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Gastroesophageal Reflux Facilitates Esophageal Imaging During Pulmonary Vein Ablation

2006; Lippincott Williams & Wilkins; Volume: 114; Issue: 6 Linguagem: Inglês

10.1161/circulationaha.106.614735

1524-4539

Lorne J. Gula, Allan C. Skanes, Emőke Pósán, Andrew D. Krahn, Raymond Yee, George J. Klein,

Cardiac Imaging and Diagnostics

HomeCirculationVol. 114, No. 6Gastroesophageal Reflux Facilitates Esophageal Imaging During Pulmonary Vein Ablation Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBGastroesophageal Reflux Facilitates Esophageal Imaging During Pulmonary Vein Ablation Lorne J. Gula, MD, MS, Allan C. Skanes, MD, Emoke Posan, MD, PhD, Andrew D. Krahn, MD, Raymond Yee, MD and George J. Klein, MD Lorne J. GulaLorne J. Gula From the Department of Medicine, Division of Cardiology, University of Western Ontario, London, Ontario, Canada. , Allan C. SkanesAllan C. Skanes From the Department of Medicine, Division of Cardiology, University of Western Ontario, London, Ontario, Canada. , Emoke PosanEmoke Posan From the Department of Medicine, Division of Cardiology, University of Western Ontario, London, Ontario, Canada. , Andrew D. KrahnAndrew D. Krahn From the Department of Medicine, Division of Cardiology, University of Western Ontario, London, Ontario, Canada. , Raymond YeeRaymond Yee From the Department of Medicine, Division of Cardiology, University of Western Ontario, London, Ontario, Canada. and George J. KleinGeorge J. Klein From the Department of Medicine, Division of Cardiology, University of Western Ontario, London, Ontario, Canada. Originally published8 Aug 2006https://doi.org/10.1161/CIRCULATIONAHA.106.614735Circulation. 2006;114:e235–e236A 45-year-old man with gastric esophageal reflux disease underwent pulmonary vein ablation for the management of paroxysmal atrial fibrillation. Because of recent reports of esophageal perforation with ablation at the posterior wall of the left atrium,1 the patient was given 30 mL of barium (Ezem Inc, Anjou, Quebec, Canada) to swallow before administration of general anesthesia, and a temperature monitor (Mallinkrodt Inc, St Louis, Mo) was positioned in the esophagus. Typical staining of endothelial folds of the esophagus was observed immediately after barium administration (Figure 1). After barium cleared from the esophagus and pooled in the stomach, reflux of the barium into the esophagus was observed (Figure 2), opacifying the entire esophageal lumen for the 5-hour duration of the procedure. Download figureDownload PowerPointFigure 1. Fluoroscopic image of barium in the esophagus (single asterisk) and stomach (double asterisk) immediately after oral administration. This image is typical of esophageal visualization with barium administration during pulmonary vein ablation.Download figureDownload PowerPointFigure 2. Subsequent fluoroscopy (left anterior oblique and right anterior oblique projections) after barium has cleared from the stomach and refluxed to opacify the entire esophageal lumen (asterisk). Note the considerably wider caliber of the esophagus in comparison to the previous figure, and the small portion of the lumen indicated by the filling defect surrounding the esophageal monitor (arrow).Pulmonary vein ablation has been increasingly recognized as an important and effective option for the management of atrial fibrillation. Esophageal perforation is a life-threatening complication of this procedure and has resulted in a widespread interest in defining the anatomic relationship between the left atrium and the esophagus.2–6 Real-time imaging of the esophagus during ablation has been achieved with barium and by observing the position of a temperature monitor placed in the esophagus. The latter also permits cessation of energy delivery if esophageal temperature rises.2,7 The reflux of barium in this case, which opacified the entire lumen of the esophagus, illustrates the limitations of usual anatomic imaging. The true width of the esophagus, which is at risk behind the left atrial wall, is considerably underrepresented by both the barium-stained endothelium and the narrow caliber of the esophageal probe. There are clearly regions of the esophagus that would appear safe for ablation but are, in fact, in apposition to the esophagus, as revealed by the barium reflux. Real-time imaging that reveals the true extent of the esophageal lumen, as demonstrated in this case, continues to be an elusive but important goal for catheter-based therapy of atrial fibrillation.DisclosuresNone.FootnotesCorrespondence to Dr Lorne J. Gula, London Health Sciences Centre, Arrhythmia Service, 339 Windermere Rd, London, Ontario, Canada N6A 5A5. E-mail [email protected]References1 Pappone C, Oral H, Santinelli V, Vicedomini G, Lang CC, Manguso F, Torracca L, Benussi S, Alfieri O, Hong R, Lau W, Hirata K, Shikuma N, Hall B, Morady F. Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation. 2004; 109: 2724–2726.LinkGoogle Scholar2 Cummings JE, Schweikert RA, Saliba WI, Burkhardt JD, Brachmann J, Gunther J, Schibgilla V, Verma A, Dery M, Drago JL, Kilicaslan F, Natale A. Assessment of temperature, proximity, and course of the esophagus during radiofrequency ablation within the left atrium. Circulation. 2005; 112: 459–464.LinkGoogle Scholar3 Cury RC, Abbara S, Schmidt S, Malchano ZJ, Neuzil P, Weichet J, Ferencik M, Hoffmann U, Ruskin JN, Brady TJ, Reddy VY. Relationship of the esophagus and aorta to the left atrium and pulmonary veins: implications for catheter ablation of atrial fibrillation. Heart Rhythm. 2005; 2: 1317–1323.CrossrefMedlineGoogle Scholar4 Lemola K, Sneider M, Desjardins B, Case I, Han J, Good E, Tamirisa K, Tsemo A, Chugh A, Bogun F, Pelosi F Jr, Kazerooni E, Morady F, Oral H. Computed tomographic analysis of the anatomy of the left atrium and the esophagus: implications for left atrial catheter ablation. Circulation. 2004; 110: 3655–3660.LinkGoogle Scholar5 Monnig G, Wessling J, Juergens KU, Milberg P, Ribbing M, Fischbach R, Wiekowski J, Breithardt G, Eckardt L. Further evidence of a close anatomical relation between the oesophagus and pulmonary veins. Europace. 2005; 7: 540–545.CrossrefMedlineGoogle Scholar6 Tsao HM, Wu MH, Higa S, Lee KT, Tai CT, Hsu NW, Chang CY, Chen SA. Anatomic relationship of the esophagus and left atrium: implication for catheter ablation of atrial fibrillation. Chest. 2005; 128: 2581–2587.CrossrefMedlineGoogle Scholar7 Redfearn DP, Trim GM, Skanes AC, Petrellis B, Krahn AD, Yee R, Klein GJ. Esophageal temperature monitoring during radiofrequency ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2005; 16: 589–593.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Buch E, Nakahara S and Shivkumar K (2008) Intra-pericardial balloon retraction of the left atrium: A novel method to prevent esophageal injury during catheter ablation, Heart Rhythm, 10.1016/j.hrthm.2008.06.023, 5:10, (1473-1475), Online publication date: 1-Oct-2008. August 8, 2006Vol 114, Issue 6 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.614735PMID: 16894042 Originally publishedAugust 8, 2006 PDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-DefibrillatorElectrophysiologyImaging