442
EP Image
Esophago-pericardial Fistula Complicating Atrial Fibrillation Ablation Using a Novel Irrigated Radiofrequency Multipolar Ablation Catheter THOMAS DENEKE, M.D.,∗ ANJA SCHADE, M.D.,∗ ANNO DIEGELER, M.D.,† and KARIN NENTWICH, M.D.∗ From the ∗ Clinic for Invasive Electrophysiology; and †Clinic for Cardio-Thoracic Surgery, Heart Center Bad Neustadt, Bad Neustadt, Germany
clinical: catheter ablation - atrial fibrillation - esophageal fistula Atrioesophageal fistula is a rare but devastating complication of atrial fibrillation ablation and has been identified with different ablation strategies and technologies. We report the case of esophagopericardial fistula with fatal outcome after an uneventful ablation of atrial fibrillation using a novel multipolar irrigated RF ablation catheter (nMARQTM , Biosense Webster, Diamond Bar, USA). During ablation, the maximum esophageal temperature rose to 40.4 ◦ C and ablation was immediately stopped. In our case, ablations were performed with high-energy output (preset maximum 25 Watts energy and a maximum temperature of 45 ◦ C, ablation duration 60 seconds),
J Cardiovasc Electrophysiol, Vol. 25, pp. 442-443, April 2014. No disclosures. Address for correspondence: Thomas Deneke, M.D., Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Salzburger Leite 1, 97616 Bad Neustadt, Germany. Fax: 49-(0)9771-65-2605; E-mail: [email protected] doi: 10.1111/jce.12308
although ablation around an accessory posterior pulmonary vein (PV) was restricted to 15 Watts maximum energy. Intraprocedurally, intraesophageal temperature was monitored to detect even mild temperature increments. Even with the cutoff value of 39.5 ◦ C, a mild esophageal thermal lesion was documented on endoscopic evaluation 1 day after the procedure leading to prescription of a more aggressive proton pump inhibitor medication. Still, esophagopericardial fistula developed almost 2 weeks after ablation. Computed tomography (CT) scans identified the fistula followed by immediate emergency surgery (Fig. 1). The presented case indicates that intraesophageal temperature monitoring does not prevent thermal esophageal damage and mural damage may have a larger extent than endoscopic evaluation may reveal. Using the nMARQ ablation catheter, further steps of energy titration to prevent collateral damage are needed. Educating patients to present for CT evaluation with any suspicious symptoms, like pain during swallowing, prolonged chest pain, or fever, is crucial for early detection and potentially successful treatment are of importance during follow-up of AF ablation patients independent to the technology used.
Deneke et al.
Esophago-pericardial Fistula Complicating Atrial Fibrillation Ablation
443
Figure 1. Endoscopy (A), CT image (B), and intraprocedural electroanatomic map (C) of PVI lesions (red dots) are displayed. A: Postablation endoscopic evaluation of the esophagus showing a thermal lesion (→). B: CT image on the day of presentation indicating air within the pericardial space accompanied by pus. Also, air can be identified within the mediastinum (encircled) posterior to the left atrium (LA). C: Posterior view of the Carto3 merged CT image and ablation sites (red dots) with the nMARQ catheter. A posterior accessory PV (aPV) was isolated with circumferential ablation with the nMARQ using 15 Watts maximum energy for a single 60-second ablation. For a high quality, full color version of this figure, please see Journal of Cardiovascular Electrophysiology’s website: www.wileyonlinelibrary.com/journal/jce
EP Image
Esophago-pericardial Fistula Complicating Atrial Fibrillation Ablation Using a Novel Irrigated Radiofrequency Multipolar Ablation Catheter THOMAS DENEKE, M.D.,∗ ANJA SCHADE, M.D.,∗ ANNO DIEGELER, M.D.,† and KARIN NENTWICH, M.D.∗ From the ∗ Clinic for Invasive Electrophysiology; and †Clinic for Cardio-Thoracic Surgery, Heart Center Bad Neustadt, Bad Neustadt, Germany
clinical: catheter ablation - atrial fibrillation - esophageal fistula Atrioesophageal fistula is a rare but devastating complication of atrial fibrillation ablation and has been identified with different ablation strategies and technologies. We report the case of esophagopericardial fistula with fatal outcome after an uneventful ablation of atrial fibrillation using a novel multipolar irrigated RF ablation catheter (nMARQTM , Biosense Webster, Diamond Bar, USA). During ablation, the maximum esophageal temperature rose to 40.4 ◦ C and ablation was immediately stopped. In our case, ablations were performed with high-energy output (preset maximum 25 Watts energy and a maximum temperature of 45 ◦ C, ablation duration 60 seconds),
J Cardiovasc Electrophysiol, Vol. 25, pp. 442-443, April 2014. No disclosures. Address for correspondence: Thomas Deneke, M.D., Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Salzburger Leite 1, 97616 Bad Neustadt, Germany. Fax: 49-(0)9771-65-2605; E-mail: [email protected] doi: 10.1111/jce.12308
although ablation around an accessory posterior pulmonary vein (PV) was restricted to 15 Watts maximum energy. Intraprocedurally, intraesophageal temperature was monitored to detect even mild temperature increments. Even with the cutoff value of 39.5 ◦ C, a mild esophageal thermal lesion was documented on endoscopic evaluation 1 day after the procedure leading to prescription of a more aggressive proton pump inhibitor medication. Still, esophagopericardial fistula developed almost 2 weeks after ablation. Computed tomography (CT) scans identified the fistula followed by immediate emergency surgery (Fig. 1). The presented case indicates that intraesophageal temperature monitoring does not prevent thermal esophageal damage and mural damage may have a larger extent than endoscopic evaluation may reveal. Using the nMARQ ablation catheter, further steps of energy titration to prevent collateral damage are needed. Educating patients to present for CT evaluation with any suspicious symptoms, like pain during swallowing, prolonged chest pain, or fever, is crucial for early detection and potentially successful treatment are of importance during follow-up of AF ablation patients independent to the technology used.
Deneke et al.
Esophago-pericardial Fistula Complicating Atrial Fibrillation Ablation
443
Figure 1. Endoscopy (A), CT image (B), and intraprocedural electroanatomic map (C) of PVI lesions (red dots) are displayed. A: Postablation endoscopic evaluation of the esophagus showing a thermal lesion (→). B: CT image on the day of presentation indicating air within the pericardial space accompanied by pus. Also, air can be identified within the mediastinum (encircled) posterior to the left atrium (LA). C: Posterior view of the Carto3 merged CT image and ablation sites (red dots) with the nMARQ catheter. A posterior accessory PV (aPV) was isolated with circumferential ablation with the nMARQ using 15 Watts maximum energy for a single 60-second ablation. For a high quality, full color version of this figure, please see Journal of Cardiovascular Electrophysiology’s website: www.wileyonlinelibrary.com/journal/jce
