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During A-Fib Ablation Cooling Esophageal Reduces Injury

One of the very rare and dreaded complications of catheter ablation is Atrial Esophageal Fistula (1 case in 500 to 2,000+). Unlike most other ablation complications which are generally minor, temporary and easily resolved, a fistula can kill you!

Atrial Esophageal Fistula

How does this happen? The esophagus often lies just behind the posterior wall of the left atrium. During an ablation, heat from the RF (radio frequency) catheter applied to the back of the heart can damage the esophagus. (This can also happen during a Cryo ablation.)

If RF heat damages the esophagus, ulcer-like lesions form in the esophagus. In the 2-3 weeks following the ablation (post-ablation), gastric acids (reflux) can eat away at these lesions creating a fistula (hole) leading from the esophagus into the heart. Without major intervention, stomach contents can pass from the esophagus into the heart, leading to bloodstream infection (sepsis) and death.

Established strategies used to prevent esophageal injury include:

1. Reduce power applied to the vulnerable regions (Lesions with lower power may not always be effective.).

2. Monitor Esophageal temperature, stopping the ablation when temperature rises. (Note: This is a reactive approach of limited efficacy. By the time temperature rises, serious damage may have already been done to the esophagus.)

3. Deviate the esophagus during the ablation to bend it away from the area being ablated. (Can cause Esophageal trauma and involve difficulties in use. And requires procedural pauses for device manipulation.)

Cooling the Esophagus

“We know that most strategies (to prevent fistula) don’t work,” Says Dr. Mark Gallagher from St. George’s University Hospital in London, United Kingdom.

Illustration: Esophageal temperature management device

In an innovative and important research study reported at the 2020 AF Symposium, Dr. Mark Gallagher describes a cooling system used in the esophagus to prevent fistulas.

How does it work? In preparation for ablation of heart tissue, a 3-foot-long silicon soft tube is inserted into the patient’s esophagus. It’s connected to what is basically a refrigerator. Then whenever the EP (electrophysiologist) works near the esophagus, this closed loop system pumps cooled water (39.2 °F, 4 °C) down one loop of the tube, then back through another loop to the console. The EP controls the temperature.

Results of Using the Cooling System

A recent meta-analysis of esophageal cooling for the purpose of protecting the esophagus during RF ablation found a 61% reduction in high-grade lesion formulation in a total of 494 patients.

A recent randomized-controlled trial found a statistically significant 83% reduction in endoscopically identified lesions when using a dedicated cooling device compared to standard luminal esophageal temperature (LET) monitoring.

Another research study led by Dr. Marcela M. Montoya of Silico Science & Engineering S.A.S, Medellin, Colombia, found  “the rapidly growing use of esophageal cooling during ablation has resulted in the publication or presentation of data on thousands of patients. Well over 10,000 ablations have now been completed with no Atrioesophageal fistula (AEF) formation yet reported and only a single pericardio-esophageal injury is known to have occurred.” (Pericardio-esophageal injury is a rarer and less severe subset of fistula formation.)

These various research studies show that cooling the esophagus works and is a major advance in the ablation of A-Fib.

Update 5/8/23:
Attune Medical reports that over 25,000 cooling devices were used in ablation procedures without a reported atrioesophageal fistula, and only a single pericardio-esophageal fistula known.

Editor's Comments about Cecelia's A-Fib story

Editor’s Comments

Fistula Is a Major Emergency: A fistula is an all-hands-on-deck emergency involving not just the EP department but surgeons and many hospital staffers. A surgeon may have to perform emergency surgery to insert stents in the esophagus in order to close off the fistula, or the surgeon may have to cut out part of the damaged esophagus, which is particularly risky.
(I remember one EP describing how he and his staff were running down a hospital corridor with their fistula patient close to dying, in order to get the patient to an operating surgeon.).
Treating patients with a fistula is a huge expense and a nightmare for both EPs and hospital staff.
No More Threat of Fistula! Most fistula patients die. And for those who live through the emergency treatment, they are often compromised for life. But with the esophageal cooling system, patients and doctors may never again have to worry about the dreaded complication Atrial-Esophageal Fistula!
Cooling the Esophagus is a Major Medical Breakthrough! Cooling the esophagus is simple and relatively easy to do. And, barring future research findings, the system seems near foolproof, at least with typical ablation technique.
Esophageal Cooling Means Better Ablations:  And as a bonus, using the esophageal cooling system enables EPs to do a better job. They can ablate all areas of the heart rather than avoiding areas too close to the esophagus or using lower power with shorter duration or less contact force. And procedure time is reduced, resulting in fewer complications.

List of Hospitals and Medical Centers using Esophageal Cooling

To assist you in seeking facilities offering esophageal cooling during Catheter Ablation for Atrial Fibrillation, I’ve compiled a list from my reference sources
This list is not an endorsement of any center, and is only offered for your convenience. Refer to Steve’s Directory of Doctors and Facilities for more information about a specific medical center or hospital.

Go to Steve’s List of Hospitals and Medical Centers using Esophageal Cooling

References
• Zagrodzky, J. et al. Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation. Journal of Visualized Experiments, 3/15/2020. (157), e60733. https://www.jove.com/pdf/60733/jove-protocol-60733-cooling-or-warming-esophagus-to-reduce-esophageal-injury-during-left. DOI: doi:10.3791/60733.

• Leung LWM, Toor P, Akhtar Z, et al. Real-world results of oesophageal protection from a temperature control device during left atrial ablation [published online ahead of print, 2023 Apr 25]. Europace. 2023;euad099. doi:10.1093/europace/euad099

• Montoya, M. M. et al. Proactive esophageal cooling protects against thermal insults during high-power short-duration radiofrequency cardiac ablation. Int J Hyperthermia. 2022;39(1): 1202-1212. https://pubmed.ncbi.nlm.nih.gov/36104029/ DOI: 10.1080/02656736.2022.2121860

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