Ischemic Esophageal Ulceration That Developed After an Early Endoscopic Surveillance in a Patient Receiving Catheter Ablation for Atrial Fibrillation
2013; Lippincott Williams & Wilkins; Volume: 127; Issue: 21 Linguagem: Inglês
10.1161/circulationaha.112.000976
ISSN1524-4539
AutoresHiro Yamasaki, Takashi Kaneshiro, Yukio Sekiguchi, Hiroshi Tada, Kazutaka Aonuma,
Tópico(s)Eosinophilic Esophagitis
ResumoHomeCirculationVol. 127, No. 21Ischemic Esophageal Ulceration That Developed After an Early Endoscopic Surveillance in a Patient Receiving Catheter Ablation for Atrial Fibrillation Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBIschemic Esophageal Ulceration That Developed After an Early Endoscopic Surveillance in a Patient Receiving Catheter Ablation for Atrial Fibrillation Hiro Yamasaki, MD, Takashi Kaneshiro, MD, Yukio Sekiguchi, MD, Hiroshi Tada, MD and Kazutaka Aonuma, MD Hiro YamasakiHiro Yamasaki From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan. , Takashi KaneshiroTakashi Kaneshiro From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan. , Yukio SekiguchiYukio Sekiguchi From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan. , Hiroshi TadaHiroshi Tada From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan. and Kazutaka AonumaKazutaka Aonuma From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan. Originally published28 May 2013https://doi.org/10.1161/CIRCULATIONAHA.112.000976Circulation. 2013;127:e635–e636An atrioesophageal fistula is a rare but lethal complication that develops a week to several weeks after the pulmonary vein isolation for atrial fibrillation.1 Because the thermal injury resulting from radiofrequency energy application peaks within a few days,2 the ischemic or gastric reflux injury that progresses during the following weeks was assumed to play a pivotal role in the delayed development of this complication.1 However, no report has ever precisely described the nature of the ischemic injury. Here, we report a case of an esophageal ulceration that developed after an early endoscopic surveillance that was assumed to be the result of the ischemic injury observed in patients receiving extensive pulmonary vein isolation for atrial fibrillation.A 55-year-old man with a symptomatic paroxysmal atrial fibrillation underwent extensive pulmonary vein isolation under conscious sedation. After a simultaneous pulmonary vein angiogram and esophagogram (Figure 1A), the extensive pulmonary vein isolation was carried out with an open-irrigation-tip catheter (ThermoCool, Biosense, Webster, Diamond Bar, CA). A maximum of 15 to 20 W with a duration of 20 to 30 seconds was delivered on the left atrial posterior wall (Figure 1B), and 50-second intervals were used to avoid temperature stacking.3 The extensive pulmonary vein isolation was accomplished uneventfully, and a prophylactic proton pump inhibitor was initiated from the day of the procedure. On postablation day (PAD) 1, bloating of the stomach appeared, and periesophageal nerve injury was suspected. On PAD 4, an endoscopy was scheduled to exclude the possibility of an esophageal ulceration. The stomach was filled with retained food as a result of the periesophageal nerve injury (Figure 1C), but neither an esophageal ulceration nor reflux esophagitis was present (Figure 1D and 1E). Because a gastric cancer-like lesion was detected (Figure 1C), the endoscopy was rescheduled on PAD 14. The cancer-like lesion resolved, but the development of an esophageal ulceration was detected in the anterior portion of the esophagus (Figure 2A). Because no progression of the gastric reflux injury was observed with the proton pump inhibitor (Figure 2B), ischemic injury was suspected as the mechanism. After another 14 days (PAD 28) without any signs of fever or chest discomfort, an endoscopy was performed with careful CO2 insufflation (Figure 2C). The esophageal ulceration improved, and the patient was discharged with a proton pump inhibitor. The scar resolved gradually and was still visible by PAD 55 (Figure 2D).Download figureDownload PowerPointFigure 1. A, An esophagogram simultaneously performed with a pulmonary vein angiogram in the anterior-posterior projection revealed a broad esophagus located just adjacent to the ostium of the left pulmonary vein. B, Electroanatomic mapping of the left atrium in the posterior-anterior projection. The yellow tags represent the ablation sites where the patient complained of chest pain, and the energy application was immediately terminated. C, Endoscopy performed on postablation day 5. Gastric hypomotility caused by periesophageal nerve injury was observed, and a massive amount of retained food was found despite an overnight period of fasting. A cancer-like lesion was detected at the gastric angle (black arrowheads). D, A small amount of the retained food refluxed into the esophagus (white arrows), but no thermal esophageal injury was detected. E, At the gastroesophageal junction, only Candida esophagitis was detected, but no gastric reflux injury was detected even in the presence of periesophageal injury.Download figureDownload PowerPointFigure 2. A-1, Endoscopy performed on postablation day (PAD) 14. An esophageal ulceration (white arrowheads) was found at the anterior aspect of the esophagus just behind the left atrium. A-2, The contour of the esophageal ulceration (white arrowheads) is clearly visualized with the use of indigo carmine dye. A-3, No progression of the gastric reflux injury was detected under the use of a proton pump inhibitor. B, Endoscopy performed on PAD 30. The esophageal ulceration transformed into a scar lesion (white arrowheads). C, Endoscopy performed on PAD 58. Gradual improvement in the esophageal ulceration was detected, but the scar was still visible.To the best of our knowledge, this is the first clinical case report to describe the nature of the ischemic injury associated with an esophageal ulceration. The specific features of this injury were both the delayed development and the delayed healing resulting from the compromised blood flow. Many previous studies have described the prevalence in or characteristics of patients with thermal injury detected by early endoscopic surveillance, but the nature of the ischemic injury remained unknown. This case reminds us that early endoscopic surveillance performed within a few days after the extensive pulmonary vein isolation could miss the development of the ischemic injury. Our observation strongly supports the 2-hit phenomenon hypothesis as a mechanism of an atrioesophageal fistula formation.3 When the thermal injury was accompanied by ischemic injury, the recovery of the lesion volume due to thermal injury became delayed and lesion volume became even greater during the several weeks that followed, leading to an atrioesophageal fistula formation. A gastric reflux injury had been proposed as another mechanism of a delayed atrioesophageal fistula formation.4 However, the prophylactic use of a proton pump inhibitor in our case had prevented the development of gastric reflux injury even in the presence of periesophageal nerve injury. Therefore, ischemic injury was assumed to be the key pathogenesis of the atrioesophageal fistula formation.DisclosuresNone.FootnotesCorrespondence to Hiro Yamasaki, MD, Cardiovascular Division, Faculty of Medicine, University of Tsukuba 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan. E-mail [email protected]References1. Liu E, Shehata M, Liu T, Amorn A, Cingolani E, Kannarkat V, Chugh SS, Wang X. Prevention of esophageal thermal injury during radiofrequency ablation for atrial fibrillation.J Interv Card Electrophysiol. 2012; 35:35–44.CrossrefMedlineGoogle Scholar2. Ripley KL, Gage AA, Olsen DB, Van Vleet JF, Lau CP, Tse HF. Time course of esophageal lesions after catheter ablation with cryothermal and radiofrequency ablation: implication for atrio-esophageal fistula formation after catheter ablation for atrial fibrillation.J Cardiovasc Electrophysiol. 2007; 18:642–646.CrossrefMedlineGoogle Scholar3. Bahnson TD. Strategies to minimize the risk of esophageal injury during catheter ablation for atrial fibrillation.Pacing Clin Electrophysiol. 2009; 32:248–260.CrossrefMedlineGoogle Scholar4. Yokoyama K, Nakagawa H, Seres KA, Jung E, Merino J, Zou Y, Ikeda A, Pitha JV, Lazzara R, Jackman WM. Canine model of esophageal injury and atrial-esophageal fistula after applications of forward-firing high-intensity focused ultrasound and side-firing unfocused ultrasound in the left atrium and inside the pulmonary vein.Circ Arrhythm Electrophysiol. 2009; 2:41–49.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Grosse Meininghaus D, Freund R, Kleemann T and Christoph Geller J (2022) Calculated parameters of luminal esophageal temperatures predict esophageal injury following conventional and high‐power short‐duration radiofrequency pulmonary vein isolation, Journal of Cardiovascular Electrophysiology, 10.1111/jce.15509, 33:6, (1167-1176), Online publication date: 1-Jun-2022. Ayoub T, El Hajjar A, Singh Sidhu G, Bhatnagar A, Zhang Y, Mekhael M, Noujaim C, Dagher L, Pottle C and Marrouche N (2021) Esophageal temperature during atrial fibrillation ablation poorly predicts esophageal injury: An observational study, Heart Rhythm O2, 10.1016/j.hroo.2021.11.002, 2:6, (570-577), Online publication date: 1-Dec-2021. Kaneshiro T, Kamioka M, Hijioka N, Yamada S, Yokokawa T, Misaka T, Hikichi T, Yoshihisa A and Takeishi Y (2020) Characteristics of Esophageal Injury in Ablation of Atrial Fibrillation Using a High-Power Short-Duration Setting, Circulation: Arrhythmia and Electrophysiology, 13:10, (e008602), Online publication date: 1-Oct-2020. Tajima H, Narasaka T, Akutsu D, Suzuki H, Matsui H, Maruo K, Yamasaki H and Mizokami Y (2020) The Risks of Exfoliative Esophagitis in Patients with Atrial Fibrillation, Medicine, 10.1097/MD.0000000000021681, 99:33, (e21681) Kuck K, Böcker D, Chun J, Deneke T, Hindricks G, Hoffmann E, Piorkowski C and Willems S (2017) Qualitätskriterien zur Durchführung der Katheterablation von VorhofflimmernQuality criteria for performing catheter ablation of atrial fibrillation, Der Kardiologe, 10.1007/s12181-017-0146-0, 11:3, (161-182), Online publication date: 1-Jun-2017. May 28, 2013Vol 127, Issue 21 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.112.000976PMID: 23716384 Originally publishedMay 28, 2013 PDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-Defibrillator
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