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Abstract 10771: Avoidance of Lethal Isotherm Formation in Esophageal Tissue with an Active Cooling Device Under High-Power, Short-Duration Ablation

DOI:10.1161/circ.144.suppl_1.10771
  • Conference: AHA Scientific Sessions 2021
  • At: Virtual
Authors:
Erik Kulstad at University of Texas Southwestern Medical Center
Erik Kulstad
Marcela Mercado Montoya at University of Antioquia
Marcela Mercado Montoya
Enrique Berjano at Universitat Politècnica de València
Enrique Berjano
Tatiana Gomez-Bustamante at University of Antioquia
Tatiana Gomez-Bustamante
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Abstract

Introduction: Atrioesophageal fistula (AEF) is a severe complication of left atrial ablation for the treatment of atrial fibrillation. Thermal injury is the proposed mechanism, and a potential pathway occurs through exceeding the lethal isotherm of esophageal tissue in contact with the left atrial posterior wall. Active cooling with a novel cooling device has been shown to significantly reduce thermal injury, with no AEFs encountered after more than 4200 treatments worldwide. We aimed to evaluate the effects of active cooling when specifically using newer high-power short-duration (HPSD) ablation settings to further estimate the protective mechanisms of this novel approach to reduce serious injury. Hypothesis: Active cooling may preclude attainment of a lethal isotherm in esophageal tissue under HPSD ablation. Methods: We developed a model of the left atrium and esophagus, and simulated radiofrequency (RF) ablation of the left atrium under HPSD settings. Tissue thickness was set to typical posterior-wall parameters (Figure). Power settings were evaluated at 50 W for 10 seconds, and 90 W for 4 seconds. Active cooling was set to a typical 4 °C coolant temperature. Lethal isotherm temperature was taken as 50 °C. Results: In both scenarios of HPSD ablation, the peak esophageal mucosal temperature reached 39° C in control conditions, using no active cooling. With active cooling in place, peak temperatures remained below 11 °C (Figure). Peak temperatures at the epi-esophageal region of esophageal tissue exceeded the lethal isotherm of 50 °C in control conditions, but remained at or below the lethal isotherm with active cooling in place. Conclusions: Based on our mathematical modeling, esophageal cooling significantly reduced temperature rise and prevented the achievement of temperatures thought to be lethal to esophageal tissue. This finding may offer a mechanistic rationale for the absence of serious esophageal injury encountered to date using this approach.
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11/22/21, 9:24 AM
Abstract 10771: Avoidance of Lethal Isotherm Formation in Esophageal Tissue with an Active Cooling Device Under High-Power,…
https://www.ahajournals.org/doi/10.1161/circ.144.suppl_1.10771
1/2
ELECTROPHYSIOLOGY AND ARRHYTHMIAS
SESSION TITLE: AF ABLATION
Abstract 10771: Avoidance of Lethal Isotherm Formation in
Esophageal Tissue with an Active Cooling Device Under High-
Power, Short-Duration Ablation
Marcela Mercado Montoya, Enrique Berjano, Steven R Mickelsen, James D Daniels, Tatiana Gomez-Bustamante,
Pablo Hernandez-Arango, Erik Kulstad
Abstract
Introduction: Atrioesophageal fistula (AEF) is a severe complication of left atrial ablation for the
treatment of atrial fibrillation. Thermal injury is the proposed mechanism, and a potential pathway
occurs through exceeding the lethal isotherm of esophageal tissue in contact with the left atrial
posterior wall. Active cooling with a novel cooling device has been shown to significantly reduce
thermal injury, with no AEFs encountered after more than 4200 treatments worldwide. We aimed to
evaluate the effects of active cooling when specifically using newer high-power short-duration (HPSD)
ablation settings to further estimate the protective mechanisms of this novel approach to reduce
serious injury.
Hypothesis: Active cooling may preclude attainment of a lethal isotherm in esophageal tissue under
HPSD ablation.
Methods: We developed a model of the left atrium and esophagus, and simulated radiofrequency
(RF) ablation of the left atrium under HPSD settings. Tissue thickness was set to typical posterior-wall
parameters (Figure). Power settings were evaluated at 50 W for 10 seconds, and 90 W for 4 seconds.
Active cooling was set to a typical 4 °C coolant temperature. Lethal isotherm temperature was taken
as 50 °C.
Results: In both scenarios of HPSD ablation, the peak esophageal mucosal temperature reached 39°
C in control conditions, using no active cooling. With active cooling in place, peak temperatures
remained below 11 °C (Figure). Peak temperatures at the epi-esophageal region of esophageal tissue
exceeded the lethal isotherm of 50 °C in control conditions, but remained at or below the lethal
isotherm with active cooling in place.
Conclusions: Based on our mathematical modeling, esophageal cooling significantly reduced
temperature rise and prevented the achievement of temperatures thought to be lethal to esophageal
tissue. This finding may offer a mechanistic rationale for the absence of serious esophageal injury
encountered to date using this approach.
Originally published 8 Nov 2021 Circulation. 2021;144:A10771
11/22/21, 9:24 AM
Abstract 10771: Avoidance of Lethal Isotherm Formation in Esophageal Tissue with an Active Cooling Device Under High-Power,…
https://www.ahajournals.org/doi/10.1161/circ.144.suppl_1.10771
2/2
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Footnotes
Author Disclosures: For author disclosure information, please visit the AHA Scientific Sessions
2021 Online Program Planner and search for the abstract title.
... This effect is believed to stem from two primary factors. First is the direct thermal impact of cooling, which has been shown to reduce, or eliminate, the potential for esophageal tissue to reach lethal isotherm temperatures [31][32][33]. Prevention of lethal isotherm temperatures in the esophageal wall is believed to preclude development of the degree of thermal injury that may lead to an AEF weeks after the initial ablation. The second factor impacting safety is the downstream anti-inflammatory effect of cooling. ...
Active esophageal cooling during radiofrequency ablation of the left atrium: data review and update
Article
Full-text available
  • Nov 2022
Introduction Radiofrequency (RF) ablation of the left atrium of the heart is increasingly used to treat atrial fibrillation (AF). Unfortunately, inadvertent thermal injury to the esophagus can occur during this procedure, potentially creating an atrioesophageal fistula (AEF) which is 80% fatal. The ensoETM (Attune Medical, Chicago, IL), is an esophageal cooling device that has been shown to reduce thermal injury to the esophagus during RF ablation. Areas covered This review summarizes growing evidence related to active esophageal cooling during RF ablation for the treatment of AF. The review presents data demonstrating improved outcomes related to patient safety and procedural efficiency and suggests directions for future research. Expert opinion The use of active esophageal cooling during RF ablation reduces esophageal injury, reduces or eliminates fluoroscopy requirements, reduces procedure duration and post-operative pain, and increases long-term freedom from arrhythmia. These effects in turn increase patient same-day discharge rates, decrease operator cognitive load, and reduce cost. These findings are likely to further accelerate adoption of active esophageal cooling.
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