin Electrophysiol. 2019;5(11):1280–8. https://doi.org/10.1016/j.jacep.2019.07.013.

    Article  Google Scholar 

  9. Schoene K, Arya A, Grashoff F, et al. Oesophageal Probe Evaluation in Radiofrequency Ablation of Atrial Fibrillation (OPERA): results from a prospective randomized trial. Europace. 2020;22(10):1487–94. https://doi.org/10.1093/europace/euaa209.

    Article  Google Scholar 

  10. Grosse Meininghaus D, Blembel K, Waniek C, et al. Temperature monitoring and temperature-driven irrigated radiofrequency energy titration do not prevent thermally induced esophageal lesions in pulmonary vein isolation: a randomized study controlled by esophagoscopy before and after catheter ablation. Heart Rhythm. 2021;18(6):926–34. https://doi.org/10.1016/j.hrthm.2021.02.003.

    Article  Google Scholar 

  11. Kottkamp H, Piorkowski C, Tanner H, et al. Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2005;16(2):146–50. https://doi.org/10.1046/j.1540-8167.2005.40604.x.

    Article  Google Scholar 

  12. Zhang X, Kuang X, Gao X, et al. RESCUE-AF in patients undergoing atrial fibrillation ablation: the RESCUE-AF trial. Circ Arrhythm Electrophysiol. 2019;12(5):e007044. https://doi.org/10.1161/CIRCEP.118.007044.

    Article  Google Scholar 

  13. Aguinaga L, Palazzo A, Bravo A, et al. Esophageal deviation with vacuum suction and mechanical deflection during ablation of atrial fibrillation: first in man evaluation. J Cardiovasc Electrophysiol. 2021;32(1):67–70. https://doi.org/10.1111/jce.14801.

    Article  Google Scholar 

  14. Leung LWM, Bajpai A, Zuberi Z, et al. Randomized comparison of oesophageal protection with a temperature control device: results of the IMPACT study. Europace. 2021;23(2):205–15. https://doi.org/10.1093/europace/euaa276.

    Article  Google Scholar 

  15. Teres C, Soto-Iglesias D, Penela D, et al. Personalized paroxysmal atrial fibrillation ablation by tailoring ablation index to the left atrial wall thickness: the “Ablate by-LAW” single-centre study-a pilot study. Europace. 2022;24(3):390–9. https://doi.org/10.1093/europace/euab216.

    Article  Google Scholar 

  16. Teres C, Soto-Iglesias D, Penela D, et al. Relationship between the posterior atrial wall and the esophagus: esophageal position during atrial fibrillation ablation. In Press Corrected Proof. Published online: February 13, 2022. https://doi.org/10.1016/j.hroo.2022.02.007

  17. Falasconi G, Penela D, Soto-Iglesias D, et al. A standardized stepwise zero-fluoroscopy approach with transesophageal echocardiography guidance for atrial fibrillation ablation. J Interv Card Electrophysiol. 2021. https://doi.org/10.1007/s10840-021-01086-9.

    Article  Google Scholar 

  18. Teres C, Soto-Iglesias D, Penela D, et al. Left atrial wall thickness of the pulmonary vein reconnection sites during atrial fibrillation redo procedures. Pacing Clin Electrophysiol. 2021;44(5):824–34. https://doi.org/10.1111/pace.14222.

    Article  Google Scholar 

  19. Ye Y, Chen S-Q, Lu Y-F, et al. PV isolation guided by esophageal visualization with a tailored ablation strategy for the avoidance of esophageal thermal injury: a randomized trial. J Interv Card Electrophysiol an Int J Arrhythm pacing. 2020;58(2):219–27. https://doi.org/10.1007/s10840-019-00572-5.

    Article  Google Scholar 

  20. Parikh V, Swarup V, Hantla J, et al. Feasibility, safety, and efficacy of a novel preshaped nitinol esophageal deviator to successfully deflect the esophagus and ablate left atrium without esophageal temperature rise during atrial fibrillation ablation: the DEFLECT GUT study. Heart Rhythm. 2018;15(9):1321–7. https://doi.org/10.1016/j.hrthm.2018.04.017.

    Article  Google Scholar 

  21. Leung LWM, Akhtar Z, Sheppard MN, Louis-Auguste J, Hayat J, Gallagher MM. Preventing esophageal complications from atrial fibrillation ablation: a review. Heart Rhythm O2. 2021;2(6Part A):651–64. https://doi.org/10.1016/j.hroo.2021.09.004.

    Article  Google Scholar 

  22. Carroll BJ, Contreras-Valdes FM, Heist EK, et al. Multi-sensor esophageal temperature probe used during radiofrequency ablation for atrial fibrillation is associated with increased intraluminal temperature detection and increased risk of esophageal injury compared to single-sensor probe. J Cardiovasc Electrophysiol. 2013;24(9):958–64. https://doi.org/10.1111/jce.12180.

    Article  Google Scholar 

  23. Müller P, Dietrich J-W, Halbfass P, et al. Higher incidence of esophageal lesions after ablation of atrial fibrillation related to the use of esophageal temperature probes. Heart Rhythm. 2015;12(7):1464–9. https://doi.org/10.1016/j.hrthm.2015.04.005.

    Article  Google Scholar 

  24. Sherzer AI, Feigenblum DY, Kulkarini S, et al. Continuous nonfluoroscopic localization of the esophagus during radiofrequency catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18(2):157–60. https://doi.org/10.1111/j.1540-8167.2006.00674.x.

    Article  Google Scholar 

  25. Hayashi K, Okumura K, Okamatsu H, Kaneko S, Negishi K, Tsurugi T, Tanaka Y, Nakao K, Sakamoto T, Koyama J. Real-time visualization of the esophagus and left atrial posterior wall by intra-left atrial echocardiography. J Interv Card Electrophysiol. 2022;63(3):629–37. https://doi.org/10.1007/s10840-021-01093-w.

    Article  Google Scholar 

  26. Nakatani Y, Nuñez-Garcia M, Cheniti G, et al. Preoperative personalization of atrial fibrillation ablation strategy to prevent esophageal injury: impact of changes in esophageal position. J Cardiovasc Electrophysiol. 2022;33(5):908–16. https://doi.org/10.1111/jce.15447.

    Article  Google Scholar 

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Authors and Affiliations

  1. Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain

    Cheryl Teres, David Soto-Iglesias, Diego Penela, Giulio Falasconi, Daniel Viveros, Julia Meca-Santamaria, Aldo Bellido, Jose Alderete, Alfredo Chauca, Augusto Ordoñez, Julio Martí-Almor, Claudia Scherer, Alejandro Panaro, Julio Carballo, Jose-Tomás Ortiz-Pérez & Antonio Berruezo

  2. Lausanne University Hospital, Lausanne, Switzerland

    Cheryl Teres

  3. Department of Information and Communication Technologies, BCN-MedTech, Universitat Pompeu Fabra, PhySense group, Barcelona, Spain

    Óscar Cámara

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  1. Cheryl Teres
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Corresponding author

Correspondence to Antonio Berruezo.

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Ethical approval

The local ethics committee approved the study protocol.

Informed consent

All participants included in the study provided written informed consent.

Conflict of interest

Dr. Berruezo is stockholder of Galgo Medical. Dr. Soto-Iglesias is an employee of Biosense Webster. All remaining authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

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Teres, C., Soto-Iglesias, D., Penela, D. et al. Relationship between the posterior atrial wall and the esophagus: esophageal position and temperature measurement during atrial fibrillation ablation (AWESOME-AF). A randomized controlled trial. J Interv Card Electrophysiol 65, 651–661 (2022). https://doi.org/10.1007/s10840-022-01302-0

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