Endoscopic evaluation of the esophagus after catheter ablation of atrial fibrillation using contiguous and optimized radiofrequency applications

Background The incidence of endoscopically detected esophageal lesions after pulmonary vein isolation (PVI) is as high as 18%. Intraesophageal temperature rise (ITR) during ablation is a predictor of esophageal injury. Objective The purpose of this study was to describe an ablation strategy aiming to enclose the pulmonary veins with contiguous, stable, and optimized radiofrequency applications (referred to as CLOSE-PVI). We evaluated esophageal and periesophageal injury with endoscopy in patients revealing ITR during CLOSE-PVI. Methods Eighty-five patients with ITR during CLOSE-PVI underwent endoscopy of the esophagus (with ultrasound in 38 patients). PVI consisted of contact force (CF)-guided encircling of the veins using 35-W applications, respecting strict criteria of intertag distance (≤6 mm) and ablation index (AI; 550 arbitrary unit [au] anterior wall, 400 au posterior wall, 300 au if ITR >38.5°C). Results Endoscopy was performed 9 ± 4 days after PVI. At the posterior wall, median power was 35 W [interquartile range (IQR) 35–35], application time 18 ± 5 seconds, CF 13 ± 6g, and AI 403 ± 38 au. A median of 5 applications [IQR 4–7] per patient over a length of 21.8 ± 6.8 mm resulted in ITR >38.5°C (median 39.9°C, IQR 39.2°C–41.2°C, range 38.6°C–50.0°C). For these applications, median power was 35 W [IQR 30–35], application time 14 ± 3 seconds, CF 12 ± 5g, and AI 351 ± 38 au. The incidence of esophageal erythema/erosion on endoscopy was 1 of 85 (1.2%) and of ulceration was 0 of 85 (0%). The incidence of mediastinal or esophageal injury on ultrasound was 0 of 38 (0%). Conclusion The occurrence of esophageal or periesophageal injury after CLOSE-PVI is markedly low (1.2%). Absence of esophageal ulceration in patients with ITR suggests that this strategy of delivering contiguous, relatively high-power, and short-duration radiofrequency applications at the posterior wall is safe.