Case Study Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(9) 1116–1118 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313504767 aan.sagepub.com
Esophageal perforation after radiofrequency ablation for atrial fibrillation Namdar Manouchehri1, Simon R Turner1, Evan Lockwood2, Laurence D Sterns3 and Eric LR Be´dard1
Abstract A 69-year-old man underwent left atrial radiofrequency ablation for atrial fibrillation. After 10 minutes, the procedure was terminated due to pericardial tamponade secondary to perforation during mapping. Pericardiocentesis resolved the tamponade. Ablation was completed one week later, and the patient was discharged. Two days later, he presented with odynophagia. Computed tomography demonstrated small bilateral pleural effusions. He was judged to be stable and was discharged again, but returned 2 days later with chest pain. He was found to have esophageal perforation with empyema, which was repaired using a muscle patch and esophageal stenting, successfully treating the lesion with minimal morbidity.
Keywords Atrial Fibrillation, Catheter ablation, Empyema, pleural, Esophageal perforation
Introduction Radiofrequency ablation (RFA) is increasingly used to treat atrial fibrillation. Given the proximity of the esophagus to the left atrium, thermal injury and perforation may occur, a potentially fatal complication. Patients present with fever, odynophagia, chest pain, or leukocytosis. There is scant literature on treating ablation-related esophageal perforation. Previous reports have described esophagectomy and exclusion.1–3
Case report A 69-year-old man underwent left atrial RFA for treatment of atrial fibrillation. The procedure was performed using a NavX 3-dimensonal mapping system and a dual transseptal approach (Figure 1). The procedure was terminated after 10 minutes of RFA around the left inferior pulmonary vein, due to the development of pericardial tamponade secondary to perforation during mapping. Bright blood (350 mL) was drained by pericardiocentesis, resolving the tamponade. Ablation was repeated one week later, delivered over 24.45 minutes with a maximum of 30 W on the lateral
wall and septum and 25 W on the posterior wall. Thirty seconds of RFA followed by 30 seconds of cooling was used to prevent esophageal heating. Esophageal temperature was not monitored. Each vein was isolated with encircling lesions, enclosing each ipsilateral pair as a unit. No linear lesions or additional substrate ablation was performed. The patient was discharged the following day on a proton pump inhibitor and dabigatran. Two days later, he presented to the emergency room with odynophagia. Chest computed tomography demonstrated small bilateral pleural effusions. He was judged to be stable and was discharged home. Two days later, he presented to our institution with pleuritic right-sided chest pain. He was afebrile with normal hemodynamics, but he had leukocytosis (white blood 1 Department of Surgery, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada 2 Department of Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada 3 Department of Medicine, Royal Jubilee Hospital, Victoria, Canada
Corresponding author: Eric Be´dard, MD, 416 Community Services Center, 10240 Kingsway Ave., Edmonton AB, T5H 3V9, Canada. Email: [email protected]
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Figure 3. Esophagogram showing perforation into the right hemithorax. Figure 1. Three-dimensional map for atrial ablation (ablation points are marked by arrows).
The posterior mediastinum was very fibrotic with significant scarring already occurring between the esophagus, pericardium, and pulmonary veins. The perforation was identified and patched using a vascularized intercostal muscle flap. The pleura was drained with 3 thoracostomy tubes. Due to the widespread thermal injury and concerns of poor healing despite the muscle patch on the esophagus, a Polyflex stent was inserted endoscopically the following day. An esophagogram 2 days later revealed proper stent position and no contrast extravasation. The patient’s leukocytosis improved and the stent was removed 17 days postinsertion. A repeat esophagogram documented no leak and the drains were removed. He was discharged on a 6-week course of intravenous antibiotics.
Discussion Figure 2. Computed tomography scan demonstrating right empyema.
cell count 19.4 109 L 1). Computed tomography revealed changes consistent with a right-sided empyema (Figure 2). Soft tissue abnormalities were seen in the posterior mediastinum although no oral contrast was administered. The patient was admitted to the Thoracic Surgery Service, but decortication was delayed due to hypocoagulability from dabigatran. The next day, he developed high fevers. Esophagography demonstrated perforation with contrast extravasation into the right hemithorax (Figure 3). Flexible endoscopy at the time of the operation had confirmed a perforation at 34 cm. A right thoracotomy was undertaken, and decortication and mediastinal debridement were performed.
Esophageal thermal injury is a complication of atrial RFA described in a small number of reported cases. Whereas historically, treatment has focused on esophageal resection or diversion, the morbidity of emergency esophageal surgery in the setting of mediastinitis mandates the consideration of alternatives. We believe this is the first report describing the management of esophageal perforation with empyema secondary to left atrial RFA. The combination of open drainage with stenting of the esophagus adds to the previous experience of Bunch and colleagues4 who initially described the use of stenting for less complex RFA perforations, as well as the growing trend of stent use for esophageal perforations in general. This case demonstrates a successful approach to the treatment of a frequently fatal complication, without the morbidity often associated with esophageal resection or diversion.
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Asian Cardiovascular & Thoracic Annals 22(9)
The finding of odynophagia after RFA of the left atrium should necessitate contrast esophagography or oral contrast computed tomography. Early intervention is fundamental in controlling sepsis. The management of pleural sepsis in this case focused on wide drainage and avoidance of direct surgical intervention on the esophagus, because previous cases demonstrated significant mortality due to esophageal surgery following RFA-related injuries. Individual adjustment of ablation lines and improved esophageal monitoring may reduce inadvertent injury,5,6 as may transesophageal echocardiography, nasoenteric feeding tubes, and bipolar diathermy.7,8 Any evidence of esophageal bleeding may indicate an atrioesophageal fistula, and flexible esophagoscopy should be avoided in this setting, given the risk of massive air embolism, precluding the use of a stent. This case has prompted changes in the management of RFA patients in our center. Patients are given a letter for emergency physicians, should they present within 6 weeks. Each emergency room in the city has also been alerted to the potential complications that may arise from RFA, including esophageal injury. This case also prompted patient safety discussions at the national level, leading the Canadian Heart Rhythm Society to create a working group to develop guidelines. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
References 1. Gillinov AM, Pettersson G and Rice TW. Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg 2001; 122: 1239–1240. 2. Doll N, Borger MA, Fabricius A, et al. Esophageal perforation during left atrial radiofrequency ablation: is the risk too high? J Thorac Cardiovasc Surg 2003; 125: 836–842. 3. Dagres N, Kottkamp H, Piorkowski C, et al. Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: lessons from five cases. J Cardiovasc Electrophysiol 2006; 17: 1213–1215. 4. Bunch TJ, Nelson J, Foley T, et al. Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2006; 17: 435–439. 5. Kottkamp H, Piorkowski C, Tanner H, et al. Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation. J Cardiovasc Electrophysiol 2005; 16: 146–150. 6. Cummings JE, Schweikert RA, Saliba WI, et al. Assessment of temperature, proximity and course of the esophagus during radiofrequency ablation within the left atrium. Circulation 2005; 112: 459–464. 7. Hall B, Shah A, Huang D, Rosero S and Daubert J. Visualization of the esophagus during catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2005; 13: 135–137. 8. Herweg B, Johnson N, Postler G, Curtis AB, Barold SS and Ilercil A. Mechanical esophageal deflection during ablation of atrial fibrillation. Pacing Clin Electrophysiol 2006; 29: 957–961.
Conflict of interest statement None declared.
Downloaded from aan.sagepub.com by guest on November 14, 2015
Esophageal perforation after radiofrequency ablation for atrial fibrillation Namdar Manouchehri1, Simon R Turner1, Evan Lockwood2, Laurence D Sterns3 and Eric LR Be´dard1
Abstract A 69-year-old man underwent left atrial radiofrequency ablation for atrial fibrillation. After 10 minutes, the procedure was terminated due to pericardial tamponade secondary to perforation during mapping. Pericardiocentesis resolved the tamponade. Ablation was completed one week later, and the patient was discharged. Two days later, he presented with odynophagia. Computed tomography demonstrated small bilateral pleural effusions. He was judged to be stable and was discharged again, but returned 2 days later with chest pain. He was found to have esophageal perforation with empyema, which was repaired using a muscle patch and esophageal stenting, successfully treating the lesion with minimal morbidity.
Keywords Atrial Fibrillation, Catheter ablation, Empyema, pleural, Esophageal perforation
Introduction Radiofrequency ablation (RFA) is increasingly used to treat atrial fibrillation. Given the proximity of the esophagus to the left atrium, thermal injury and perforation may occur, a potentially fatal complication. Patients present with fever, odynophagia, chest pain, or leukocytosis. There is scant literature on treating ablation-related esophageal perforation. Previous reports have described esophagectomy and exclusion.1–3
Case report A 69-year-old man underwent left atrial RFA for treatment of atrial fibrillation. The procedure was performed using a NavX 3-dimensonal mapping system and a dual transseptal approach (Figure 1). The procedure was terminated after 10 minutes of RFA around the left inferior pulmonary vein, due to the development of pericardial tamponade secondary to perforation during mapping. Bright blood (350 mL) was drained by pericardiocentesis, resolving the tamponade. Ablation was repeated one week later, delivered over 24.45 minutes with a maximum of 30 W on the lateral
wall and septum and 25 W on the posterior wall. Thirty seconds of RFA followed by 30 seconds of cooling was used to prevent esophageal heating. Esophageal temperature was not monitored. Each vein was isolated with encircling lesions, enclosing each ipsilateral pair as a unit. No linear lesions or additional substrate ablation was performed. The patient was discharged the following day on a proton pump inhibitor and dabigatran. Two days later, he presented to the emergency room with odynophagia. Chest computed tomography demonstrated small bilateral pleural effusions. He was judged to be stable and was discharged home. Two days later, he presented to our institution with pleuritic right-sided chest pain. He was afebrile with normal hemodynamics, but he had leukocytosis (white blood 1 Department of Surgery, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada 2 Department of Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada 3 Department of Medicine, Royal Jubilee Hospital, Victoria, Canada
Corresponding author: Eric Be´dard, MD, 416 Community Services Center, 10240 Kingsway Ave., Edmonton AB, T5H 3V9, Canada. Email: [email protected]
Downloaded from aan.sagepub.com by guest on November 14, 2015
Manouchehri et al.
1117
Figure 3. Esophagogram showing perforation into the right hemithorax. Figure 1. Three-dimensional map for atrial ablation (ablation points are marked by arrows).
The posterior mediastinum was very fibrotic with significant scarring already occurring between the esophagus, pericardium, and pulmonary veins. The perforation was identified and patched using a vascularized intercostal muscle flap. The pleura was drained with 3 thoracostomy tubes. Due to the widespread thermal injury and concerns of poor healing despite the muscle patch on the esophagus, a Polyflex stent was inserted endoscopically the following day. An esophagogram 2 days later revealed proper stent position and no contrast extravasation. The patient’s leukocytosis improved and the stent was removed 17 days postinsertion. A repeat esophagogram documented no leak and the drains were removed. He was discharged on a 6-week course of intravenous antibiotics.
Discussion Figure 2. Computed tomography scan demonstrating right empyema.
cell count 19.4 109 L 1). Computed tomography revealed changes consistent with a right-sided empyema (Figure 2). Soft tissue abnormalities were seen in the posterior mediastinum although no oral contrast was administered. The patient was admitted to the Thoracic Surgery Service, but decortication was delayed due to hypocoagulability from dabigatran. The next day, he developed high fevers. Esophagography demonstrated perforation with contrast extravasation into the right hemithorax (Figure 3). Flexible endoscopy at the time of the operation had confirmed a perforation at 34 cm. A right thoracotomy was undertaken, and decortication and mediastinal debridement were performed.
Esophageal thermal injury is a complication of atrial RFA described in a small number of reported cases. Whereas historically, treatment has focused on esophageal resection or diversion, the morbidity of emergency esophageal surgery in the setting of mediastinitis mandates the consideration of alternatives. We believe this is the first report describing the management of esophageal perforation with empyema secondary to left atrial RFA. The combination of open drainage with stenting of the esophagus adds to the previous experience of Bunch and colleagues4 who initially described the use of stenting for less complex RFA perforations, as well as the growing trend of stent use for esophageal perforations in general. This case demonstrates a successful approach to the treatment of a frequently fatal complication, without the morbidity often associated with esophageal resection or diversion.
Downloaded from aan.sagepub.com by guest on November 14, 2015
1118
Asian Cardiovascular & Thoracic Annals 22(9)
The finding of odynophagia after RFA of the left atrium should necessitate contrast esophagography or oral contrast computed tomography. Early intervention is fundamental in controlling sepsis. The management of pleural sepsis in this case focused on wide drainage and avoidance of direct surgical intervention on the esophagus, because previous cases demonstrated significant mortality due to esophageal surgery following RFA-related injuries. Individual adjustment of ablation lines and improved esophageal monitoring may reduce inadvertent injury,5,6 as may transesophageal echocardiography, nasoenteric feeding tubes, and bipolar diathermy.7,8 Any evidence of esophageal bleeding may indicate an atrioesophageal fistula, and flexible esophagoscopy should be avoided in this setting, given the risk of massive air embolism, precluding the use of a stent. This case has prompted changes in the management of RFA patients in our center. Patients are given a letter for emergency physicians, should they present within 6 weeks. Each emergency room in the city has also been alerted to the potential complications that may arise from RFA, including esophageal injury. This case also prompted patient safety discussions at the national level, leading the Canadian Heart Rhythm Society to create a working group to develop guidelines. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
References 1. Gillinov AM, Pettersson G and Rice TW. Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg 2001; 122: 1239–1240. 2. Doll N, Borger MA, Fabricius A, et al. Esophageal perforation during left atrial radiofrequency ablation: is the risk too high? J Thorac Cardiovasc Surg 2003; 125: 836–842. 3. Dagres N, Kottkamp H, Piorkowski C, et al. Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: lessons from five cases. J Cardiovasc Electrophysiol 2006; 17: 1213–1215. 4. Bunch TJ, Nelson J, Foley T, et al. Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2006; 17: 435–439. 5. Kottkamp H, Piorkowski C, Tanner H, et al. Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation. J Cardiovasc Electrophysiol 2005; 16: 146–150. 6. Cummings JE, Schweikert RA, Saliba WI, et al. Assessment of temperature, proximity and course of the esophagus during radiofrequency ablation within the left atrium. Circulation 2005; 112: 459–464. 7. Hall B, Shah A, Huang D, Rosero S and Daubert J. Visualization of the esophagus during catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2005; 13: 135–137. 8. Herweg B, Johnson N, Postler G, Curtis AB, Barold SS and Ilercil A. Mechanical esophageal deflection during ablation of atrial fibrillation. Pacing Clin Electrophysiol 2006; 29: 957–961.
Conflict of interest statement None declared.
Downloaded from aan.sagepub.com by guest on November 14, 2015
