- Email: [email protected]
Global Survey of Esophageal and Gastric Injury in Atrial Fibrillation Ablation
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 65, NO. 13, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
Letters Global Survey of Esophageal and Gastric Injury in Atrial Fibrillation Ablation
6 to 59 days) (Figure 1). Of the 28 patients with esophageal perforation or fistula for whom detailed information
was
provided,
20
(71%)
had
an
atrial-esophageal fistula (AEF), 4 (14%) a pericardialesophageal fistula, and 4 (14%) esophageal perforation without fistula formation. Of these 28 patients, a significantly greater proportion of those who died
Incidence, Time to Presentation, and Outcomes
or had severe neurological injury ultimately received a diagnosis of AEF (94% vs. 36%; p ¼ 0.002). All patients with AEF who survived without severe neurological injury underwent thoracic surgery. Two
Catheter ablation of the left atrial (LA) posterior wall
patients (7%) in whom an AEF developed died after
may result in esophageal injury ranging from mild
AF ablation with a second-generation cryoballoon
erythema to ulceration and, in rare but devastating
procedure.
cases, esophageal perforation or fistula (1). In addi-
The
present
survey—the
largest
dataset
of
tion, vagus nerve damage can result in gastric hypo-
gastroesophageal injury in AF ablation to date—
motility and gastroparesis (2). There are limited data
demonstrates that gastroparesis, esophageal ulcer,
regarding the incidence and outcomes of these
and esophageal perforation occur in a bimodal
complications.
temporal
distribution
of
injury;
spontaneously
We circulated an online survey to the 3080 regis-
resolving injury presents primarily in the first
tered physician members of the Heart Rhythm
several days post-ablation, and more severe injury
Society, as well as all physicians who perform atrial
primarily after 10 days. Proposed mechanisms for
fibrillation (AF) ablation. We collected responses
esophageal injury include direct thermal injury,
between November 1, 2013 and June 1, 2014. Of the
which
3080 physicians who received the survey, 405
ischemic injury, which may account for later, more
responded (13%). In aggregate, 191,215 AF abla-
severe injury (3).
may
account
for
early
symptoms,
and
tions were performed by responding physicians, and
In a previous global survey of complications
esophageal perforation or fistula was reported in 31
related to AF ablation performed from 2003 to 2006,
patients (0.016%) by responding physicians 30 (7%).
Cappato et al. (4) reported a 0.04% rate of AEF. In a
Gastroparesis was reported in 63 patients by 47
national survey performed from 2004 to 2005 by
physicians. The mean postoperative day (POD) of
Ghia et al. (5), AEF occurred in 0.03% of patients in a
diagnosis was 5.7 5.8 days, and gastroparesis
cohort of 20,425. The incidence of esophageal
symptoms resolved completely in 59 patients (94%).
perforation without fistula formation and pericardial-
Patients in whom gastroparesis did not completely
esophageal fistula was not reported in either previous
resolve received the diagnosis at a significantly
survey. The 0.016% incidence of esophageal perfora-
later POD compared with patients whose symptoms
tion and 0.011% incidence of AEF in the present
resolved completely (15.3 6.2 vs. 5.0 5.2;
study are both significantly lower (p < 0.001) than the
p < 0.001) (Figure 1).
incidence of AEF reported in the previous surveys,
Esophageal ulcer was reported in 51 patients, of
and the total number of AF ablations performed by
whom 37 (73%) had complete resolution of ulcer
survey physicians is greater than in previous studies,
symptoms. Patients whose esophageal ulcer symp-
suggesting that the risk of esophageal perforation
toms did not completely resolve received the diag-
with AF ablation may now be lower than previously
nosis at a significantly later POD than patients with
reported.
complete symptom resolution (16.2 4.3 vs. 2.9 3.1; p < 0.001) (Figure 1).
Self-selection bias is a limitation of survey-based data. Physicians retrospectively reported all data,
Symptom onset for esophageal perforation or
and inaccurate responses due to poor recall were not
fistula was reported on POD 19.3 12.6 (range,
excluded. Given the observational nature of the
JACC VOL. 65, NO. 13, 2015
Letters
1378
APRIL 7, 2015:1377–84
F I G U R E 1 Time Course of Gastroesophageal Injury After Atrial Fibrillation Ablation
A
if patients do not report symptoms in the first few
Gastroparesis - Unresolved
days after ablation of the posterior LA wall.
40
Proportion of Patie
nts (%)
*Chirag R. Barbhaiya, MD Saurabh Kumar, BSc [Med]/MBBS, PhD Roy M. John, MD, PhD Usha B. Tedrow, MD, MSc Bruce A. Koplan, MD, MPH Laurence M. Epstein, MD William G. Stevenson, MD Gregory F. Michaud, MD
30 20 10
*Brigham and Women’s Hospital
>3 0
Day of D
Boston, Massachusetts 02115 26 –3 0
–2 5 21
erative
16
11 –1 5
Post-O p
–2 0
75 Francis Street
6– 10
1– 5
0
E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2014.12.053
iagnos
is
Esophageal Perforation
B
Esophageal Ulcer - Resolved Esophageal Ulcer - Unresolved
80 ts (%)
close postoperative follow-up after AF ablation, even
Gastroparesis - Resolved
50
Proportion of Patien
severe injury. Our data reinforce the importance of
70 60 50 40 30 20
Please note: Dr. Kumar is a recipient of the Neil Hamilton Fairley Overseas Research scholarship cofunded by the National Health and Medical Research Council and the National Heart Foundation of Australia; and the Bushell Travelling Fellowship funded by the Royal Australasian College of Physicians. Dr. Tedrow has received consulting fees/honoraria from Boston Scientific Corp. and St. Jude Medical; and research funding from Biosense Webster, Inc. and St. Jude Medical. Dr. John has received consulting fees/honoraria from St. Jude Medical, Medtronic, and Boston Scientific. Dr. Koplan is a consultant for St. Jude Medical and Boston Scientific. Dr. Epstein is a consultant and speaker for Boston Scientific Corp., Medtronic, Inc., and Spectranetics Corp. Dr. Michaud has received consulting fees/honoraria from Boston Scientific Corp., Medtronic, Inc., AtriCure, Inc., and St. Jude Medical; and research funding from Boston Scientific Corp., and Biosense Webster, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
REFERENCES
10 1. Bunch TJ, Nelson J, Foley T, et al. Temporary esophageal stenting allows
–2 5
>3 0
rative Day
26 –3 0
Post-Ope
21
–2 0
healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2006;17:435–9.
16
11 –1 5
6– 10
1– 5
0
of Diagnos
is
(A) Time course of gastroparesis diagnosis stratified by patients with spontaneous resolution of symptoms (n ¼ 59, red) and patients whose symptoms remain unresolved (n ¼ 4, blue). (B) Time course of esophageal injury diagnosis stratified by patients with
2. Shah D, Dumonceau JM, Burri H, et al. Acute pyloric spasm and gastric hypomotility: an extracardiac adverse effect of percutaneous radiofrequency ablation for atrial fibrillation. J Am Coll Cardiol 2005;46:327–30. 3. Vijayaraman P, Netrebko P, Geyfman V, Dandamudi G, Casey K, Ellenbogen KA. Esophageal fistula formation despite esophageal monitoring and low-power radiofrequency catheter ablation for atrial fibrillation. Circ Arrhythm Electrophysiol 2009;2:e31–3.
did not resolve spontaneously but did not have esophageal perforation (n ¼ 14, blue),
4. Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2010;3:32–8.
and patients in whom esophageal perforation developed (n ¼ 31, green).
5. Ghia KK, Chugh A, Good E, et al. A nationwide survey on the prevalence of
spontaneous resolution of ulcer symptoms (n ¼ 37, red), patients whose ulcer symptoms
atrioesophageal fistula after left atrial radiofrequency catheter ablation. J Interv Card Electrophysiol 2009;24:33–6.
study, it is impossible to determine causation versus correlation. We observed a bimodal temporal distribution of gastroesophageal injury after AF ablation, and all
Blunted Cardiomyocyte Remodeling Response in Exercise-Resistant Rats
gastroparesis and esophageal injury diagnosed in the first 5 days after ablation resolved spontaneously.
Increasing a subject’s aerobic exercise capacity with
Symptom onset of gastric and esophageal injury more
training decreases cardiovascular morbidity and mor-
than 5 days after AF ablation is concerning for more
tality. Of major concern is the key observation that
VOL. 65, NO. 13, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
Letters Global Survey of Esophageal and Gastric Injury in Atrial Fibrillation Ablation
6 to 59 days) (Figure 1). Of the 28 patients with esophageal perforation or fistula for whom detailed information
was
provided,
20
(71%)
had
an
atrial-esophageal fistula (AEF), 4 (14%) a pericardialesophageal fistula, and 4 (14%) esophageal perforation without fistula formation. Of these 28 patients, a significantly greater proportion of those who died
Incidence, Time to Presentation, and Outcomes
or had severe neurological injury ultimately received a diagnosis of AEF (94% vs. 36%; p ¼ 0.002). All patients with AEF who survived without severe neurological injury underwent thoracic surgery. Two
Catheter ablation of the left atrial (LA) posterior wall
patients (7%) in whom an AEF developed died after
may result in esophageal injury ranging from mild
AF ablation with a second-generation cryoballoon
erythema to ulceration and, in rare but devastating
procedure.
cases, esophageal perforation or fistula (1). In addi-
The
present
survey—the
largest
dataset
of
tion, vagus nerve damage can result in gastric hypo-
gastroesophageal injury in AF ablation to date—
motility and gastroparesis (2). There are limited data
demonstrates that gastroparesis, esophageal ulcer,
regarding the incidence and outcomes of these
and esophageal perforation occur in a bimodal
complications.
temporal
distribution
of
injury;
spontaneously
We circulated an online survey to the 3080 regis-
resolving injury presents primarily in the first
tered physician members of the Heart Rhythm
several days post-ablation, and more severe injury
Society, as well as all physicians who perform atrial
primarily after 10 days. Proposed mechanisms for
fibrillation (AF) ablation. We collected responses
esophageal injury include direct thermal injury,
between November 1, 2013 and June 1, 2014. Of the
which
3080 physicians who received the survey, 405
ischemic injury, which may account for later, more
responded (13%). In aggregate, 191,215 AF abla-
severe injury (3).
may
account
for
early
symptoms,
and
tions were performed by responding physicians, and
In a previous global survey of complications
esophageal perforation or fistula was reported in 31
related to AF ablation performed from 2003 to 2006,
patients (0.016%) by responding physicians 30 (7%).
Cappato et al. (4) reported a 0.04% rate of AEF. In a
Gastroparesis was reported in 63 patients by 47
national survey performed from 2004 to 2005 by
physicians. The mean postoperative day (POD) of
Ghia et al. (5), AEF occurred in 0.03% of patients in a
diagnosis was 5.7 5.8 days, and gastroparesis
cohort of 20,425. The incidence of esophageal
symptoms resolved completely in 59 patients (94%).
perforation without fistula formation and pericardial-
Patients in whom gastroparesis did not completely
esophageal fistula was not reported in either previous
resolve received the diagnosis at a significantly
survey. The 0.016% incidence of esophageal perfora-
later POD compared with patients whose symptoms
tion and 0.011% incidence of AEF in the present
resolved completely (15.3 6.2 vs. 5.0 5.2;
study are both significantly lower (p < 0.001) than the
p < 0.001) (Figure 1).
incidence of AEF reported in the previous surveys,
Esophageal ulcer was reported in 51 patients, of
and the total number of AF ablations performed by
whom 37 (73%) had complete resolution of ulcer
survey physicians is greater than in previous studies,
symptoms. Patients whose esophageal ulcer symp-
suggesting that the risk of esophageal perforation
toms did not completely resolve received the diag-
with AF ablation may now be lower than previously
nosis at a significantly later POD than patients with
reported.
complete symptom resolution (16.2 4.3 vs. 2.9 3.1; p < 0.001) (Figure 1).
Self-selection bias is a limitation of survey-based data. Physicians retrospectively reported all data,
Symptom onset for esophageal perforation or
and inaccurate responses due to poor recall were not
fistula was reported on POD 19.3 12.6 (range,
excluded. Given the observational nature of the
JACC VOL. 65, NO. 13, 2015
Letters
1378
APRIL 7, 2015:1377–84
F I G U R E 1 Time Course of Gastroesophageal Injury After Atrial Fibrillation Ablation
A
if patients do not report symptoms in the first few
Gastroparesis - Unresolved
days after ablation of the posterior LA wall.
40
Proportion of Patie
nts (%)
*Chirag R. Barbhaiya, MD Saurabh Kumar, BSc [Med]/MBBS, PhD Roy M. John, MD, PhD Usha B. Tedrow, MD, MSc Bruce A. Koplan, MD, MPH Laurence M. Epstein, MD William G. Stevenson, MD Gregory F. Michaud, MD
30 20 10
*Brigham and Women’s Hospital
>3 0
Day of D
Boston, Massachusetts 02115 26 –3 0
–2 5 21
erative
16
11 –1 5
Post-O p
–2 0
75 Francis Street
6– 10
1– 5
0
E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2014.12.053
iagnos
is
Esophageal Perforation
B
Esophageal Ulcer - Resolved Esophageal Ulcer - Unresolved
80 ts (%)
close postoperative follow-up after AF ablation, even
Gastroparesis - Resolved
50
Proportion of Patien
severe injury. Our data reinforce the importance of
70 60 50 40 30 20
Please note: Dr. Kumar is a recipient of the Neil Hamilton Fairley Overseas Research scholarship cofunded by the National Health and Medical Research Council and the National Heart Foundation of Australia; and the Bushell Travelling Fellowship funded by the Royal Australasian College of Physicians. Dr. Tedrow has received consulting fees/honoraria from Boston Scientific Corp. and St. Jude Medical; and research funding from Biosense Webster, Inc. and St. Jude Medical. Dr. John has received consulting fees/honoraria from St. Jude Medical, Medtronic, and Boston Scientific. Dr. Koplan is a consultant for St. Jude Medical and Boston Scientific. Dr. Epstein is a consultant and speaker for Boston Scientific Corp., Medtronic, Inc., and Spectranetics Corp. Dr. Michaud has received consulting fees/honoraria from Boston Scientific Corp., Medtronic, Inc., AtriCure, Inc., and St. Jude Medical; and research funding from Boston Scientific Corp., and Biosense Webster, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
REFERENCES
10 1. Bunch TJ, Nelson J, Foley T, et al. Temporary esophageal stenting allows
–2 5
>3 0
rative Day
26 –3 0
Post-Ope
21
–2 0
healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2006;17:435–9.
16
11 –1 5
6– 10
1– 5
0
of Diagnos
is
(A) Time course of gastroparesis diagnosis stratified by patients with spontaneous resolution of symptoms (n ¼ 59, red) and patients whose symptoms remain unresolved (n ¼ 4, blue). (B) Time course of esophageal injury diagnosis stratified by patients with
2. Shah D, Dumonceau JM, Burri H, et al. Acute pyloric spasm and gastric hypomotility: an extracardiac adverse effect of percutaneous radiofrequency ablation for atrial fibrillation. J Am Coll Cardiol 2005;46:327–30. 3. Vijayaraman P, Netrebko P, Geyfman V, Dandamudi G, Casey K, Ellenbogen KA. Esophageal fistula formation despite esophageal monitoring and low-power radiofrequency catheter ablation for atrial fibrillation. Circ Arrhythm Electrophysiol 2009;2:e31–3.
did not resolve spontaneously but did not have esophageal perforation (n ¼ 14, blue),
4. Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2010;3:32–8.
and patients in whom esophageal perforation developed (n ¼ 31, green).
5. Ghia KK, Chugh A, Good E, et al. A nationwide survey on the prevalence of
spontaneous resolution of ulcer symptoms (n ¼ 37, red), patients whose ulcer symptoms
atrioesophageal fistula after left atrial radiofrequency catheter ablation. J Interv Card Electrophysiol 2009;24:33–6.
study, it is impossible to determine causation versus correlation. We observed a bimodal temporal distribution of gastroesophageal injury after AF ablation, and all
Blunted Cardiomyocyte Remodeling Response in Exercise-Resistant Rats
gastroparesis and esophageal injury diagnosed in the first 5 days after ablation resolved spontaneously.
Increasing a subject’s aerobic exercise capacity with
Symptom onset of gastric and esophageal injury more
training decreases cardiovascular morbidity and mor-
than 5 days after AF ablation is concerning for more
tality. Of major concern is the key observation that