Accepted Manuscript Gastroparesis Related to Atrial Fibrillation Ablation Serkan Cay, MD, Dursun Aras, MD, Serkan Topaloglu, MD, Firat Ozcan, MD, Ozcan Ozeke, MD PII:
S0002-9149(15)01546-5
DOI:
10.1016/j.amjcard.2015.06.028
Reference:
AJC 21258
To appear in:
The American Journal of Cardiology
Received Date: 18 June 2015 Accepted Date: 20 June 2015
Please cite this article as: Cay S, Aras D, Topaloglu S, Ozcan F, Ozeke O, Gastroparesis Related to Atrial Fibrillation Ablation, The American Journal of Cardiology (2015), doi: 10.1016/ j.amjcard.2015.06.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Gastroparesis Related to Atrial Fibrillation Ablation I read the article entitled ‘Gastroparesis as a Complication of Atrial Fibrillation Ablation’ by Aksu et al.1 They presented their experiences in regard to cryoballoon ablation
RI PT
of atrial fibrillation (AF). In the study, a relatively high prevalence of symptomatic gastroparesis, 6 of 58 (10.3%) patients with cryoballoon application, was found and, more cooling of the inferior veins and smaller left atrial size were found to be associated with
SC
gastroparesis in contrary to previous reports.2-4 Some important issues related to the study should be mentioned; 1) What may be the mechanisms for gastroparesis in this study? Close
M AN U
anatomic relationships between the periesophageal nerve plexus and more posteriorly located inferior pulmonary veins and posterior left atrium may result in collateral damage to the nerve fibers, especially in patients with inflated balloons in the veins instead of the antrum. In addition, relatively larger sized balloons compared to smaller atria may result in inappropriate
TE D
cooling of the posterior wall, especially with the application of the external forces through the body of the catheter and the sheath to occlude the veins. 2) Although the authors had some exclusion criteria it has been known that diabetes is one of the major causes of gastroparesis
EP
and no data was reported about the ratio of the diabetic patients with gastroparesis or blood glucose levels that hyperglycemia is associated with antral hypomotility.5 In addition, no data
AC C
was presented related to other less common causes such as eating disorders, thyroid functions (hypothyroidism) and used drugs (i.e. diabetic agents such as glucagon-like peptide-1 analogues) which have been demonstrated as gastroparesis risk factors.6 3) There are some inconsistencies about the methods and results of the study. First, patients underwent one of the ablation methods randomly in the methods section. However, the authors have stated that the study was not a randomized one at the end of the article. Second, statistically significant difference is seen in regard to left atrial diameter between the 2 groups although they
ACCEPTED MANUSCRIPT mentioned comparable baseline characteristics. Radiofrequency ablation group had larger left atria. This may be due to patient selection for ablation method that point-by-point radiofrequency ablation may be the preferred method in patients with larger atrium and persistent AF. Third, all pulmonary veins in both groups were isolated in the study. In the
RI PT
cryo group (n = 58) all 232 veins were isolated although 3 patients had left-sided common ostium. Lastly, no data was found regarding the mean left atrial diameter in patients with gastroparesis although the authors have concluded that smaller left atrial diameter was
SC
associated with symptomatic gastroparesis.
Serkan Cay, MD; Dursun Aras, MD; Serkan Topaloglu, MD; Firat Ozcan, MD; Ozcan Ozeke,
M AN U
MD Ankara, Turkey
AC C
EP
TE D
June 18, 2015
ACCEPTED MANUSCRIPT
1- Aksu T, Golcuk S, Guler TE, Yalin K, Erden I. Gastroparesis as a Complication of Atrial Fibrillation Ablation. Am J Cardiol 2015;116:92-97. 2- Guiot A, Savouré A, Godin B, Anselme F. Collateral nervous damages after
RI PT
cryoballoon pulmonary vein isolation. J Cardiovasc Electrophysiol 2012;23:346-351. 3- Ahmed H, Neuzil P, d'Avila A, Cha YM, Laragy M, Mares K, Brugge WR, Forcione DG, Ruskin JN, Packer DL, Reddy VY. The esophageal effects of cryoenergy during
SC
cryoablation for atrial fibrillation. Heart Rhythm 2009;6:962-969.
4- Fürnkranz A, Chun KR, Metzner A, Nuyens D, Schmidt B, Burchard A, Tilz R,
M AN U
Ouyang F, Kuck KH. Esophageal endoscopy results after pulmonary vein isolation using the single big cryoballoon technique. J Cardiovasc Electrophysiol 2010;21:869874.
5- Nguyen LA, Snape WJ Jr. Clinical presentation and pathophysiology of gastroparesis.
TE D
Gastroenterol Clin North Am 2015;44:21-30.
6- Pasricha PJ, Parkman HP. Gastroparesis: definitions and diagnosis. Gastroenterol Clin
AC C
EP
North Am 2015;44:1-7.
S0002-9149(15)01546-5
DOI:
10.1016/j.amjcard.2015.06.028
Reference:
AJC 21258
To appear in:
The American Journal of Cardiology
Received Date: 18 June 2015 Accepted Date: 20 June 2015
Please cite this article as: Cay S, Aras D, Topaloglu S, Ozcan F, Ozeke O, Gastroparesis Related to Atrial Fibrillation Ablation, The American Journal of Cardiology (2015), doi: 10.1016/ j.amjcard.2015.06.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Gastroparesis Related to Atrial Fibrillation Ablation I read the article entitled ‘Gastroparesis as a Complication of Atrial Fibrillation Ablation’ by Aksu et al.1 They presented their experiences in regard to cryoballoon ablation
RI PT
of atrial fibrillation (AF). In the study, a relatively high prevalence of symptomatic gastroparesis, 6 of 58 (10.3%) patients with cryoballoon application, was found and, more cooling of the inferior veins and smaller left atrial size were found to be associated with
SC
gastroparesis in contrary to previous reports.2-4 Some important issues related to the study should be mentioned; 1) What may be the mechanisms for gastroparesis in this study? Close
M AN U
anatomic relationships between the periesophageal nerve plexus and more posteriorly located inferior pulmonary veins and posterior left atrium may result in collateral damage to the nerve fibers, especially in patients with inflated balloons in the veins instead of the antrum. In addition, relatively larger sized balloons compared to smaller atria may result in inappropriate
TE D
cooling of the posterior wall, especially with the application of the external forces through the body of the catheter and the sheath to occlude the veins. 2) Although the authors had some exclusion criteria it has been known that diabetes is one of the major causes of gastroparesis
EP
and no data was reported about the ratio of the diabetic patients with gastroparesis or blood glucose levels that hyperglycemia is associated with antral hypomotility.5 In addition, no data
AC C
was presented related to other less common causes such as eating disorders, thyroid functions (hypothyroidism) and used drugs (i.e. diabetic agents such as glucagon-like peptide-1 analogues) which have been demonstrated as gastroparesis risk factors.6 3) There are some inconsistencies about the methods and results of the study. First, patients underwent one of the ablation methods randomly in the methods section. However, the authors have stated that the study was not a randomized one at the end of the article. Second, statistically significant difference is seen in regard to left atrial diameter between the 2 groups although they
ACCEPTED MANUSCRIPT mentioned comparable baseline characteristics. Radiofrequency ablation group had larger left atria. This may be due to patient selection for ablation method that point-by-point radiofrequency ablation may be the preferred method in patients with larger atrium and persistent AF. Third, all pulmonary veins in both groups were isolated in the study. In the
RI PT
cryo group (n = 58) all 232 veins were isolated although 3 patients had left-sided common ostium. Lastly, no data was found regarding the mean left atrial diameter in patients with gastroparesis although the authors have concluded that smaller left atrial diameter was
SC
associated with symptomatic gastroparesis.
Serkan Cay, MD; Dursun Aras, MD; Serkan Topaloglu, MD; Firat Ozcan, MD; Ozcan Ozeke,
M AN U
MD Ankara, Turkey
AC C
EP
TE D
June 18, 2015
ACCEPTED MANUSCRIPT
1- Aksu T, Golcuk S, Guler TE, Yalin K, Erden I. Gastroparesis as a Complication of Atrial Fibrillation Ablation. Am J Cardiol 2015;116:92-97. 2- Guiot A, Savouré A, Godin B, Anselme F. Collateral nervous damages after
RI PT
cryoballoon pulmonary vein isolation. J Cardiovasc Electrophysiol 2012;23:346-351. 3- Ahmed H, Neuzil P, d'Avila A, Cha YM, Laragy M, Mares K, Brugge WR, Forcione DG, Ruskin JN, Packer DL, Reddy VY. The esophageal effects of cryoenergy during
SC
cryoablation for atrial fibrillation. Heart Rhythm 2009;6:962-969.
4- Fürnkranz A, Chun KR, Metzner A, Nuyens D, Schmidt B, Burchard A, Tilz R,
M AN U
Ouyang F, Kuck KH. Esophageal endoscopy results after pulmonary vein isolation using the single big cryoballoon technique. J Cardiovasc Electrophysiol 2010;21:869874.
5- Nguyen LA, Snape WJ Jr. Clinical presentation and pathophysiology of gastroparesis.
TE D
Gastroenterol Clin North Am 2015;44:21-30.
6- Pasricha PJ, Parkman HP. Gastroparesis: definitions and diagnosis. Gastroenterol Clin
AC C
EP
North Am 2015;44:1-7.
