How to prevent atrial-oesophageal fistula following ablation of atrial fibrillation: are there actually any effective methods?

How to prevent atrial-oesophageal fistula following ablation of atrial fibrillation: are there... 562 Letters to the Editor grant from the Netherlands Organization for patients and multiple sensors in two patients). *Corresponding author. Tel: þ39 050 993043; Scientific Research (Veni Grant 016.136.055). This finding is disappointing, although it could be fax: þ39 050 992352. E-mail address: g.zucchelli@ speculated that many other AEF cases may have ao-pisa.toscana.it emerged without this monitoring. What hap- References 1. Abbasi A. Urine albumin excretion and the risk of inci- pened to patient number 3 is difficult to under- dent atrial fibrillation: predictive or aetiological rele- stand because the region where the oesophageal vance? Europace 2018;20:547. temperature increased does not correspond to 2. Marcos EG, Geelhoed B, Van Der Harst P, Bakker SJL, doi:10.1093/europace/eux224 the left atrium region where the AEF formed. Gansevoort RT, Hillege HL et al. Relation of renal Published online 10 August 2017 Hence, oesophageal temperature monitoring, es- dysfunction with incident atrial fibrillation and cardiovascular morbidity and mortality: the PREVEND pecially in patients under general anaesthesia, is How to prevent atrial study. Europace 2017;19:1930–6. not enough to prevent AEF, and even though an 3. Chatterjee NA, Giulianini F, Geelhoed B, Lunetta KL, oesophageal fistula following association between oesophageal temperature Misialek JR, Niemeijer MN et al. Genetic obesity ablation of atrial fibrillation: monitoring and reduced oesophageal injury dur- and the risk of atrial fibrillation: causal estimates from Mendelian randomization. Circulation 2017;135: ing AF ablation has been shown in some studies, a are there actually any effective 741–54. net clinical benefit using either a single sensor or a methods?—Authors’ reply 4. Van Gelder IC, Hobbelt AH, Marcos EG, Schotten U, multisensor probe is not clearly demonstrated. Cappato R, Lewalter T et al. Tailored treatment strat- Additionally, we note that all the AEF cases egies: a new approach for modern management of We would like to thank Dr Giulio Zucchelli and atrial fibrillation. J Intern Med 2016;279:457–66. occurred in general anaesthesia, thus supporting 1 colleagues for their letter regarding our recent the suggestion that one of the best measures to report, which highlighted atrial oesophageal fistula prevent this complication would be to perform (AEF), a severe complication of atrial fibrillation Anne H. Hobbelt, Pim Van Der Harst, AF ablation in conscious sedation. What we do (AF) catheter ablation, and presenting very high- and Michiel Rienstra* not know from this article is the percentage 2 mortality rate in that population. Department of Cardiology, University of of general anaesthesia in their AF ablation Atrial oesophageal fistula is a well-known dan- Groningen, University Medical Center Groningen, procedures. gerous complication following AF ablation that Hanzeplein 1, 9713 GZ Groningen, The Secondly, it is quite unusual to encounter the has been recognized since pulmonary vein (PV) Netherlands use of 8-mm catheters for AF ablation and, fur- isolation strategy changed from ostial to antral ab- * Corresponding author. Tel: þ31 50 3612355; thermore, the authors documented that 3 of 10 lation. Our report stressed that the risk for AEF fax þ31 50 3614391. E-mail address: AEF cases were associated with this technology. still persists, despite the important technological m.rienstra@umcg.nl Were those cases from the same centre? What improvement and impressive worldwide growth was the percentage of 8-mm catheter use in the of PV isolation in the last years. Brazilian centres participating in this survey? Also, Initially, it seemed that recognizing the problem in two cases where AEF occurred after radiofre- and using simple strategies, as reducing radiofre- doi:10.1093/europace/eux181 quency ablation with an irrigated tip with contact quency (RF) power when ablating on the poster- Published online 12 June 2017 force sensing technology, it would be of great ior left atrial wall, or limiting RF power based on interest to have further information regarding the the intra-oesophageal temperature monitoring How to prevent atrial- type of roving catheter (i.e. TactiCath or with specific temperature probes, could prevent oesophageal fistula following SmartTouch), the average force or force time in- new cases. ablation of atrial fibrillation: tegral used, and whether the operators reduced Unfortunately, our report demonstrated that their target parameters in the posterior wall. are there actually any effective the risk of AEF persists along the years despite In conclusion, given the high-mortality rate of methods? several oesophageal protections attempts as we AEF complication due to its difficult and delayed have described. Interestingly, a recent report also diagnosis, the best way to reduce it remains a sub- We read with great interest the article by detected an increasing risk of AEF that was corre- 1 ject of interesting debate and research. Despite Medeiros De Vasconcelos et al. recently published lated to new technology introduction to obtain a only poor and divergent data being available at 3 in the journal. The authors presented a series of more efficient PV isolation. present, we believe that all the preventive meas- atrial-oesophageal fistula (AEF) cases between The first underlined comment by our colleague ures detailed in the article should be taken into 2003 and2015ineight centresinBrazil. Tencases was the occurrence of AEF in 8 out of 10 patients, account. (0.113%) of AEF were reported in 8863 ablations, despite monitoring the oesophageal temperature and 8 of the 10 recruiting centres were referral during RF delivery on the left atrium (LA) poster- units for atrial fibrillation (AF) ablation and had per- References ior wall. It is import to clarify that all the oesopha- 1. Medeiros D, Vasconcelos JT, Filho SD, Atie ´ J, Maciel formed more than 200 procedures at the time of geal thermometers used in the reported cases, W, D, Souza OF et al. Atrial oesophageal fistula follow- AEF occurrence. The level of mortality was ex- even with multiple sensors, were mounted in a lin- ing percutaneous radiofrequency catheter ablation of tremely high (70%) regardless of the treatment ear probe. That is a known limitation of these de- atrial fibrillation: the risk still persists. Europace given (surgical in 60% of patients, stenting in one pa- vices, since the temperature probe position can 2017;19:250–8. 2. Tschabrunn CM, Silverstein J, Berzin T, Ellis E, Buxton tient), and only one patient was cured without miss the real temperature monitoring in the AE, Josephson ME et al. Comparison between single 4 neurological sequelae. Of note, the incidence of contralateral oesophageal wall. It can explain the and multi-sensor oesophageal temperature probes AEF was particularly high at the beginning of the AF case #3, in which apparently the oesophagus during atrial fibrillation ablation: thermodynamic char- ablation programme (1%; 2003–2004), reducing to probe was close to the right inferior pulmonary acteristics. Europace 2015;17:891–7. a more acceptable level of 0.1% between 2005 and vein and the AEF occurred in the left inferior pul- 2013, before rising to 0.23% at the end of the pro- monary vein. gramme (2014–2015). Giulio Zucchelli*, Andrea Di Cori, We cannot speculate the risk of patients We think that some points in the aforemen- Luca Segreti and undergoing RF catheter ablation without tioned article merit comment. First, AEF Maria Grazia Bongiorni oesophageal temperature monitoring, since all Cardiac Vascular and Thoracic Department, via occurred in 8 patients subjected to oesophageal groups involved in that report have used this Paradisa 2 - 56100, Pisa, Italy temperature monitoring (a single sensor in 6 strategy in their patients. In addition, all patients Downloaded from https://academic.oup.com/europace/article-abstract/20/3/562/3866778 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Europace Oxford University Press

How to prevent atrial-oesophageal fistula following ablation of atrial fibrillation: are there actually any effective methods?

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Abstract

562 Letters to the Editor grant from the Netherlands Organization for patients and multiple sensors in two patients). *Corresponding author. Tel: þ39 050 993043; Scientific Research (Veni Grant 016.136.055). This finding is disappointing, although it could be fax: þ39 050 992352. E-mail address: g.zucchelli@ speculated that many other AEF cases may have ao-pisa.toscana.it emerged without this monitoring. What hap- References 1. Abbasi A. Urine albumin excretion and the risk of inci- pened to patient number 3 is difficult to under- dent atrial fibrillation: predictive or aetiological rele- stand because the region where the oesophageal vance? Europace 2018;20:547. temperature increased does not correspond to 2. Marcos EG, Geelhoed B, Van Der Harst P, Bakker SJL, doi:10.1093/europace/eux224 the left atrium region where the AEF formed. Gansevoort RT, Hillege HL et al. Relation of renal Published online 10 August 2017 Hence, oesophageal temperature monitoring, es- dysfunction with incident atrial fibrillation and cardiovascular morbidity and mortality: the PREVEND pecially in patients under general anaesthesia, is How to prevent atrial study. Europace 2017;19:1930–6. not enough to prevent AEF, and even though an 3. Chatterjee NA, Giulianini F, Geelhoed B, Lunetta KL, oesophageal fistula following association between oesophageal temperature Misialek JR, Niemeijer MN et al. Genetic obesity ablation of atrial fibrillation: monitoring and reduced oesophageal injury dur- and the risk of atrial fibrillation: causal estimates from Mendelian randomization. Circulation 2017;135: ing AF ablation has been shown in some studies, a are there actually any effective 741–54. net clinical benefit using either a single sensor or a methods?—Authors’ reply 4. Van Gelder IC, Hobbelt AH, Marcos EG, Schotten U, multisensor probe is not clearly demonstrated. Cappato R, Lewalter T et al. Tailored treatment strat- Additionally, we note that all the AEF cases egies: a new approach for modern management of We would like to thank Dr Giulio Zucchelli and atrial fibrillation. J Intern Med 2016;279:457–66. occurred in general anaesthesia, thus supporting 1 colleagues for their letter regarding our recent the suggestion that one of the best measures to report, which highlighted atrial oesophageal fistula prevent this complication would be to perform (AEF), a severe complication of atrial fibrillation Anne H. Hobbelt, Pim Van Der Harst, AF ablation in conscious sedation. What we do (AF) catheter ablation, and presenting very high- and Michiel Rienstra* not know from this article is the percentage 2 mortality rate in that population. Department of Cardiology, University of of general anaesthesia in their AF ablation Atrial oesophageal fistula is a well-known dan- Groningen, University Medical Center Groningen, procedures. gerous complication following AF ablation that Hanzeplein 1, 9713 GZ Groningen, The Secondly, it is quite unusual to encounter the has been recognized since pulmonary vein (PV) Netherlands use of 8-mm catheters for AF ablation and, fur- isolation strategy changed from ostial to antral ab- * Corresponding author. Tel: þ31 50 3612355; thermore, the authors documented that 3 of 10 lation. Our report stressed that the risk for AEF fax þ31 50 3614391. E-mail address: AEF cases were associated with this technology. still persists, despite the important technological m.rienstra@umcg.nl Were those cases from the same centre? What improvement and impressive worldwide growth was the percentage of 8-mm catheter use in the of PV isolation in the last years. Brazilian centres participating in this survey? Also, Initially, it seemed that recognizing the problem in two cases where AEF occurred after radiofre- and using simple strategies, as reducing radiofre- doi:10.1093/europace/eux181 quency ablation with an irrigated tip with contact quency (RF) power when ablating on the poster- Published online 12 June 2017 force sensing technology, it would be of great ior left atrial wall, or limiting RF power based on interest to have further information regarding the the intra-oesophageal temperature monitoring How to prevent atrial- type of roving catheter (i.e. TactiCath or with specific temperature probes, could prevent oesophageal fistula following SmartTouch), the average force or force time in- new cases. ablation of atrial fibrillation: tegral used, and whether the operators reduced Unfortunately, our report demonstrated that their target parameters in the posterior wall. are there actually any effective the risk of AEF persists along the years despite In conclusion, given the high-mortality rate of methods? several oesophageal protections attempts as we AEF complication due to its difficult and delayed have described. Interestingly, a recent report also diagnosis, the best way to reduce it remains a sub- We read with great interest the article by detected an increasing risk of AEF that was corre- 1 ject of interesting debate and research. Despite Medeiros De Vasconcelos et al. recently published lated to new technology introduction to obtain a only poor and divergent data being available at 3 in the journal. The authors presented a series of more efficient PV isolation. present, we believe that all the preventive meas- atrial-oesophageal fistula (AEF) cases between The first underlined comment by our colleague ures detailed in the article should be taken into 2003 and2015ineight centresinBrazil. Tencases was the occurrence of AEF in 8 out of 10 patients, account. (0.113%) of AEF were reported in 8863 ablations, despite monitoring the oesophageal temperature and 8 of the 10 recruiting centres were referral during RF delivery on the left atrium (LA) poster- units for atrial fibrillation (AF) ablation and had per- References ior wall. It is import to clarify that all the oesopha- 1. Medeiros D, Vasconcelos JT, Filho SD, Atie ´ J, Maciel formed more than 200 procedures at the time of geal thermometers used in the reported cases, W, D, Souza OF et al. Atrial oesophageal fistula follow- AEF occurrence. The level of mortality was ex- even with multiple sensors, were mounted in a lin- ing percutaneous radiofrequency catheter ablation of tremely high (70%) regardless of the treatment ear probe. That is a known limitation of these de- atrial fibrillation: the risk still persists. Europace given (surgical in 60% of patients, stenting in one pa- vices, since the temperature probe position can 2017;19:250–8. 2. Tschabrunn CM, Silverstein J, Berzin T, Ellis E, Buxton tient), and only one patient was cured without miss the real temperature monitoring in the AE, Josephson ME et al. Comparison between single 4 neurological sequelae. Of note, the incidence of contralateral oesophageal wall. It can explain the and multi-sensor oesophageal temperature probes AEF was particularly high at the beginning of the AF case #3, in which apparently the oesophagus during atrial fibrillation ablation: thermodynamic char- ablation programme (1%; 2003–2004), reducing to probe was close to the right inferior pulmonary acteristics. Europace 2015;17:891–7. a more acceptable level of 0.1% between 2005 and vein and the AEF occurred in the left inferior pul- 2013, before rising to 0.23% at the end of the pro- monary vein. gramme (2014–2015). Giulio Zucchelli*, Andrea Di Cori, We cannot speculate the risk of patients We think that some points in the aforemen- Luca Segreti and undergoing RF catheter ablation without tioned article merit comment. First, AEF Maria Grazia Bongiorni oesophageal temperature monitoring, since all Cardiac Vascular and Thoracic Department, via occurred in 8 patients subjected to oesophageal groups involved in that report have used this Paradisa 2 - 56100, Pisa, Italy temperature monitoring (a single sensor in 6 strategy in their patients. In addition, all patients Downloaded from https://academic.oup.com/europace/article-abstract/20/3/562/3866778 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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EuropaceOxford University Press

Published: Mar 1, 2018

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